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An estimated 2.8 million people in the US aged 13 years or older identify as transgender, according to a recent report — and many take hormonal medications that can boost the risk for skin disorders. Here are some recommendations from three dermatologists about managing acne and other skin-related issues when caring for transgender patients.

Transgender males, who were born as biological females, often take testosterone — a major driver of acne — as part of gender-affirming hormone therapy. As a result, testosterone-induced acne is “definitely the number one reason that transmasculine patients visit dermatology,” Philadelphia-based dermatologist, Jules Lipoff, MD, said in an interview.

Indeed, among 11,234 transmasculine individuals without acne at baseline (mean age at start, 27.7 years), tracked for 5 years, the cumulative incidence of new acne at 5 years was 15.8% vs 3.8% in matched cisgender males and 10.5% in matched cisgender females, according to a retrospective cohort study published in JAMA Dermatology in January 2026. Acne risk was highest in the first year after starting testosterone treatment among transmasculine individuals (hazard ratio, 8.29 vs matched cisgender males and 2.63 vs matched cisgender females).

“We still don’t know exactly why some people have significant acne, and why some people don’t get much,” Lipoff said. But in transgender males, risk factors for acne include a higher BMI, higher serum testosterone levels, smoking, younger age, and a history of acne prior to starting masculinizing therapy, he said.

Howa Yeung, MD, MSc, assistant professor of dermatology at Emory University, Atlanta, one of the study authors, highlighted the fact that acne can be especially wrenching for transgender males. “Acne can worsen gender dysphoria and is linked to higher rates of anxiety and depression in transmasculine patients on testosterone,” he told Medscape Medical News. “For some, acne can feel like yet another hurdle in the transitioning process, making it uniquely distressing.”

Isotretinoin Effective, but Consider Pregnancy Risk

For transgender males, Lipoff said he tries topical treatments and oral antibiotics but finds isotretinoin to be the most effective treatment. He co-authored a case series of transgender and gender-diverse individuals with acne published in 2024 that supported the use of isotretinoin for acne in people receiving masculinizing therapy via testosterone.

Among 55 patients (mean age, 25.4 years) with acne who were receiving masculinizing gender-affirming hormonal therapy and were treated with isotretinoin, acne improved in 97% of those receiving cumulative isotretinoin doses of at least 120 mg/kg and 63.6% achieved clearance, the authors reported. They added, however, that premature treatment discontinuation was common and “associated with suboptimal outcomes,” and that “further efforts are needed to understand optimal dosing and treatment barriers to improve outcomes in transgender and gender-diverse individuals receiving testosterone.”

In a presentation at the annual meeting of the American Academy of Dermatology in 2024, Yeung pointed out that transgender males may still have the capacity to become pregnant. If so, caution is warranted regarding the use of isotretinoin, a highly teratogenic drug available only through the iPLEDGE REMS program.

Monitor Patients for Hair Loss and Unwanted Hair

Multiple studies have highlighted the risk for androgenetic alopecia in transgender males taking testosterone, although the data has varied widely. A 2014 study that included 50 transmasculine individuals treated with testosterone found that nearly 64% developed hair loss over 10 years (32.7% with mild frontotemporal hair loss and 31% with moderate-to-severe androgenetic alopecia). But in a 2021 study of 988 transgender and gender-diverse individuals who received masculinizing hormone therapy, just 2.7% developed androgenetic alopecia over a mean of about 3 years.

“Finasteride is often deferred until at least 2 years after initiation of testosterone due to concern for potential attenuation of desired androgen-dependent masculinization,” Brian Ginsberg, MD, a New York City-based dermatologist, said in an interview. “For this reason, treatment is commonly initiated with topical or low-dose oral minoxidil, with the addition of finasteride if hair loss continues to progress.”

On another front, unwanted facial hair is a burden for transgender females, who were born as biological males and often take estrogen to appear more feminine. “Many transfeminine individuals have long-standing androgen-stimulated facial hair that persists despite estrogen therapy,” Ginsberg said. “Its presence is often a major driver of gender dysphoria rather than merely a cosmetic concern.”

For these patients, he recommended laser hair removal and electrolysis, along with topical retinoids, benzoyl peroxide, and anti-inflammatory agents for patients who develop pseudofolliculitis barbae from frequent shaving.

Watch for Melasma in Transgender Females

“The combined effects of estrogen therapy and anti-androgens in transfeminine patients appears to increase the prevalence of melasma with ultraviolet exposure, similar to what is seen in cisgender women during pregnancy or with oral contraceptives,” Ginsberg said.

To address this risk, he recommended rigorous photoprotection including daily use of broad-spectrum sunscreens that block visible light. He added that first-line topical therapies include hydroquinone, azelaic acid, retinoids, and combination creams. Chemical peels or lasers are procedural treatment options when needed.

Be Aware of Possible Hidradenitis Suppurativa (HS) Risk

Researchers have been concerned about a possible heightened risk of HS in transgender males because of a potential link reported between the disease and testosterone use, in a case series of two cisgender males and a cisgender female who were prescribed testosterone for hypogonadism/low libido.

In February 2026, Yeung and colleagues reported in the Journal of the American Academy of Dermatology that an analysis of 17,364 transmasculine males found that they had a higher 5-year cumulative incidence of HS (0.78%) than matched cisgender males (0.24%) and matched cisgender females (0.74%). However, the study, published as a brief report, did not show any significant increase in risk related to the use of testosterone. There was no significantly increased risk in 11,734 transfeminine individuals.

In a 2023 review of HS in transgender patients, Ginsberg and colleagues noted that “HS occurs in parts of the body that may be uncomfortable for transgender patients to have examined, especially the groin and chest.” Transgender patients, they added, “may be reluctant to show these parts of their body due to mistrust of healthcare professionals based on past experiences. Discussing physical examinations and procedures in advance, including the order in which they will occur, may help alleviate anxiety and empower SGM [sexual and gender minority] patients to voice their concerns.”

Create a Welcoming Environment

“Inclusive intake forms that allow patients to state their name, pronouns, and gender identity, along with staff training on how to use that information consistently, help establish trust, especially as many transgender individuals have had prior experience of negative interactions in healthcare settings,” Ginsberg told Medscape Medical News.

It’s also helpful to provide “clear explanations of why sensitive areas need to be examined or photographed,” he added. Many transgender patients have experienced negative healthcare experiences and/or avoidance of care, “so asking permission before exams, offering chaperones, and allowing patients control over pacing can be particularly important,” he said.

Lipoff disclosed having a relationship with Pfizer. Yeung disclosed having relationships with L’Oreal Dermatological Beauty, Pfizer, Sanofi Genzyme, American Acne and Rosacea Society, the American Academy of Dermatology, the Dermatology Foundation, and Eli Lilly. Ginsberg had no disclosures.