Introduction
Upon starting testosterone therapy, many guys experience problems with acne and related skin conditions. There are two main reasons that breakouts often begin after starting testosterone. First, testosterone causes the the skin's sebaceous glands to produce more sebum (oil), which can cause plugged pores and lead to acne lesions. Second, testosterone also causes increased hair growth on the face, neck, chest, arms, and back, which can lead to irritated follicles and ingrown hairs in those areas, causing puss-filled lesions. In tandem with the increase of hair growth on the face and neck, many trans men begin shaving, and improper shaving technique can lead to rashes and ingrown hairs that can further affect the skin.
There are a number of things that you can do to prevent and treat conditions like acne, ingrown hairs, and shave bumps, but it is important to know which problem you are trying to treat in order to be effective. It may be wise to see a dermatologist (a doctor who is a skin specialist) if the methods listed on this page are not helping-- you may be dealing with a particularly stubborn case of acne, or you may have a combination of multiple skin problems that a dermatologist could better help you to address.
What is Acne?
Acne is a disorder that effects the pilosebaceous units (PSUs) of the skin. PSUs consist of a "sebaceous" gland (oil-producing gland) connected to a canal called a "follicle." The follicle contains a fine hair, and the hair grows out through the open end of the canal at the skin's surface. This open end is usually called a "pore." There are numerous PSUs on the face, upper back, and chest (where acne problems often are worst).
The sebaceous glands produce an oily substance called "sebum" that normally empties onto the skin's surface through the pore. Trouble begins when the follicle becomes plugged, thereby preventing the normal draining of sebum. If a follicle becomes blocked for some reason, the mixture of oil cells within allows the bacteria "Propionibacterium acnes" (P. acnes), which is normally present on the skin, to grow inside the plugged follicle.
The P. acnes bacteria multiplies inside the plugged follicle, causing the body to send white blood cells to that follicle, which in turn causes the area to become inflamed and painful. This leads to a variety of skin lesions.
The basic acne lesion is called the "comedo." It is simply an enlarged and plugged hair follicle. If the comedo remains beneath the skin, it is called a "closed comedo" and produces a white bump called a "whitehead." A comedo that reaches the surface of the skin and opens up is called a "blackhead" because it looks black on the skin's surface.
A "papule" is an inflamed lesion that usually appears as a small, pink bump on the skin that may be tender to the touch. A "pustule" is a papule topped by a pus-filled lesion that may be red at the base-- this is commonly called a "pimple." A "nodule" is a large, painful, solid lesion that is lodged deep within the skin. A "cyst" is a deep, painful, pus-filled lesion that can cause scarring.
What Causes Acne?
The exact cause of acne is unknown, but a major contributing factor is an increase in testosterone, as testosterone causes the sebaceous glands to produce more oil. Other factors that are believed to contribute to acne include: heredity, frequent irritation caused by rubbing or picking the skin, pressure from tight-fitting hats or clothing, environmental irritants, colognes or other scented products, and scrubbing the skin too hard or too often.
For trans men, the beginning of a testosterone regimen might bring on acne. This might be a temporary condition that clears itself up over a period of months or a couple of years (much like in puberty), or it might remain a persistent problem that requires rigorous treatment.
How is Acne Treated?
The goals when treating acne are to heal any existing lesions, stop new lesions from forming, and to prevent scarring wherever possible. Treatment is aimed at reducing the problems that play a part in causing acne in the first place: abnormal clumping of cells in the follicles, increased oil production, the presence of bacteria, and inflammation. Depending on the severity of a person's acne, one or more strategies or products may be utilized in a treatment regimen.
There are a variety of tips and techniques that have been reported to help reduce breakouts, as well as numerous over-the-counter (OTC) products to treat mild to moderate acne. Such products and methods are listed below.
