Isotretinoin for Acne in Patients Undergoing Masculinizing Hormone Therapy
In this video, John Barbieri, MD, MBA, FAAD, dermatologist and epidemiologist at Brigham and Women’s Hospital and Harvard Medical School, discusses his research on managing acne in individuals undergoing masculinizing hormone therapy as part of gender-affirming care. The study evaluated the effectiveness of isotretinoin in this population, finding that nearly all patients who completed a full course experienced acne improvement, with 70–80% achieving clearance. However, about 40% discontinued treatment prematurely due to side effects, logistical barriers, or scheduling conflicts with gender-affirming surgeries. Dr. Barbieri emphasizes the importance of coordinated care and addressing these unique challenges to optimize outcomes for transgender patients receiving isotretinoin.
Additional Resource:
- Choe J, Shields A, Ferreira A, et al. Isotretinoin for Acne in Transgender and Gender-Diverse Individuals Receiving Masculinizing Hormone Therapy. JAMA Dermatol. 2024;160(7):741-745. doi:10.1001/jamadermatol.2024.1420
TRANSCRIPTION:
John Barbieri, MD, MBA, FAAD: Hi everyone, I'm Dr. John Barbieri. I'm a dermatologist and epidemiologist at the Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts.
Consultant360: What motivated you to focus on this patient population in your study?
Dr Barbieri: We know that individuals who are receiving masculinizing hormonal therapy as part of gender affirming care can often end up developing acne as a side effect of that treatment, and sometimes that acne can be quite severe and difficult to treat. We were interested in trying to understand how well does isotretinoin work in this specific population when it comes to managing this acne, which can be a really important consequence of masculinizing hormone therapy.
C360: What were the key findings from the study?
Dr Barbieri: So to answer this question, we conducted a chart review where we included 55 individuals who are receiving masculinizing hormone therapy and treated with isotretinoin. And we found that among those who received a cumulative dose of at least 120 milligrams per kilogram, nearly 100% of them had improvement in acne, and about 70% to 80% of them had clearance of acne at that dose.
One finding we did notice in the study is that many people ended up having to discontinue their course of isotretinoin prematurely, so before they necessarily wanted to stop from getting their acne-clear standpoint, it was about 40% of people in this cohort. And that was an important finding of this work, and when we looked at why it highlighted some of the barriers that can be unique to this population, like surgical procedures, which can potentially interrupt courses and the importance of being thoughtful about planning with any other healthcare providers in the team about when to use isotretinoin knowing that it’s going to take about 6 to 12 months depending on the dosing. And additionally, iPledge and other barriers that we see kind of across isotretinoin users, were also challenging this population as well.
C360: Was there anything that surprised you about the study results?
Dr Barbieri: As I mentioned before, one thing I was a bit surprised by is how many people ended up having to stop their treatment course prematurely. About 40 % of people weren't able to complete a course of isotretinoin. They stopped really before they reached the efficacy outcome that they were going for of getting clear skin. I think this highlights some of the challenges of using isotretinoin in this population, and they need to be really thoughtful about trying to address as many of those barriers as we can to be able to optimize outcomes because we did see that those who received courses that were less than 120 milligrams per kilogram had worse outcomes than those who had higher cumulative doses and we've seen that just across isotretinoin users in general that higher cumulative doses are associated with better outcomes. This is a population I think, especially at risk of having interruptions in their care, which is a problem more broadly across isotretinoin, but we really need to be thoughtful in this population on how we can address any potential barriers to care to prevent them from becoming an issue to get the best possible outcomes.
C360: Can you expand on the reasons for discontinuation you observed in the study?
Dr Barbieri: When it came to premature discontinuation, reasons kind of fell into a few different categories. There were side effects, which we really see across isotretinoin. Some people have issues with dryness or mood or other kinds of side effects that lead to having to stop and do other treatment strategies. There were logistical barriers like iPledge, like costs, insurance issues, which I think were a bit more common in this population than what we see more broadly. And then there were some unique barriers like gender affirming surgical care that led to discontinuation around those procedures. And so, again, being thoughtful about the timing of the isotretinoin treatment and those procedures can be helpful to prevent interruptions that might lead to worse outcomes in terms of long-term clearance.
C360: What are the most important takeaways for clinicians treating transgender patients undergoing masculinizing hormone therapy?
Dr Barbieri: It's important for clinicians to be aware that acne can be a common and meaningful side effect from masculinizing hormonal therapy, and many patients do require stronger treatments like isotretinoin. Fortunately, our data suggests that isotretinoin can work really well in this population, just like we see for acne more broadly, but with some unique considerations that it can sometimes have more logistical barriers than we see traditionally in the broader population of isotretinoin users, and to be really thoughtful about what we can do to optimize clinical outcomes in this population.