Testosterone Replacement Therapy (TRT) has become a widely utilized medical intervention for men experiencing hypogonadism, a condition characterized by clinically low testosterone levels and associated symptoms such as fatigue, decreased libido, and reduced muscle mass. While TRT offers significant benefits in restoring hormonal balance and improving overall quality of life, it is also associated with a range of potential side effects. Among these, acne is a frequently reported dermatological concern that can impact patient satisfaction and adherence to therapy. The relationship between testosterone, its metabolites, and skin physiology is complex, with hormonal fluctuations playing a pivotal role in the pathogenesis of acne. This evidence-based review aims to critically examine the scientific literature concerning TRT-induced acne, elucidating its underlying mechanisms, prevalence, and effective management strategies. By synthesizing current research, we seek to provide a comprehensive understanding for both patients and healthcare providers, facilitating informed decision-making and optimal patient care in the context of TRT.
What Is TRT and Hormonal Acne?
Testosterone Replacement Therapy (TRT) is a medical treatment administered to men with diagnosed hypogonadism to normalize testosterone levels. This therapy is crucial for alleviating symptoms like chronic fatigue, diminished sex drive, erectile dysfunction, and mood disturbances, thereby enhancing overall well-being. TRT can be delivered through various modalities, including injections, topical gels, patches, and subcutaneous pellets [1].
Hormonal Acne refers to acne that is primarily influenced by hormonal fluctuations, particularly androgens. It is characterized by breakouts, often cystic or nodular, typically occurring on the lower third of the face (jawline, chin, neck), chest, and back. While commonly associated with adolescence and women, hormonal acne can also affect adult men, especially when exogenous hormones like testosterone are introduced [2].
How It Works: The Androgenic Pathway to Acne
The development of acne during TRT is primarily mediated by the influence of androgens, specifically testosterone and its more potent derivative, dihydrotestosterone (DHT), on the sebaceous glands:
- Sebaceous Gland Stimulation: Testosterone and DHT are potent stimulators of the sebaceous glands, which are responsible for producing sebum, an oily substance that lubricates the skin and hair. Elevated androgen levels, as achieved during TRT, lead to an increase in sebum production, making the skin more oily [3].
- Follicular Hyperkeratinization: Excess sebum, combined with abnormal shedding of dead skin cells, can lead to the clogging of hair follicles (pores). This creates a microenvironment conducive to bacterial proliferation [4].
- Bacterial Proliferation: The clogged follicles become an anaerobic environment where Cutibacterium acnes (formerly Propionibacterium acnes), a bacterium naturally present on the skin, can thrive and multiply [5].
- Inflammatory Response: The presence of excess sebum, dead skin cells, and C. acnes triggers an inflammatory response within the follicle, leading to the formation of various acne lesions, including papules, pustules, nodules, and cysts [6].
- Hormonal Fluctuations and Peaks: While TRT aims to maintain stable testosterone levels, certain administration methods (e.g., less frequent, larger injections) can result in significant peaks in testosterone, which may lead to transient elevations in DHT and exacerbate sebaceous gland activity, contributing to acne flare-ups [7].
Key Benefits of an Evidence-Based Review
An evidence-based review of TRT and acne offers several critical benefits:
- Clarifies Misconceptions: It helps distinguish between anecdotal evidence and scientifically supported facts regarding TRT-induced acne, providing a clearer picture for patients and clinicians [8].
- Informs Treatment Decisions: By understanding the mechanisms and prevalence, healthcare providers can make more informed decisions about TRT protocols and adjunctive acne management strategies [9].
- Empowers Patients: Patients gain a better understanding of why acne might occur and what effective, evidence-based treatments are available, reducing anxiety and improving adherence [10].
- Optimizes Patient Outcomes: A thorough review supports the development of personalized treatment plans that balance the benefits of TRT with effective management of dermatological side effects [11].
- Highlights Research Gaps: It identifies areas where further research is needed to refine understanding and improve treatment protocols for TRT-induced acne [12].
