What is the relationship between acne and testosterone replacement therapy (TRT)?

From the Guidelines

Acne is a minor inconvenience associated with testosterone replacement therapy (TRT).

Relationship between Acne and TRT

• Acne is listed as a minor inconvenience in men receiving TRT, along with oily skin, increased body hair, and flushing 1.
• The study does not provide a specific commonality for acne, but it is mentioned as a potential skin-related effect of TRT.
• Other skin reactions, such as erythema and pruritus, are more common with patch preparations (up to 66%) than with gel preparations (5%) 1.
• Local pain, soreness, bruising, erythema, swelling, nodules, or furuncles can occur with intramuscular injections of testosterone, but acne is not specifically mentioned as a common effect of injections 1.
• Another study mentions acne as a potential risk associated with TRT, but it does not provide further information on its commonality or severity 1.

From the FDA Drug Label

Inappropriate changes in genital size or development of pubic hair or libido in children, or changes in body hair distribution, significant increase in acne, or other signs of virilization in adult women should be brought to the attention of a physician and the possibility of secondary exposure to testosterone gel should also be brought to the attention of a physician

The relationship between acne and testosterone replacement therapy (TRT) is that acne may be a sign of virilization in adult women due to secondary exposure to testosterone gel.

• Significant increase in acne is listed as one of the signs of virilization in adult women.
• The drug label advises that such signs should be brought to the attention of a physician, and the possibility of secondary exposure to testosterone gel should be considered 2.

From the Research

Relationship Between Acne and Testosterone Replacement Therapy (TRT)

• The relationship between acne and testosterone replacement therapy (TRT) is supported by several studies, which suggest that increased testosterone concentrations can lead to the development of acne 3, 4, 5.
• A study published in the European journal of dermatology found that the prevalence of moderate/severe acne increased from 11.8% to 39.1% after one year of gender-affirming masculinizing testosterone therapy (GATT) 3.
• Risk factors for the development of moderate/severe acne in testosterone-treated transgender men include high body mass index (BMI), younger age at initiation of GATT, and testosterone concentrations within or above the target range 3.
• Another study published in the European journal of dermatology found that the administration of masculinizing hormones frequently causes moderate to severe acne, which requires oral treatments, while the use of feminizing hormones reduces the risk of more severe forms of acne but may cause skin dryness and irritation 4.
• The treatment of acne in transgender patients may be challenging, but efficacious treatment options exist, including the use of ceramide-enriched emollients and maintenance topical treatment 4, 5.
• Elevated serum androgen levels, including testosterone, have been associated with the presence of acne in women, regardless of whether acne is the presenting complaint or an incidental finding 6, 7.
• Studies have found that women with acne have higher serum testosterone levels than those without acne, and that elevated free testosterone levels are a more sensitive indicator of hyperandrogenism than total testosterone values 6, 7.