Managing Acne and Hidradenitis Suppurativa in Gender-Diverse Patients

Conclusions

• Gender-affirming hormone therapy meaningfully changes acne and hidradenitis suppurativa risk, with testosterone generally worsening both conditions and estrogen/androgen-blocking therapy often improving them.
• Transmasculine patients on testosterone have a substantially higher likelihood of developing acne, especially early in therapy and at younger ages, and the acne can be more severe.
• Standard acne treatments can still be used in gender-diverse patients, but spironolactone is usually avoided in transmasculine patients because of its feminizing potential while clascoterone and isotretinoin remain useful options.
• Isotretinoin can be used safely with testosterone, but clinicians should proactively address pregnancy potential, contraception, and the possibility of surgery-related timing concerns.
• For pregnancy prevention and iPLEDGE counseling, testosterone should not be assumed to be effective contraception, and culturally sensitive, behavior-based discussions are preferred over assumptions about identity.
• Transgender and gender-diverse patients may benefit from serum pregnancy testing and confidential, individualized reproductive counseling to reduce dysphoria and improve adherence.
• Testosterone appears to increase hidradenitis suppurativa risk and severity, while estrogen and spironolactone are associated with improvement, mirroring their known hormonal effects.
• In larger cohort data, hormone initiation seems to shift HS risk toward the pattern typical of the affirmed gender, with transmasculine patients resembling cisgender women more and transfeminine patients resembling cisgender men more.
• HS treatment in transfeminine patients can align well with gender-affirming care, and options such as spironolactone, estrogen-containing OCPs, laser hair removal, and finasteride can be helpful.
• Laser hair removal is a useful adjunct for HS and can serve both medical and gender-affirming goals, though insurance coverage remains variable.
• HS should not automatically be treated as an infection or a reason to delay surgery, and biologics like adalimumab can often be continued through the perioperative period without increasing complications.
• Cultural humility, advance explanation of exams, and patient choice about participation in the exam are important for reducing distress during dermatologic care.
• Binding, cosmetics, and genital or chest exams can all trigger acne or discomfort, so routine counseling should include these gender-affirming context-specific issues.
• Acne and HS can significantly worsen psychosocial burden and suicidality in sexual and gender minority patients, making prompt and respectful treatment especially important.