Transgender dermatology care faces unique challenges

Addressing dermatologists' unfamiliarity with the transgender community and its skin health needs will help eliminate a barrier to care for this underserved population, physicians reported at the American Academy of Dermatology annual meeting in February.

The skin conditions for which transgender patients seek dermatologic care are not unique, said New York City-based dermatologist Brian Ginsberg, M.D., but these issues often require a different approach in this population. "Many transgender men suffer from significant acne. Acne is something we're prepared to treat, but some of the care may be a little different than the conventional approach."¹

For many transgender men, he explained, taking testosterone fuels severe acne requiring isotretinoin. Under the iPLEDGE program for reducing fetal exposures, he said that presently, "Most trans men have to register as females of childbearing potential (FCBPs), which could be a very large barrier to their care because it is often a difficult conversation for many doctors to have with these patients. It's also understandably difficult for many patients to accept" that they must register as FCBPs.

Navigating these conversations requires building strong relationships with patients and emphasizing the necessity of registering as required. "Hopefully, the governing bodies for the iPLEDGE program will change the registration requirements in the future."

Testosterone administration is also known to cause androgenetic alopecia, Dr. Ginsberg added. "There's still no large-scale study about how to treat this patient population." Current conventional treatment for male pattern hair loss includes using finasteride or minoxidil foam. "But it's still unclear what dose is the most appropriate in this population. In cisgender men, we use the 1 mg dose, but in many cisgender women, we use 5 mg. Will trans men necessitate the standard dose for cisgender men, which is what we currently do, or will they need a higher dose? There are studies that show that 1 mg is effective in this population,²" but no definitive large-scale trials.

Dermatologists also must be aware that putting trans males on finasteride can have secondary effects such as blocking the development of desired testosterone effects including hair growth, voice changes, and muscle mass redistribution, said Dr. Ginsberg. "A recommendation for many of these patients is to wait until they've hit their desired outcome of secondary sex changes before initiating finasteride treatment."

Additionally, he said, neuromodulators and fillers that dermatologists use for rejuvenation can greatly help to masculinize or feminize facial features in trans patients. "This is very important in this population because there's a very high rate (20%-50% in the United States) of illicit injection use – of people going to non-doctors and having nonmedical-grade products put into their faces. And we're seeing a lot of complications from those injections."

As dermatologists, "We want to be prepared to treat the complications that arise from illicit injections. But we also need to create an environment where these patients feel comfortable coming to us to get proper care initially and prevent these negative outcomes in the first place. Overall, a huge priority in terms of dermatology and the transgender community is improving cultural competence and access to care."

REFERENCES

1. U072 - LGBT Health: “Providing Culturally Competent Care to Patients who are Sexual and Gender Minorities.” Brian Ginsberg, M.D. 5 p.m., Feb. 18. American Academy of Dermatology 2018 annual meeting.

2. Moreno-Arrones OM, Becerra A, Vano-Galvan S. Therapeutic experience with oral finasteride for androgenetic alopecia in female-to-male transgender patients. Clin Exp Dermatol. 2017 Oct;42(7):743-748.