General Health

Transgender Skincare Guidelines for Dermatologists

MedPiper Technologies and JournoMed had conducted a Webinar Series to “Improve Healthcare Access for Transgender and Sexual Minorities For The Doctors and By The Doctors” with IRIA Kerala- RakshaShakthi, Social Wings, IMA Kerala and CARB where the discussion is about the topics addressing Transgender Skin Care and the event was held on 23rd July 2022.

Dr Pranaya Bagde, a leading hair transplant surgeon and a dermatologist gave deep insight into the topics of transgender skincare and hair-related issues. She is the founder of Insight Derma Clinic in Kochi, Kerala and Vice President for Pride in Practice Society. 

Skincare is the most sought medical care among trans people as the skin is the essential organ of expression and visibility. W Path (World) Professional Association for Transgender Health) and IPath (Indian Professional Association for Transgender Health) have set certain Guidelines for Skin Health in Transgender. 

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Basic Practice Principles in LGBTQ+ Healthcare

The principles a practitioner must follow include:

  • Communication: Communication creates a rapport with the trans person. One needs to ask how to address them (eg: he/she/they) which is the basic part of communication.
  • Family addressing: When dealing with venereological issues, the history of the partner is very important.
  • Mental Health: Mental Health Perspective is crucial. When trans people approach a dermatologist, one needs to identify the stressors and provide them with supportive care. Respect their beliefs and grief, avoid discrimination and always be a patient listener. 
  • Disease Management: Always identify the causative factors, triggers and health risks. Involve trans people in decision-making for any treatment options that they choose. 
  • Understand the legal rights, spirituality and religious faith of the patient.

These are the basic things that any practitioner should follow while they are dealing with any LGBTQ+ person. 

General Dermatological issues in Transgender people

The general dermatological issues that the transgender faces vary depending on the identity (transmen or transwomen). The skin issues in transmen and transwomen are mainly related to 

  • Hormone replacement therapy 
  • Gender affirming procedures
  • Gender transitioning interventions (In cosmetology)

The common skin conditions observed among the transgender population are:

Acne Vulgaris: 

Acne again has a multi-factorial origin. Usually, acne starts developing at puberty because of the hormonal surge. Acne happens in cisgenders due to this reason. It may happen again in transgenders because of hormonal therapy eg: when a transman is on testosterone therapy. Based on acne severity, antibiotics, oral retinoids, topical medication, cosmetic peel treatment and certain cosmetic treatments are suggested. 

Hyperpigmentation:

Hyperpigmentation is a very common condition that general dermatologists observe. Hyperpigmentation on the face and structural areas are quite common among the trans population. Sun protection is mandatory to reduce hyperpigmentation. For cosmetic concerns, pigmentation treatment removal can be done. Chemical peeling or laser treatment can be considered as adjuvant treatments. 

Unwanted hair growth and hair loss: 

In the trans population, when they are in the transition phase, both things can happen. There can be unwanted hair growth and unwanted hair loss. Transwomen continue to develop unwanted facial growth (Hypertrichosis/ Hirsuitism) even though they are on estrogen and antiandrogen therapy. Transmen develop androgenetic alopecia (patterned baldness) due to increased androgen receptor activity when on testosterone therapy.

Dry skin (Ichthyosis) or oily skin (Seborrhoea): 

There are different skin textures i.e. dry skin, oily skin, normal skin, combination skin and sensitive skin. The skin texture differs particularly among the transgender population when they are subjected to hormonal therapy. There is a sudden change in the sebaceous glandular secretions of the skin and above all, there is a change in the receptor activity. The skin texture either becomes oily or extremely dry. The occurence for dry skin is equal in the trans and cis populations. Due to hormone replacement therapy, transmen and transwomen can have oily skin on the face and trunk. 

Seborrheic Dermatitis 

Seborrheic Dermatitis is prevalent among the trans population. Seborrhea means increased sebum secretion on the skin. Sebum secretion is under the influence of hormones and any change in the hormone can alter sebum secretion. This is quite common in both transmen and transwomen especially those on hormone replacement therapy. There are different forms of seborrheic dermatitis such as Dandruff (scalp seborrhea). It is present on the scalp and creates scalp itching, scaling, greasy, powdery flakes and hair fall. 

Cosmetology or aesthetic needs during transition and otherwise 

A very common sort of treatment is cosmetology, because the skin is a visible organ and how good one looks matters a lot. Even in a trans population, their appearance is their treasure. They want to look as they desire. It is very critical for a dermatologist to understand their needs and realistic expectations. 

Unwanted Facial and Body hair removal

The maximum number of trans population visit a dermatologist basically for hair removal on certain body areas. It can be either facial hair or body hair removal. Transwomen approach facial hair removal and body hair removal. Sometimes transmen visit for hair growth on certain body parts. In certain body areas, they go for smoothening. 

