TRANSGENDER individuals, particularly those initiating testosterone therapy, experience significantly higher rates of acne compared with matched cisgender populations, according to a large multicentre cohort. The findings highlight the need for proactive acne monitoring and management in transgender patients receiving gender-affirming hormone therapy.
Using electronic health record data from four Kaiser Permanente regions, researchers conducted a retrospective matched cohort study including nearly 281,000 individuals without baseline acne. The cohort comprised 11,234 transmasculine individuals and 9,486 transfeminine individuals, each matched with cisgender men and women by age, race and ethnicity, region, and enrolment year. Participants were followed for up to five years after the earliest documentation of transgender status, with acne incidence assessed through diagnostic coding and treatment patterns.
Acne Peaks During the First Year of Gender-Affirming Hormone Therapy
At five years, cumulative acne incidence was substantially higher among transmasculine individuals (15.8%) compared with matched cisgender men (3.8%) and cisgender women (10.5%). Acne risk peaked during the first year following testosterone initiation, when transmasculine individuals had more than an eightfold higher risk than cisgender men and nearly threefold higher risk than cisgender women. Although risk declined after the first year, it remained significantly elevated throughout the five-year follow-up period.
Transfeminine individuals initiating estradiol therapy also demonstrated altered acne risk patterns. Their overall acne incidence at five years was 6.0%, higher than that observed in matched cisgender men (2.9%) but lower than in cisgender women (8.4%). After estradiol initiation, transfeminine individuals had a modestly increased acne risk compared with cisgender men, while remaining at lower risk than cisgender women.
Patterns for moderate to severe acne, defined by subsequent prescriptions for isotretinoin or prolonged oral antibiotic use, mirrored those observed for overall acne incidence. Exploratory analyses suggested differences in acne-related care utilisation by transgender status, underscoring potential gaps in dermatologic management.
Guideline-Based Acne Monitoring During Gender-Affirming Care
The authors note that androgen exposure likely explains the pronounced acne risk among transmasculine individuals receiving testosterone, particularly during early treatment. However, the development of acne in transfeminine individuals receiving estradiol highlights that acne is not limited to androgen-dominant therapies.
The study’s findings emphasise the importance of anticipatory guidance, early intervention, and guideline-based acne treatment in transgender care. Clinicians prescribing gender-affirming hormone therapy are encouraged to monitor for acne development, especially during the first year of testosterone therapy, and to recognise that transfeminine individuals may also require dermatologic assessment following estradiol initiation.
Reference
Smith CA et al. Acne Incidence and Severity in Transgender Individuals. JAMA Dermatol. 2026; doi:10.1001/jamadermatol.2025.5597.