For more severe or persistent acne, it may be wise to seek the advice of a dermatologist. A dermatologist may prescribe medications in combination with OTC products, and/or they may diagnose additional skin problems (such as ingrown hairs or other types of skin irritation or infection) that might be contributing to breakouts on the face, back, or shoulders. The most common prescription acne treatments are listed near the end of this page.
Acne Prevention: Tips and Techniques
While most persistent acne will require at least some form of treatment regimen with cleansers and OTC medications, there are a few basic things that you can do (or not do) that may dramatically reduce breakouts.
Avoid picking and rubbing your skin
First and foremost, you should avoid picking, scratching, or rubbing the affected skin, and you should especially avoid picking at already existing breakouts. The dirt from your fingers and fingernails can further contribute to clogged pores, and picking can cause additional inflammation and irritation, making symptoms worse.You should also avoid squeezing existing pimples. This is especially true if the lesion is a nodule or cyst that is deep within the skin. Squeezing such a lesion will probably only squeeze the bacteria and infection deeper into the skin, thus making the cyst deeper and more irritated, while also making it last longer than it would have normally. It also may increase the chances of scarring. If you have a pimple with a white head where the puss is very near the surface, squeezing it may not be permanently damaging, but the bacteria that are released upon squeezing can spread to other nearby pores, and may also spread deeper within the originally infected pore, causing additional soreness and redness. In general, it is best to treat acne lesions with medicated products, and avoid picking as much as possible.
Avoid scented or harsh soaps/skin products
Because acne can be worsened by skin irritants, you may wish to discontinue use of scented products such as colognes, after-shaves, deodorant soaps, or scented oils. Keep in mind that natural products, such as essential oils, can also be irritants to some people. Alcohol-based products, such as certain after-shaves, can also irritate the skin.Cleanse the skin gently
When choosing a soap for washing the face or other affected areas, look for a gentle cleanser that cleans but does not strip your skin of moisture. Do not use deodorant soap or typical shower soap, as these will tend to over-dry and irritate your skin. Do not scrub vigorously with rough scrub pads or abrasives-- this will irritate the skin and might make the problem worse. Try to gently wash once in the morning and once in the evening, and as necessary after vigorous exercise or very dirty tasks.Use a non-comedogenic moisturizer
Many OTC acne medications will tend to dry the skin, as will alcohol-based facial products. While clearing excess oil from the face can be a good thing when trying to prevent acne, if skin becomes to be too dried out it will tend to produce even more oil to compensate, potentially causing additional breakouts. The use of a quality, non-comedogenic (non-pore-clogging) moisturizer in combination with gentle cleansing and acne medications can help the skin stay balanced and healthy. Look for moisturizers that are specifically labeled as "non-comedogenic" and fragrance free, so they cause as little irritation and clogging as possible.Use proper shaving technique
Because shaving can irritate the skin, it is best to use proper shaving technique to keep all kinds of facial breakouts, including ingrown hairs, shave bumps, and acne, to a minimum. The Shaving page provides detailed information about proper shaving technique, as well as notes on shaving and sensitive skin.Be consistent with your skin care regimen
Once you have begun a regimen of gentle cleansing, an OTC or prescription acne treatment, moisturizing, and proper shaving technique, stick with it and be consistent. It can take several weeks for positive effects to show, and once old breakouts are cleared you will still need to be vigilant in order to prevent future breakouts. Washing your face only occasionally or using a product once or twice a week will probably not help with persistent acne.Modification of your Testosterone dose, dosing schedule, or T delivery method
There is much anecdotal evidence of improvement in acne symptoms from trans men who have modified their T dose, their dosing schedule, or the type of T they are using. For example, some trans men note a reduction in acne by switching from a 200mg/2-weeks schedule to a 100mg/week schedule. Others report results from slightly reducing their T dose (for example, from 100mg/week to 90mg/week). Finally, still others report results from switching from T suspended in cottonseed oil to T suspended in sesame oil (or vice-versa), or from injectable T to a daily T cream or gel. Each individual's results may vary.You may wish to work with your doctor to try adjusting your dose, schedule, or T delivery method to help reduce acne. You should monitor blood levels and your physical progress while trying such an experiment. For many, a slight reduction in dosage may keep T blood levels squarely within a male range while dramatically reducing acne. Remember that T doses are not "one size fits all," and that your optimum dose may be 70 or 80mg/week rather than 100mg/week-- the "standard doses" given to most trans men can be finely tuned for each individual. (More on testosterone types, dosing, and delivery.)
