What is the treatment for testosterone-induced red, dry skin on the face and forehead in a male receiving testosterone pellets?

Treatment for Testosterone Pellet-Induced Facial Dermatitis

Apply a high-potency topical corticosteroid to the affected facial areas, which has been shown to rapidly resolve testosterone-induced erythematous skin reactions. 1

Understanding the Problem

Testosterone-induced skin reactions are well-documented adverse effects of androgen replacement therapy, though the specific manifestation varies by delivery method:

• Transdermal patches cause erythema or pruritus in up to 66% of users 2
• Gel preparations cause skin reactions in only 5% of users 2
• Testosterone pellets can cause dermatitis presenting as erythematous plaques and patches, typically appearing within 28 days of insertion 1

The red, dry skin on the face and forehead in this patient receiving testosterone pellets represents a systemic dermatologic reaction rather than a local injection site reaction, which is an important distinction.

Primary Treatment Approach

High-potency topical corticosteroids are the evidence-based first-line treatment:

• Apply to affected facial areas once or twice daily 1
• Case reports demonstrate rapid resolution of testosterone pellet-induced erythematous plaques and patches with this approach 1
• This treatment addresses the inflammatory component causing the redness and can help restore the skin barrier function to address dryness 1

Adjunctive Symptomatic Management

While not specifically studied for testosterone-induced reactions, standard supportive care for facial dermatitis should be implemented:

• Gentle moisturizers for the dry skin component (general medical knowledge)
• Avoid harsh cleansers that may further irritate compromised skin (general medical knowledge)
• Sun protection as inflamed skin may be more photosensitive (general medical knowledge)

Critical Consideration: Recurrence Pattern

A major caveat: The published case of testosterone pellet-induced dermatitis showed that the same cutaneous eruption recurred with each subsequent pellet insertion 1. This suggests:

• The dermatitis may be a reproducible reaction to the pellet formulation 1
• Topical corticosteroids treat the symptoms but do not prevent recurrence 1
• If the reaction recurs with each pellet insertion, switching to an alternative testosterone delivery method should be strongly considered 1

Alternative Testosterone Delivery Methods

If dermatitis recurs with repeat pellet insertions, transition to a different formulation:

• Testosterone gel preparations have the lowest rate of skin reactions at 5%, compared to 66% for patches 2
• Subcutaneous or intramuscular injections (weekly dosing of 50 mg preferred over biweekly to minimize peaks/troughs) provide stable levels without the dermatitis risk associated with pellets 2, 3
• The New England Journal of Medicine notes that intramuscular injections can cause local reactions (pain, erythema, swelling) but not the systemic facial dermatitis seen with pellets 2

Monitoring Considerations

While treating the dermatitis, ensure appropriate testosterone monitoring continues:

• Measure testosterone levels 2-3 months after any formulation change, targeting mid-normal values of 500-600 ng/dL 2, 3
• Once stable, monitor every 6-12 months 2, 3
• Continue routine monitoring of PSA and hematocrit as recommended for all testosterone therapy 2

When to Refer to Dermatology

Consider dermatology consultation if:

• The dermatitis does not respond to high-potency topical corticosteroids within 2-4 weeks (general medical knowledge)
• Skin changes progress or develop concerning features (general medical knowledge)
• Hyperpigmentation develops, as testosterone therapy has been associated with facial hyperpigmentation in rare cases 4