Medications to Manage Acne on Testosterone Cypionate: First-Line and Beyond
At a glance
- Acne on the cypionate label / Listed under skin and appendages [1]
- Label acne rate / Not given [1]
- Label acne treatment advice / None named [1]
- Label dose / 50 to 400 mg intramuscularly every 2 to 4 weeks [1]
- How the dose is adjusted / By response and adverse reactions [1]
- Topical retinoids / A first-line treatment for acne vulgaris in a 2019 systematic review of 54 trials [5]
- Severe scarring acne in a man on intramuscular testosterone / Described as a case scenario in a 2021 editorial on isotretinoin [2]
What does the testosterone cypionate label say about acne?
The Depo-Testosterone label lists acne in its adverse reactions under 'Skin and appendages', together with seborrhea, hirsutism and male pattern baldness [1]. It gives no acne rate, no time course and no treatment advice, and it does not name, rank or recommend benzoyl peroxide, a retinoid, an oral antibiotic, isotretinoin or any other acne treatment [1].What do general acne reviews say about medications?
These reviews were not run in men treated with testosterone cypionate. An American Family Physician review of acne vulgaris states that topical retinoids are indicated for acne of any severity and for maintenance therapy, that systemic and topical antibiotics should be used only in combination with benzoyl peroxide and retinoids and for a maximum of 12 weeks, and that isotretinoin is used for severe, recalcitrant acne and requires registration in the iPLEDGE program [4].A systematic review of 54 trials of topical retinoids calls them a first-line treatment for acne vulgaris. A topical retinoid combined with benzoyl peroxide improved Investigator Global Assessment in 26.1% to 34.9% of patients versus 7% to 11.8% with vehicle at week 12 [5]. For testosterone-associated acne specifically, a practical guide for clinicians treating transmasculine patients reviews isotretinoin's indications, contraindications and iPLEDGE barriers for severe or refractory cases [6].
What does the label say about dose and dose changes?
The labeled dose is 50 to 400 mg every 2 to 4 weeks, given deep in the gluteal muscle and never intravenously [1]. The label says dosage is adjusted according to the patient's response and the appearance of adverse reactions [1]. It does not attach acne to a particular dose, a testosterone blood level, or an injection interval, and it does not say that splitting a dose reduces acne [1].The pharmacokinetic reason the label gives for the 2 to 4 week interval is slow absorption of the oil-based ester from the injection site; the half-life after intramuscular injection is about eight days [1].
What is known about testosterone-related acne in general?
A review of testosterone therapy for transgender men lists acne among the undesired effects and risks of treatment, alongside alopecia, reduced HDL cholesterol, increased triglycerides and a possible rise in systolic blood pressure [3]. The same review notes a paucity of randomized trials, few prospective and long-term studies, and difficulties with recruitment in this area [3].What about severe or scarring acne?
A 2021 editorial on prescribing isotretinoin for transgender patients opens with a case scenario: a 26-year-old transgender man on weekly intramuscular testosterone injections for four years who presents with severe nodulocystic scarring acne [2].Frequently asked questions
Does the testosterone cypionate label recommend benzoyl peroxide or a retinoid?
No. It lists acne as a skin reaction but names no acne medicine and gives no treatment sequence [1]. General acne reviews describe topical retinoids as a first-line treatment, alone or with benzoyl peroxide [4][5].
How often does testosterone cypionate cause acne?
The Depo-Testosterone label gives no rate for acne; it appears in the adverse reactions list without a frequency [1].
Is acne tied to a particular dose or injection schedule on the label?
The label gives 50 to 400 mg every 2 to 4 weeks and says the dose is adjusted by response and adverse reactions, with no acne-specific rule [1].
Is acne a contraindication to testosterone cypionate?
No. Acne appears in the adverse reactions list; the contraindications are hypersensitivity, breast carcinoma, known or suspected prostate carcinoma, pregnancy, and serious cardiac, hepatic or renal disease [1].
What is known about treating severe acne in men on testosterone injections?
A 2021 editorial on isotretinoin for transgender patients opens with a case scenario of a man on weekly intramuscular testosterone with severe nodulocystic scarring acne [2]. A practical guide for transmasculine patients on testosterone reviews isotretinoin's indications, contraindications and iPLEDGE barriers [6].
References
- U.S. National Library of Medicine, DailyMed. Depo-Testosterone (cypionate) intramuscular, Pharmacia & Upjohn/Pfizer (testosterone cypionate) prescribing information. Depo-Testosterone (cypionate) intramuscular, Pharmacia & Upjohn/Pfizer (testosterone cypionate) label
- Sanchez DP, Brownstone N, Thibodeaux Q, Reddy V, Myers B, Chan S, et al. Prescribing Isotretinoin for Transgender Patients: A Call to Action and Recommendations. J Drugs Dermatol. 2021;20(1):106-108. Prescribing Isotretinoin for Transgender Patients: A Call to Action and Recommendations
- Irwig MS. Testosterone therapy for transgender men. Lancet Diabetes Endocrinol. 2017;5(4):301-311. Testosterone therapy for transgender men
- Oge' LK, Broussard A, Marshall MD. Acne Vulgaris: Diagnosis and Treatment. Am Fam Physician. 2019;100(8):475-484. Acne Vulgaris: Diagnosis and Treatment
- Kolli SS, Pecone D, Pona A, Cline A, Feldman SR. Topical Retinoids in Acne Vulgaris: A Systematic Review. Am J Clin Dermatol. 2019;20(3):345-365. Topical Retinoids in Acne Vulgaris: A Systematic Review
- Radi R, Gold S, Acosta JP, Barron J, Yeung H. Treating Acne in Transgender Persons Receiving Testosterone: A Practical Guide. Am J Clin Dermatol. 2022;23(2):219-229. Treating Acne in Transgender Persons Receiving Testosterone: A Practical Guide