Thread by @TravisABenson

Recently, I had the opportunity to help create some LGBTQ curriculum for the @harvardmed derm program with @EricaDommasch and @DrKlintPeebles. Since I've been getting some questions about the topic, I figured I'd make a tweetorial 🧵

#MedTwitter #MedStudentTwitter #DermTwitter

This will focus on the derm issues that the transgender community may face. Some disclaimers to start with: just as gender identity exists on a spectrum, these manifestations may present in a variety of gender identities and should be considered as such. 2/

Additionally, for the ease of organization, they are presented in “transmasculine” and “transfeminine” categories, but these conditions are not necessarily exclusive to any one gender identity. So let's begin with derm conditions affecting transmasculine persons... 3/

1. Acne vulgaris.
One study showed that 94% of transmasculine adults had facial acne and 88% had back acne vs 29% and 17% pre-testosterone, respectively. The severity is thought to peak in the first 6 months of testosterone therapy and may improve over 1 to 2 years. 4/

2. Pseudofolliculitis barbae.
This is a chronic inflammatory disorder that primarily affects individuals with curled hair, especially following onset of T. Post-inflammatory hyperpigmentation or keloids can develop. Proper shaving techniques and topical depilatories may help. 5/

3. Androgenetic alopecia.
This is characterized by hair loss in temporal scalp, midfrontal scalp, and vertex area. Often begins a few years after initiation of testosterone and can often be a desired marker of affirmation. 6/

One study showed hair loss in 62% of transmasculine patients on long-term testosterone. While it should not be assumed that an individual desires treatment, topical minoxidil or finasteride can be used. However, finasteride may interfere with gender-affirmation. 7/

Patients may want to delay finasteride until all desired gender-affirming changes secondary to hormone therapy are complete, typically 2 years after onset of testosterone therapy. Additionally, finasteride may cause breast tissue enlargement in patients pre-mastectomy. 8/

4. Chest binding skin changes
Binding is the compression of breast tissue in order to create a flatter appearance of the chest. One study showed that 87% of transmasculine individuals had engaged in chest binding. 9/

A study found that an average of 10 hours a day, 7 days a week is spent binding. The median duration was for 2 years. 87.2% reported using a professional binder while 16.5% used elastic bandage and 4.3% used duct tape or plastic wrap. 76.3% reported a derm complication. 10/

Some derm complications of binding include ptosis, pruritus, acne, miliaria, fungal infection, dermatitis, and scarring. Additionally, these issues can delay and complicate future mastectomy. Proper binding technique should be shared with patients. 11/ point5cc.com/binding-101-ti…

Professional binding garments should be used, correctly sized, removed while sleeping, and limited to 8-12 hours a day. If cost is a barrier, @pointofpride, @ftmessentials, and @Point5cc have binder donation programs. 12/

5. Phalloplasty concerns.
In a paper I wrote that is forthcoming, we found that 56% of transmasculine phalloplasty consults at our clinic had forearm tattoos. 54% of those patients chose an alternative flap site associated with greater morbidity. 13/

There are anecdotes of pre-operative laser tattoo removal with Nd:YAG, but no studies demonstrating safety of flap site tissue. It's unclear if post-operative laser tattoo removal would be safe or effective due to limited lymphatics in flap. 14/

Additionally, there is potential for increased risk of skin cancer on the neophallus when taken from radial forearm sites with higher incidence of actinic damage. Medical neophallus micropigmentation can increase patient satisfaction, although not covered by insurance. 15/