Drink more water
While diet appears to have little effect on acne breakouts, many guys report that increasing their water intake seems to help their skin stay healthy. While this is not a proven medical fact, it can't hurt to give it a try.
Over-The-Counter (OTC) Acne Treatment
Benzoyl peroxide, salicylic acid, resorcinol, and sulfur are the most common OTC medicines used to treat acne. These products are all applied topically to the skin in the affected areas, and are available in many forms, including gel, lotion, cream, soap, or medicated pads. Tea tree oil is a natural product that also has been shown to be effective in treating acne.
Benzoyl Peroxide
Benzoyl peroxide is an effective antibacterial agent that kills the P. acnes bacteria. It also tends to dry the skin, an effect which is best balanced with the use of a non-comedogenic (non-pore-clogging) moisturizer. (www.acne.org provides advice on a benzoyl peroxide/moisturizing regimen.) Keep in mind that benzoyl peroxide can bleach hair and clothing.Salicylic Acid
Salicylic acid encourages the sloughing of skin cells, thus helping prevent blockage of the follicles. Salicylic acid also helps break down existing blackheads and whiteheads.Resorcinol
Resorcinol helps breakdown hard, rough skin; as such is it good at breaking down existing blackheads and whiteheads. It is usually used in combination with sulfur (see below).Sulfur
Sulfur causes peeling and drying of the skin. It is effective at breaking down existing blackheads and whiteheads.Tea Tree Oil
Tea tree oil is a natural plant product known for its beneficial effects as a deep cleansing, antibacterial, and antifungal agent. Tea tree oil solutions can help clear up acne blemishes and prevent further outbreaks in a manner similar to benzoyl peroxide solution, though it may take longer to produce results. An advantage of tea tree oil is that it does not usually produce the same drying and irritation of the skin that the other products listed above sometimes cause.
Be sure to read the active ingredients list on the products you are considering. Because each of these products is potentially irritating to the skin, it is wise to use them only as directed, and to use caution if combining more than one product. For example, if you are regularly using a regimen of benzoyl peroxide to treat your acne, you may not want to add salicylic acid, as the potential irritation may outweigh any added benefit.
Keep in mind that it might take up to 8 weeks of regular use for an acne regimen to really begin to show dramatic results. If, after this time, the OTC products you are using have not produced signs of improvement, you might wish to see a dermatologist. He or she may recommend a different regimen or combine prescription and OTC products in a manner that may show better results.
Prescription Acne Treatment: Topical and Oral
Patients with moderate to severe acne, or whose acne does not respond to OTC treatments, may be treated by a dermatologist with prescription topical and/or oral medicines. Treatments commonly prescribed by doctors for acne are listed below.
Prescription Topical Medicines
Like OTC topical medicines, prescription topical medicines can be prescribed as creams, lotions, solutions, or gels, depending on the patient's needs. With certain prescription products, the skin may look worse before improving, and treatment may take 4 to 8 weeks before producing signs of improvement. Side effects should be carefully discussed with your doctor.
