Transitioning Patients: Medical and Aesthetic Recommendations for Dermatologists

A review of the unique transition-related medical and aesthetic dermatologic needs of patients undergoing transition.

For the approximately 1.4 million individuals in the United States who want to physically realize their gender identity, transitioning will require a multidisciplinary effort from a range of clinicians. These patients also face numerous barriers to healthcare, from social stigma to a lack of access to providers trained in the field of transgender health.

The dermatologic needs of a transitioning patient not only include aesthetic alterations reflecting the differences in male and female facial structures and skin characteristics, but specific therapeutic approaches necessary to treat complications related to hormone therapy, such as testosterone-induced acne vulgaris and postoperative procedures to minimize scars and refine the results of surgical procedures.

An effort should be made to make the clinical environment welcoming and inclusive for this population by following such practices as asking what gender pronouns and names a patient prefers and respecting their individual wishes, goals, finances, and access to resources. There is no set transition protocol for patients — patient care should be tailored to each unique individual.¹̛ ²

Hormone-Associated Changes

The dermatologic needs of a transitioning patient are most often associated with the first medical step in the transitioning process — hormone therapy. When the goal is feminization for a male-to-female (MTF) patient, the therapy is estradiol, usually in conjunction with an antiandrogen. This leads to fat redistribution in the body and face and a reduction in the density and quantity of body hair — usually desired effects — but also a rapid reduction in sebum production, which can result in undesired eczematous changes, generalized xerosis, and pruritus.

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Topical steroids and moisturizers can be used to treat these conditions. As complete elimination of facial hair is rare, laser removal is a common procedure for transitioning patients, although electrolysis and topical eflornithine are also options.¹̛ ²

When masculinization is the goal for a female-to-male (FTM) patient, androgen therapy is prescribed, which alters the distribution of body fat and stimulates male pattern hair growth but can also trigger male pattern hair loss. Topical minoxidil is an effective treatment to counteract this effect and will not adversely interact with hormone therapy. The excess sebum production stimulated by increased testosterone can initiate or worsen acne vulgaris, often resulting in an inflammatory form that can easily lead to scarring. This adverse event is one of the more challenging hormone-associated dermatologic issues due to prolonged androgen exposure.