What is the appropriate dosage and administration of a testosterone patch for patients requiring testosterone replacement therapy?

Testosterone Patch Dosing and Administration

For testosterone replacement therapy using transdermal patches (Androderm), initiate treatment at 2-6 mg per 24 hours applied once daily to dry, intact skin of the back, abdomen, upper thighs, or upper arms. 1

Starting Dose and Titration

• Begin with a 2 mg/24-hour patch applied once daily in the morning 1
• The typical dose range is 2-6 mg per 24 hours, which may require 1-3 patches depending on the formulation strength 1
• Measure testosterone levels 2-3 months after treatment initiation to guide dose adjustments 1, 2
• For transdermal patches specifically, peak testosterone values occur 6-8 hours after application, though levels can be measured at any time 1

Application Instructions

• Apply to dry, intact skin of the back, abdomen, upper thighs, or upper arms 1
• Rotate application sites to minimize skin irritation 1
• Do not apply to the scrotum, chest, axillae, or genitals 3
• The patch should remain in place for 24 hours before replacement 1

Monitoring Protocol

• Check testosterone levels at 2-3 months after starting therapy or any dose adjustment 1, 2
• Target mid-normal testosterone values (500-600 ng/dL) for transdermal preparations 1
• Once stable levels are achieved, monitor every 6-12 months 1
• Assess for clinical symptom improvement including energy, libido, muscle mass, and body composition 1

Dose Adjustment Algorithm

If testosterone level <350 ng/dL: Increase dose by one patch increment (typically adding a 2 mg patch) 3

If testosterone level 350-750 ng/dL: Continue current dose 3

If testosterone level >750 ng/dL: Decrease dose by one patch increment 3

Key Advantages of Patches vs Other Formulations

• No risk of interpersonal transfer to partners or children, unlike gels which carry significant transference risk 1
• More stable day-to-day testosterone levels compared to intramuscular injections which cause peaks and valleys 1
• Easy application without need for injections 1
• Lower cardiovascular risk compared to injectable testosterone, which may be associated with greater risk of cardiovascular events, hospitalizations, and deaths 1

Common Pitfalls and Management

Skin irritation/rash at application site occurs in a significant proportion of patch users and represents the primary disadvantage 1

• This is the most common reason for discontinuation of patch therapy 1
• Rotating application sites can minimize this issue 1
• If severe skin reactions develop, consider switching to gel formulations which have lower rates of skin reactions (approximately 5% vs 66% with patches) 2

Poor patch adherence can occur, particularly with sweating or physical activity 1

• Ensure skin is completely dry before application 3
• Apply to areas with minimal hair and movement 1

Avoid swimming or showering for at least 2 hours after application to ensure adequate absorption 3

Safety Considerations

• The FDA required labeling changes in 2015 warning of possible increased risk of heart attack and stroke with testosterone preparations for age-related hypogonadism 1
• However, transdermal preparations may have lower cardiovascular risk than injections due to more stable testosterone levels without supratherapeutic and subtherapeutic fluctuations 1
• Monitor prostate-specific antigen, hematocrit, and cardiovascular risk factors during therapy 2, 4