Moderate-to-severe acne imposes significant psychosocial and quality-of-life burdens and may be triggered by endogenous androgens or exogenous hormone therapy (HT).1–3 While moderate-to-severe acne warranting isotretinoin treatment has been observed in case series,4 the epidemiology and severity of acne in transgender populations remains to be characterized.
We aimed to determine the prevalence of moderate-to-severe acne in a cross-sectional survey of transgender adults nested in the multicenter Study of Transition, Outcomes, and Gender (STRONG). Emory University Institutional Review Board approved this study. STRONG cohort eligibility included enrollment in Kaiser Permanente Northern California, Southern California, or Georgia between January 1, 2006 and December 31, 2014. Participants were adults ≥18 years old with ≥1 transgender-specific International Classification of Diseases, Ninth Edition diagnostic code and/or medical records review. Survey methods were detailed elsewhere.5 Eligibility included physician consent for contact and self-reported gender identity differing from sex recorded at birth. Participants reported if they had “moderate-to-severe acne (pimples) as diagnosed by a doctor,” their history of gender-affirming therapies, and if they thought their acne was linked to HT. Acne prevalence in transmasculine (TM) and transfeminine (TF) persons were compared using chi-square or Fisher’s exact tests, with two-sided P<0.05 considered significant. Prevalence ratios [PR] for moderate-to-severe acne were adjusted for age in stratified analyses using Mantel-Haenszel methods in SAS 9.4 (SAS Institute, Cary, NC).
Among 2,136 eligible participants, 696 (32.6%) completed the survey, including 346 TM and 350 TF persons (Table 1). Most received HT (91.7%) and underwent ≥1 gender-affirming surgery (58.1%). Overall, 20.8% of transgender persons reported any history of moderate-to-severe acne. TM persons were more likely than TF persons to report any history of moderate-to-severe acne (28.0% vs 13.7%, P<0.001; age-adjusted PR 1.64, 95% CI, 1.17–2.30) and current moderate-to-severe acne (13.6% vs. 0.9%, P<0.001; age-adjusted PR 8.27, 95% CI, 2.80–24.41), but were less likely to have any dermatologist visit (44.5% vs. 55.1%, P<0.001). Among those with moderate-to-severe acne, TM persons were more likely than TF persons to attribute acne to HT (65.6% vs 4.4%, P<0.001). There was no significant association between current moderate-to-severe acne and either current testosterone use or route of testosterone administration in TM persons (Table 2).
Table 1.
Demographics and prevalence of moderate-to-severe acne in transgender adultsa
| All | TMb | TFc | P | |
|---|---|---|---|---|
| Characteristics, N (%) | 696 (100) | 346 (49.7) | 350 (50.3) | |
| Age at time of survey (years) | <0.001 | |||
| 18–29 | 217 (31.2) | 148 (42.8) | 69 (19.7) | |
| 30–39 | 156 (22.4) | 104 (30.1) | 52 (14.9) | |
| 40–54 | 168 (24.1) | 69 (19.9) | 99 (28.3) | |
| ≥55 | 155 (22.3) | 25 (7.2) | 130 (37.1) | |
| Race/ethnicity | 0.66 | |||
| Non-Hispanic White | 392 (56.3) | 191 (55.2) | 201 (57.4) | |
| Non-Hispanic Black | 20 (2.9) | 13 (3.8) | 7 (2.0) | |
| Non-Hispanic Asian/Pacific Islander | 48 (6.9) | 25 (7.2) | 23 (6.6) | |
| Hispanic | 133 (19.1) | 68 (19.7) | 65 (18.6) | |
| Other / Declined | 103 (14.8) | 49 (14.2) | 54 (15.4) | |
| History of gender-affirming treatmentsd | <0.001 | |||
| None | 28 (4.0) | 11 (3.2) | 17 (4.9) | |
| Hormone therapy only | 234 (33.6) | 76 (22.0) | 158 (45.1) | |
| Chest surgery without genital surgery | 171 (24.6) | 142 (41.0) | 29 (8.3) | |
| Genital surgery with or without chest surgery | 233 (33.5) | 103 (19.8) | 130 (37.2) | |
| Missing information | 30 (4.3) | 14 (4.1) | 16 (4.6) | |
| Moderate-to-severe acne diagnosis by a physiciane | <0.001 | |||
| No | 449 (64.5) | 208 (60.1) | 241 (68.9) | |
| Yes - currently | 50 (7.2) | 47 (13.6) | 3 (0.9) | |
| Yes - in the past | 95 (13.7) | 50 (14.5) | 45 (12.9) | |
| Missing information | 102 (14.7) | 41 (11.9) | 61 (17.4) | |
| Ever diagnosis of moderate or severe acne (current or past) | 145 (20.8) | 97 (28.0) | 48 (13.7) | <0.001 |
| Moderate or severe acne linked to hormone therapy | <0.001 | |||
| No | 76 (53.9) | 33 (34.4) | 43 (95.6) | |
| Yes | 65 (46.1) | 63 (65.6) | 2 (4.4) | |
| Any visit to a dermatologist | 347 (49.9) | 154 (44.5) | 193 (55.1) | <0.001 |
TM, transmasculine; TF, transfeminine
Numbers may not add up to the total number of participants because, unless otherwise specified, we excluded categories with missing data totaling less than 5%.
Transmasculine refers to transgender persons with current gender identity that differs from female natal sex
Transfeminine refers to transgender persons with current gender identity that differs from male natal sex
Chest surgery referred to any history of mastectomy or breast augmentation, while genital surgery referred to any history of hysterectomy, orchiectomy, vaginectomy, and/or vaginoplasty. The majority (98.3%) of respondents with a history of chest surgery and/or genital surgery has received hormone therapy.