Clinical Evidence
Clinical studies and reviews have consistently demonstrated a link between testosterone therapy and the development or exacerbation of acne:
- Thoreson et al. (2021): A significant study published in JAMA Dermatology investigated the incidence and factors associated with acne among transgender individuals receiving masculinizing hormone therapy (MHT), which involves testosterone. The study found that acne is a common and often persistent side effect, with an overall incidence of 70% at two years of follow-up. Younger patients and those with higher testosterone doses were more likely to develop acne. This research provides strong evidence for the direct relationship between exogenous testosterone and acne [13].
- Del Rosso et al. (2024): A comprehensive review in Skinmed discussed the cutaneous effects of androgens and their role in acne. It highlighted that androgens, including testosterone, directly stimulate sebaceous glands and contribute to inflammatory mechanisms within the skin, leading to acne. The review emphasized that even physiological increases in androgen levels, as seen with TRT, can trigger acne in susceptible individuals [14].
- Kim et al. (2025): A review in Sexual Medicine Reviews focused on dermatological adverse effects of testosterone replacement therapy. It noted that acne is one of the most common cutaneous side effects, often appearing within the first few weeks or months of treatment. The review also suggested that peaks and troughs in androgen exposure, which can occur with certain TRT administration methods, may exacerbate acne [15].
Dosing & Protocol Considerations
Managing acne while on TRT involves a strategic approach to both hormonal regulation and dermatological treatment:
-
Optimizing TRT Dosing and Administration:
- Stable Testosterone Levels: Evidence suggests that maintaining more stable testosterone levels, avoiding significant peaks and troughs, may reduce acne flare-ups. This can be achieved through more frequent, smaller injections (e.g., every 3.5 days) or by using transdermal gels that provide a consistent release [16].
- Monitoring and Adjusting: Regular monitoring of testosterone and estradiol levels is crucial. While estradiol doesn't directly cause acne, managing it within an optimal range can contribute to overall hormonal balance, which may indirectly benefit skin health [17].
-
Topical Acne Treatments: These are often the first line of defense for mild to moderate TRT-induced acne.
- Benzoyl Peroxide: An antimicrobial agent that reduces C. acnes bacteria and helps shed dead skin cells. Available over-the-counter in various concentrations [18].
- Salicylic Acid: A beta-hydroxy acid that exfoliates the skin and unclogs pores, preventing comedone formation [19].
- Topical Retinoids (e.g., Tretinoin, Adapalene): Prescription medications that normalize follicular keratinization, reduce inflammation, and prevent new lesions. They are highly effective but require consistent use and can cause initial irritation [20].
- Topical Antibiotics (e.g., Clindamycin): Used to reduce bacterial load and inflammation, often in combination with benzoyl peroxide to prevent antibiotic resistance [21].
-
Oral Acne Medications (for moderate to severe or persistent acne):
- Oral Antibiotics (e.g., Doxycycline, Minocycline): Prescribed for their anti-inflammatory properties and to reduce systemic bacterial load. Typically used for a limited duration to avoid resistance [22].
- Isotretinoin (Accutane): A highly effective oral retinoid reserved for severe, nodular, or cystic acne that is unresponsive to other treatments. It works by significantly reducing sebaceous gland size and sebum production. Due to potential side effects, it requires strict medical supervision and monitoring [23].
Side Effects & Safety of Acne Management on TRT
When managing TRT-induced acne, it is important to be aware of the potential side effects associated with the various treatments:
| Intervention | Common Side Effects | Safety Considerations |
|---|---|---|
| Topical Benzoyl Peroxide | Dryness, redness, peeling, irritation, bleaching of fabrics | Start with lower concentrations; use sunscreen as it can increase sun sensitivity [24]. |
| Topical Salicylic Acid | Mild irritation, dryness, peeling | Generally well-tolerated; use as directed [25]. |
| Topical Retinoids | Dryness, redness, peeling, sun sensitivity, initial worsening of acne (purging) | Use at night; start slowly; strict sun protection is essential; contraindicated in pregnancy [26]. |
| Topical Antibiotics | Dryness, irritation, potential for bacterial resistance if used alone | Often combined with benzoyl peroxide to minimize resistance [27]. |
| Oral Antibiotics | Gastrointestinal upset, sun sensitivity, yeast infections, dizziness | Short-term use preferred; take with food; strict sun protection [28]. |
| Isotretinoin | Severe dryness (skin, lips, eyes), sun sensitivity, muscle aches, elevated liver enzymes, elevated cholesterol/triglycerides, mood changes (rare) | Highly effective but requires strict monitoring (blood tests, pregnancy prevention program for women); contraindicated in pregnancy [29]. |
Open communication with your healthcare provider is essential to manage any side effects and adjust the protocol as needed.