Azelaic acid
Azelaic acid is a naturally occurring acid that helps the skin to renew itself more quickly. It prevents the buildup of cells that can plug pores, reduces inflammation, and also helps to kill the P. Acnes bacteria.Topical Retinoids
Retinoids are vitamin A derivatives that have been shown to help treat acne by unplugging clogged pores and preventing dead cells from clogging pores. Topical retinoids are often used along with oral antibiotics or benzoyl peroxide. A potential side-effect is that they can cause drying, redness, and irritation. Examples of topical retinoids are Tretinoin (Retin-A, Renova, Vitamin A Acid, Retin-A Micro), Adapalene (Differin), and Tazarotene (Tazorac). Tretinoin has also been shown to increase the speed at which surface skin cells are replaced; thus, it is also prescribed to treat sun-damaged skin or wrinkles.Topical antibiotics
Topical antibiotics are substances that are effective against bacteria, including P. acnes. They are often used in combination with other drugs, such as retinoids, where retinoids would be used to clear the pores of excess cells so that the antibiotics have an easier path to the bacteria in an affected follicle. Erythromycin is a commonly prescribed topical antibiotic that is effective against P. acnes and has anti-inflammatory qualities. Clindamycin is also prescribed to treat acne.Sodium Sulfacetamide
Sodium sulfacetamide is a "sulfonamide" that is used for its antibacterial activity. It curbs the growth of the P. Acnes bacteria.
Prescription Oral Medicines
For moderate or severe acne, a dermatologist might try oral medication (pills), or oral medication in combination with topical treatment. Currently, there are two main forms of oral treatment for acne: antibiotics and the retinoid isotretinoin (drug name "Accutane")
Oral antibiotics help control acne by curbing the growth of bacteria and reducing inflammation. Common oral antibiotics used to treat acne are erythromycin, tetracycline, minocycline, and doxycycline. There are a number of side effects related to these medications, and these should be discussed with your doctor.
Isotretinoin- "Accutane"
Isotretinoin is a retinoid (a derivative of vitamin A) that is prescribed in pill form, usually for 15-20 weeks. Because of its potential for serious side effects, it is considered a last resort in acne treatment, used when all other approaches have failed. Isotretinoin works by shrinking the oil glands, thus greatly reducing the amount of oil produced.Isotretinoin is a very effective medicine that can help prevent scarring. However, there is a risk of serious side effects which should be thoroughly discussed with your doctor before considering Accutane.
There are a number of helpful web sites in the resources section that provide specific advice and information about acne products and treatment regimens.
Ingrown Hairs, Razor Bumps, and Razor Burn
It is important to note that blemishes and skin breakouts other than (and in addition to) acne are often brought on by the onset of testosterone therapy. As mentioned in the introduction, increased hair growth on the face and the body can lead to irritated follicles and ingrown hairs. Shaving can also lead to ingrown hairs as well as razor bumps and razor burn. These problems are often mistaken for acne, but must be treated differently.
Ingrown hairs and razor bumps are medically known as "pseudofolliculitis barbae." Razor bumps result from a hair growing out of the skin, curling around and then growing back in. Ingrown hairs form when hair fails to grow out of the follicle. Either way, the hair lodged in the skin causes inflammation, followed by pus formation. Psuedofolliculitis barbae appear as tender, red, raised bumps. For this reason, they are sometimes mistaken for acne. If you are unable to tell if you are experiencing acne or pseudofolliculitis barbae, ask your doctor or dermatologist for help in diagnosing your problem. Pseudofolliculitis barbae can be prevented by proper shaving technique-- see the Shaving page for details, as well as for advice on shaving sensitive skin. Since acne is often worsened by irritation, it pays to shave your face as gently as possible.
Razor burn is a temporary irritation, redness or swelling of the skin. If you dry shave, shave without adequate cream or gel, or shave too hard or too fast, your skin will likely show some irritation. If you're suffering from razor burn, look for a soothing, non-comedogenic after-shave balm. Avoid alcohol-based aftershaves. You may also want to avoid shaving for a few days in order to let the skin heal itself. Razor burn should go away in a few days, and it is easily prevented through the methods outlined on the Shaving page.
Again, if you do not see improvement in acne, ingrown hair, shave bumps or other symptoms after these basic methods have been attempted, see a dermatologist in order to properly diagnose and treat your specific condition.