We combined the missing category with no prior history of moderate-to-severe acne to produce conservative estimates of current moderate-to-severe acne prevalence. Acne prevalence may be underestimated in transfeminine persons given higher levels of missing acne data.
Table 2.
Age-stratified prevalence of moderate-to-severe acne in transgender adults and association with current testosterone use in transmasculine adults
| Age | Moderate-to-severe acne | All | TM | TF | P |
|---|---|---|---|---|---|
| 18–29 | No | 127 (58.5) | 83 (56.1) | 44 (63.8) | 0.004 |
| Yes - currently | 38 (17.5) | 35 (23.7) | 3 (4.4) | ||
| Yes - in the past | 31 (14.3) | 18 (12.2) | 13 (18.8) | ||
| Missing | 21 (9.7) | 12 (8.1) | 9 (13.0) | ||
| 30–39 | No | 105 (67.3) | 67 (64.4) | 38 (73.1) | 0.35 |
| Yes - currently | 5 (3.2) | 5 (4.8) | 0 (0) | ||
| Yes - in the past | 27 (17.3) | 20 (19.2) | 7 (13.5) | ||
| Missing | 19 (12.2) | 12 (11.5) | 7 (13.5) | ||
| 40–54 | No | 116 (69.1) | 41 (59.4) | 75 (75.8) | 0.004 |
| Yes - currently | 7 (4.2) | 7 (10.1) | 0 (0) | ||
| Yes - in the past | 21 (12.5) | 9 (13.0) | 12 (12.1) | ||
| Missing | 24 (14.3) | 12 (17.4) | 12 (12.1) | ||
| ≥55 | No | 101 (65.2) | 17 (68.0) | 84 (64.6) | 0.84a |
| Yes - currently | 0 (0) | 0 (0) | 0 (0) | ||
| Yes - in the past | 16 (10.3) | 3 (12.0) | 13 (10.0) | ||
| Missing | 38 (24.5) | 5 (20.0) | 33 (25.4) | ||
| N (%) | Current Moderate-to-Severe Acne in TM | Age-adjusted PR (95% CI) | |||
| Yes | No | ||||
| Current testosterone use | |||||
| No | 58 (16.8) | 6 (10.3) | 52 (89.7) | [reference] | |
| Yes | 288 (83.2) | 41 (14.2) | 247 (85.8) | 1.26 (0.58–2.73) | |
| Route of testosterone administration | |||||
| Injection alone | 244 (84.7) | 35 (14.3) | 209 (85.7) | [reference] | |
| Other regimensb | 44 (15.3) | 6 (13.6) | 38 (86.4) | 1.08 (0.49–2.40) | |
TM, transmasculine; TF, transfeminine; PR, prevalence ratio; N/A, not applicable
Fisher’s exact test for patients ≥55 years old excluded the zero row since there were no patients reporting current moderate-to-severe acne.
Other regimens include testosterone gel, patch, and/or oral testosterone alone or in combination with testosterone injection
In this first multicenter survey of moderate-to-severe acne in transgender persons, TM persons were more likely to report moderate-to-severe acne as compared to TF persons. This is consistent with known effects of estrogen and testosterone on acne.1,3 Limitations included the cross-sectional design and reliance on self-reports. Clinical images and medical records data will validate acne severity or establish the duration and dosage of HT in future studies. The specific question on moderate-to-severe acne prevented examination of mild acne epidemiology. Survey participants were privately insured, which limited external validity to transgender persons with lower access to care. Future studies should examine the interaction of age, effects of HT dose, duration, and route of administration on acne incidence and severity. Longitudinal, prospective data on the natural history, severity, treatment, and psychosocial impact of acne are needed to optimize skin and quality-of-life outcomes of gender-affirming HT in transgender populations.
Funding:
This study is supported in part by PCORI contract AD-12-11-4532 and grant R21HD076387 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (M.G.); the National Center for Advancing Translational Sciences grants UL1TR002378 and KL2TR002381 (H.Y.); and the National Institute for Arthritis and Musculoskeletal and Skin Diseases loan repayment program L30AR076081 (H.Y.).
Footnotes
Conflicts of Interest: Dr. Yeung previously received honorarium from Syneos Health.
Prior Presentation: The abstract was presented at the American Acne & Rosacea Society and the Society of Investigative Dermatology on May 8, 2019.
IRB Statement: Reviewed and approved by Emory University Institutional Review Board #00113741
References
- 1.Yeung H, Luk KM, Chen SC, et al. Dermatologic care for lesbian, gay, bisexual, and transgender persons: Epidemiology, screening, and disease prevention. J Am Acad Dermatol. 2019;80(3):591–602. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Motosko CC, Zakhem GA, Pomeranz MK, Hazen A. Acne: a side-effect of masculinizing hormonal therapy in transgender patients. Br J Dermatol. 2019;180(1):26–30. [DOI] [PubMed] [Google Scholar]
- 3.Wierckx K, Van de Peer F, Verhaeghe E, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med. 2014;11(1):222–229. [DOI] [PubMed] [Google Scholar]
- 4.Yeung H, Chen SC, Katz KA, et al. Prescribing isotretinoin in the United States for transgender individuals: Ethical considerations. J Am Acad Dermatol. 2016;75(3):648–651. [DOI] [PubMed] [Google Scholar]
- 5.Owen-Smith AA, Gerth J, Sineath RC, et al. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals. J Sex Med. 2018;15(4):591–600. [DOI] [PMC free article] [PubMed] [Google Scholar]