New Findings on Acne Incidence in Transgender Individuals, With Howa Yeung, MD, MSc

New data suggest clinicians should address acne among transmasculine individuals prescribed testosterone per clinical guidelines; acne may develop in transfeminine individuals who begin taking estradiol as well.1,2

These new findings, published in JAMA, were authored by a team of investigators led by Howa Yeung, MD, MSc, an associate professor of Dermatology at Emory University School of Medicine. Yeung et al had set out to examine acne incidence among transgender individuals, including those beginning gender-affirming hormone therapy, using matched cisgender patients.

Following the publishing of their findings on 280,997 individuals, Yeung spoke in a Q&A interview with the HCPLive editorial team about these data. Yeung’s discussion with HCPLive is included here:

HCPLive: What were the most striking differences you observed in acne incidence and severity between transmasculine and transfeminine individuals compared with their matched cisgender counterparts?

Yeung: Thank you for even featuring this article. I really appreciate it. I think I sought out to study how hormone therapy influenced the risk of acne development in transgender population, just because there's a larger and larger transgender population in the United States. Very little is known about the effect of their hormone therapy on skin disease development. So we sought to use a very large multi-center cohort of transgender individuals to answer some questions about whether hormone therapy influences the risk of acne development compared to cisgender population around the same age, of the same race, ethnicity, and from the same area.

Perhaps it's not surprising that testosterone, starting testosterone in trans masculine patients, meaning transgender men and non binary folks who are assigned female at birth, increases the risk of acne development. It's fourfold higher compared to match cisgender men, and one and a half fold higher than cisgender women. I think that's not surprising, because we know that testosterone causes acne. What we didn't know before is that our data before has been very limited in terms of the size of the data, as well as the short-term follow-up of the data.

This time, we follow our large cohort of transgender patients for up to 5 years of follow-up after they started hormone therapy, and we show that that much higher increased acne risk, both in terms of the first year when we start testosterone, as well as that difference persists over 5 years of follow-up.

HCPLive: As you mentioned, the acne risk in transmasculine individuals was higher in the first year after initiation of testosterone, and it remained elevated over time. How do you feel this should inform dermatologic monitoring and early intervention strategies?

Yeung: The funny thing is, right now, we have no intervention strategies for testosterone-induced acne. We assume that testosterone-induced acne will respond the same way as regular acne that occurs in cisgender people. I'm not sure if I really know the answer to that, whether they are going to behave the same, because in our transgender folks, they keep on receiving they will continue to receive gender affirming testosterone. I think right now, our clinicians are relying on a lot of cisgender data to treat our transgender folks.

But in my mind, because of how high risk our transgender patients are facing in terms of their acne risk, this really behooves us to think of a better strategy to both detect their acne early, get access to acne treatment early, and really measure whether the treatments that we have available for cisgender folks work as well for our transgender patients, and so that we can have better skin outcomes after hormone therapy.

HCPLive: We know that acne is often thought of as a testosterone-driven condition, but the study also said that transfeminine individuals also experienced increased acne risk after initiating estradiol. What would you say are the possible mechanisms or clinical explanations for this finding?

Yeung: Yeah, that's probably the most surprising piece of data that our study provided. I think most people think we use estradiol, or we use estrogen, as well as testosterone blockers, like Spironolactone, to treat acne in women. Both cisgender and transgender women. One would think that for transgender women, when they start feminizing hormone therapy, they would not get any acne. But at the same time, we also know that women have many more acne diagnoses compared to men.

So, it was really interesting to see that in our transgender women, the risk of acne after starting estradiol is actually falling between cisgender women and cisgender men. They're lower than cisgender women, perhaps because they are starting on estradiol and other anti-estrogenic interest in therapy, which might be treating their acne. At the same time, we also know that women seek acne care more often than men, whether it's due to gender norms, access to care, or gender expectations.

It was really interesting to see that in our transgender women patients, transfeminine patients, their acne does not go to zero, which is what a lot of dermatologists would have expected. In fact, is higher than what we see in cisgender men, so that probably would change how we practice. We shouldn't be ignoring the acne risks that we see in transgender women, but recognize that there is still an elevated risk compared to cisgender men.

HCPLive: Moderate to severe acne followed similar incidence patterns across these cohorts. What do these findings suggest about the need for timely escalation of therapy? Did you see any notable differences in acne care use among transgender patients?

Yeung: This is one of the limitations that we have in this study, which is that we didn't specifically measure severity based on what the patient presents with, but based on the care that they received. We measured moderate-to-severe acne by treatment for moderate-to-severe acne, so we probably underestimated how much acne people are actually suffering from in real life, because we're only measuring the care that they received.

We know that transgender patients have more barriers to care than a lot of cisgender patients, and so I think I would love to study this further to see whether the severity of their acne actually differs compared to cisgender people, as well as how we can ultimately reduce the burden that our transgender patients are suffering from.

HCPLive: Broadly speaking, how would you say these results may change how dermatologists, primary care physicians, and gender affirming care teams should counsel patients before or after initiating hormone therapy?

Yeung: Thank you for asking that. The current World Professional Association for Transgender Health guidelines state that acne develops within the first 6 months of testosterone treatment and maximizes within 1 - 2 years of testosterone treatment. Our data really inform these guidelines, in the sense that we know now that acne continues to develop after 5 years of treatment. Maybe not as intensely as that first year of treatment, but the acne risk continues to increase over 5 years.

So, I think our data really helps hormone providers to really counsel patients who are starting hormone therapy to not just give them the false expectations that acne will disappear within 2 years after starting testosterone because it doesn't and really have a more data driven discussion so that our patients don't expect that their acne will go away after 2 years, but really start seeking care for this.

Long term, important skin condition, and so I would love for our dermatologists to really continue to help facilitate care for our transgender patients, provide gender inclusive care environment, and really welcome their welcome their hormone providers to provide early referral for patients who are at high risk of developing severe acne to specialist care.

Yeung reported grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases during the conduct of the study. Yeung also reported personal fees from L'Oreal Dermatological Beauty, Pfizer, and Sanofi Genzyme, personal fees from the American Academy of Dermatology, and grants from the American Acne and Rosacea Society and from the Dermatology Foundation and Eli Lilly.

References

1. Smith CA, Kaabi O, Manatunga AK, et al. Acne Incidence and Severity in Transgender Individuals. JAMA Dermatol. Published online January 21, 2026. doi:10.1001/jamadermatol.2025.5597.

2. Gao JL, King DS, Modest AM, Dommasch ED. Acne risk in transgender and gender diverse populations: a retrospective, comparative cohort study. J Am Acad Dermatol. 2022;87(5):1198-1200. doi:10.1016/j.jaad.2022.03.013.