What are the treatment options for acne in males with elevated testosterone levels?

Treatment Options for Acne in Males with Elevated Testosterone Levels

For males with acne and elevated testosterone levels, a multimodal approach combining topical treatments, systemic medications, and possibly anti-androgenic therapies is strongly recommended based on the most recent guidelines.

Initial Assessment

• Routine endocrinologic testing is not indicated for most males with acne, as most will have normal hormone levels despite having acne 1
• Testing should be considered when there are clinical features of hyperandrogenism or when acne is resistant to conventional therapy 1
• In males with suspected hormonal abnormalities, testing may include free and total testosterone, dehydroepiandrosterone sulfate (DHEA-S), androstenedione, luteinizing hormone, and follicle-stimulating hormone 1
• Patients with abnormal test results should be referred to an endocrinologist for further evaluation 1

Topical Therapy Options

• First-line treatment for mild acne includes topical therapies with multiple mechanisms of action 1
• Benzoyl peroxide is strongly recommended as a cornerstone treatment for acne and helps prevent bacterial resistance 1
• Topical retinoids (tretinoin, adapalene, tazarotene) are strongly recommended for comedonal acne and as part of combination therapy for inflammatory acne 1
• Topical antibiotics (clindamycin, erythromycin) should not be used as monotherapy due to risk of bacterial resistance 1
• Fixed-dose combination products (retinoid + benzoyl peroxide, antibiotic + benzoyl peroxide) are strongly recommended for better efficacy 1
• Clascoterone, a novel topical anti-androgen, is conditionally recommended for acne treatment 1

Systemic Therapy Options

• For moderate to severe acne, systemic antibiotics may be necessary 1
• Doxycycline is strongly recommended as first-line systemic antibiotic therapy 1
• Minocycline and sarecycline are conditionally recommended alternatives 1
• Isotretinoin is recommended for severe, scarring, or treatment-resistant acne 1
  • Requires monitoring of liver function tests and lipids 1
  • Daily dosing is preferred over intermittent dosing 1

Anti-Androgenic Approaches

• In males with confirmed elevated testosterone levels and resistant acne, addressing the hormonal component is important 2, 3
• Consultation with an endocrinologist is recommended to identify and treat any underlying endocrine disorders 1
• For males with very high testosterone levels, severe cases may require careful monitoring as high-dose testosterone has been associated with fulminant acne 4, 5
• Low-dose corticosteroids may be considered in specific cases to reduce adrenal androgen production, but this requires specialist supervision 2, 3

Treatment Algorithm

1. Mild acne with normal testosterone levels:

   • Topical therapy: Benzoyl peroxide + topical retinoid 1
   • Apply once daily before bedtime, using enough to cover affected areas lightly 6
   • Allow skin to dry completely (20-30 minutes) before application to minimize irritation 6

2. Moderate acne with elevated testosterone:

   • Topical therapy: Combination products (retinoid + benzoyl peroxide) 1
   • Consider adding systemic antibiotic (preferably doxycycline) 1
   • Endocrinology referral to address underlying hormonal issues 1

3. Severe or resistant acne with elevated testosterone:

   • Consider isotretinoin under close monitoring 1
   • Endocrinology consultation is mandatory 1
   • Treatment of underlying hormonal disorder if identified 2, 3

Important Considerations

• Expect initial worsening of acne during the first few weeks of topical retinoid therapy due to action on deep, previously unseen lesions 6
• Therapeutic results should be noticed after 2-3 weeks, but more than 6 weeks may be required for definite beneficial effects 6
• Use sun protection when using retinoids as they may increase photosensitivity 6
• Extremely high testosterone levels can trigger severe acne forms, including acne fulminans, which requires immediate medical attention 4, 5
• Studies have shown that lowering elevated androgens in patients with resistant cystic acne can lead to significant improvement 3