Trans men face increased risk of acne after starting testosterone, study finds

Results of a new study published in the American Medical Journal confirm what many transmasculine people already know: testosterone can cause acne.

It’s common enough that there’s a nickname for it: T acne.

But the research also revealed that transfeminine individuals on estradiol therapy experience a higher incidence of acne than their cisgender peers, demonstrating that androgen-dominant therapies alone (those employing male hormones) aren’t the sole cause of acne in trans individuals.

The findings highlight the need for proactive acne monitoring and management for both transmasc and transfeminine individuals receiving gender-affirming hormone therapy, the authors say.

Using electronic health record data from four Kaiser Permanente regions, researchers conducted a study including nearly 281,000 individuals without baseline acne. That number covered just over 20,000 trans patients: 11,234 transmasculine individuals and 9,486 transfeminine individuals, or about 7% of the total group.

Each trans cohort was matched with cisgender men and women by age, race and ethnicity, region, and enrollment year. Participants were followed for up to five years after the earliest documentation of transgender status, with acne incidence assessed throughout the study period.

At five years, cumulative acne incidence was substantially higher among transmasc individuals (15.8%) compared with matched cisgender men (3.8%) and cisgender women (10.5%).

Acne risk for that group peaked during the first year following testosterone initiation, when transmasc individuals had more than an eightfold higher risk than cisgender men, and a nearly threefold higher risk than cisgender women.

Although risk declined after the first year, it remained significantly elevated throughout the five-year follow-up period.

But transfeminine individuals initiating estradiol therapy also demonstrated altered acne risk patterns.

Their overall acne incidence at five years was 6.0%, higher than that observed in matched cisgender men (2.9%) but lower than that in cisgender women (8.4%).

After estradiol initiation, transfeminine individuals had a modestly increased acne risk compared with cisgender men, while remaining at lower risk than cisgender women.

Patterns for moderate to severe acne, determined by prolonged oral antibiotic use, or use of isotretinoin — a potent, oral retinoid derived from vitamin A used to treat severe acne that hasn’t responded to other treatments — mirrored those observed for overall acne incidence.

However, exploratory analyses suggested differences in acne-related care utilization by transgender status, underscoring potential gaps in dermatologic management.

Androgen exposure likely explains the pronounced acne risk among transmasculine individuals receiving testosterone, particularly during early treatment, the authors note, but the development of acne in transfeminine individuals receiving estradiol highlights that acne isn’t limited to therapies associated with testosterone.

The authors encourage clinicians prescribing gender-affirming hormone therapy to monitor for acne development, especially during the first year of testosterone therapy, and to recognize that transfeminine individuals may also require dermatologic assessment following estradiol initiation.

“If you’re noticing more breakouts on T, you’re not doing anything wrong,” the Trans Health HQ posted to its Instagram account last month. “Acne is one of the most common early changes on testosterone.”

The channel recommended consulting a dermatologist about acne, but it also noted that a common acne treatment, spironolactone, can counteract some of the effects of T as a known side effect.