Laser hair reduction

Laser hair reduction, the best option available, is done by using a diode/long pulse Nd Yag Laser. It targets the melanin in the hair follicle. It reduces hair growth. The diode laser targets the hair follicle papilla, the melanin pigment there. It destroys the hair follicle and slowly the terminal hair formation is reduced and it becomes velous hair. Transwomen who are on estrogen treatment, suppress their androgen too. So, the beard and the moustache area are difficult to treat, even the sub-mandibular area. Trans people become resistant to laser sessions. 

Electrolysis

Electrolysis is performed for facial hair removal. In this method, there is a destruction of the individual hair follicle by using an electrode. It is a little painful procedure and is suggested for permanent hair removal. Post-procedure folliculitis is very common. Painkillers and a lot of antibiotics are needed. The whole body hair removal is desired by the trans community. 

Hyperpigmentation/Tatoo removal 

Options are available for treating hyperpigmentation. The conditions include melasma, pigmentation on the face, post-acne pigmentation, post-inflammatory hyperpigmentation, dark circles, freckles, lesions, to obtain the facial glow, tan removal and tattoo removal. 

For tattoo removal, only a laser option is available i.e. Q switch NdYag Laser. But for the other pigmentation along with the oral and the topical creams, there are options of chemical peeling (a very safe and effective treatment) and micro-dermabrasion. 

Chemical peeling is the control of wounds that are created in the desired areas giving a certain change to the skin. A variety of chemical peeling procedures are available such as salicylic acid, mandelic acid, glycolic acid, azelaic acid, alpha peel, beta peels, resorcinol and gesnoskin. For any peel treatment, sun protection is mandatory and one needs to take care of the skin properly. Parlour procedures need to be avoided. 

Microdermabrasion is dermabrasion performed with the help of a machine. It causes small abrasions on the skin surface by which the pigmentation is removed. It is also performed in sessions. Once the procedure is started, one needs to wait for a minimum of three months. If one needs to perform the procedure very fast, abruptly or instantly, it is impossible and it might lead to permanent skin damage and burns which are again alarming conditions. 

The next buzz thing in cosmetology is a Skin whitening treatment. Trans community people always approach a skin dermatologist for it. Trans community people face a lot of psychological distress. Sometimes, it is out of proportion with what is present. So that has to be identified first in whitening treatment.  

Scar removal/ Scar remodelling

The next immediate concern of cosmetology is scar removal/ remodelling. Here the scar could be any scar that is present on the body such as an acne scar, surgical scar, accidental scar or another scar. Surgical scars are more prevalent among transmen post-mastectomy. So they visit the dermatologist for scar removal. After mastectomy is done, there could be a keloid formation or scar formation.

Micropigmentation 

It is a cosmetic procedure done on the scalp. It is a sort of treatment for both transmen and transwomen who have hair loss issues and scalp hair thinning. 

Microblading 

Microblading is common among cisgender females. Transwomen approach shaping their eyebrows and increasing the hair density on their eyebrows. Here, the pigment is injected in the blading form. There are special blades for microblading. Micro pigments are bladed on eyebrows with iron oxide pigment introduced at the dermal level by using special instruments. This is also a sort of treatment for transwomen to have beautiful contouring and eyebrow shaping. 

Face/ Body shaping and contouring 

Both transmen and transwomen want to have particular facial characteristics and body contouring as desired. For the face, botulinum toxin injections, hyaluronic acid fillers, threads and even fat transfers are used to enhance the facial features of the desired gender. One can remove the undereye bags, improve the smile, improve the perinasal area, change the shape and contour of the face. Fillers and botox are also injected in certain body areas. 

Hair transplant surgery

The very common hair transplant is sorted by transmen. A lot of transmen approach beard and moustache hair transplants during the transition phase (Female to male). 

Transwomen seek scalp hair transplants during the transition phase (Male to female). If the transwomen have already got a hairline recession or patterned baldness (Androgenetic alopecia) due to genetic predisposition of patterned baldness, they tend to have patterned baldness. Administration of antiandrogen medication is suggested for transwomen. Oral Finasteride works better as an antiandrogen drug here. 

Platelet-rich plasma therapy/ Mesotherapy

In platelet-rich plasma therapy, the platelet-derived growth factors play a crucial role in hair growth. In Mesotherapy, there are synthetic growth factors, vitamins and herbs that are injected into the scalp that promotes hair growth. Both transmen and transwomen seek platelet-rich plasma (PRP) therapy/ mesotherapy for 

  • Hair fall/ hair thinning issues
  • Early baldness
  • Facial rejuvenation and glow

Liposuction/ Lipofilling 

In some areas, the fat needs to be removed and in some areas, the fat needs to be deposited. This liposuction procedure is performed under general anaesthesia. Classic surgeons usually perform this procedure but currently dermatologists perform this procedure. Liposuction or lipofilling is performed among both transmen and transwomen. Body contouring and shaping are needed in both transmen and transwomen.

Conclusion 

Transgender community skin care is not only limited to skin disease treatment and aesthetic procedures but it also involves their psycho-emotional, sexual and social health too. Having an inclusive attitude in healthcare services for them is a need of the hour. More awareness and gender concept demystification is essential among caregivers to avoid transphobia. 

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