Who Should Consider Acne Management on TRT?
Acne management strategies while on TRT are particularly relevant for men who:
- Develop New or Worsening Acne: Any individual experiencing acne after starting TRT, especially if it is moderate to severe or impacts their quality of life, should seek management [30].
- Have a History of Acne: Men with a personal history of moderate to severe acne, particularly hormonal or cystic acne, are more prone to TRT-induced breakouts and should discuss preventative strategies with their physician [31].
- Are Concerned About Skin Health: Even with mild acne, if it causes distress or affects self-esteem, management is warranted [32].
- Are on Higher Doses of TRT: Higher testosterone doses may lead to more pronounced sebaceous gland stimulation, increasing the likelihood and severity of acne [33].
Consultation with a healthcare professional, ideally a dermatologist or an endocrinologist experienced in TRT, is crucial for developing a personalized and effective management plan.
Frequently Asked Questions
Q1: Is TRT-induced acne permanent? A1: No, TRT-induced acne is generally not permanent and is treatable. With appropriate management, including topical and oral medications, most individuals can achieve clear skin while continuing TRT. The acne typically resolves if TRT is discontinued, though this is usually not necessary [30].
Q2: How quickly does acne appear after starting TRT? A2: Acne can appear anywhere from a few weeks to several months after initiating TRT. It often correlates with the body adjusting to new hormone levels and increased sebaceous activity. For some, it may be an initial flare that subsides, while for others, it may persist [15].
Q3: Can diet influence TRT-induced acne? A3: While the direct link between diet and acne is complex and varies individually, some studies suggest that high glycemic index foods and dairy products might exacerbate acne in susceptible individuals. Maintaining a balanced diet rich in fruits, vegetables, and lean proteins, along with adequate hydration, can support overall skin health [34].
Q4: What is the role of a dermatologist in managing TRT-induced acne? A4: A dermatologist plays a crucial role in diagnosing the type and severity of acne and prescribing appropriate topical and oral treatments. They can also provide guidance on skincare routines and monitor for side effects of acne medications, working in conjunction with the prescribing physician [31].
Q5: Are there any preventative measures I can take before starting TRT to avoid acne? A5: If you have a history of acne, discussing this with your doctor before starting TRT is important. They might recommend starting with a lower TRT dose, using a more stable administration method, and initiating a proactive skincare regimen with products like benzoyl peroxide or salicylic acid to minimize the risk of breakouts [16, 18, 19].
Conclusion
TRT-induced acne is a common dermatological side effect that arises from the androgenic stimulation of sebaceous glands. While the benefits of Testosterone Replacement Therapy for hypogonadism are substantial, an evidence-based approach to managing acne is essential for optimizing patient outcomes and satisfaction. Clinical research consistently demonstrates the link between elevated testosterone levels and increased sebum production, leading to acne in susceptible individuals. Fortunately, a wide array of effective management strategies, ranging from optimized TRT dosing protocols to targeted topical and oral dermatological treatments, are available. By fostering a collaborative relationship between patients, endocrinologists, and dermatologists, personalized treatment plans can be developed to effectively control acne, ensuring that men can confidently pursue hormonal balance without compromising their skin health. This comprehensive approach underscores the importance of addressing all aspects of patient well-being during TRT.
Medical Disclaimer
This article is intended for informational purposes only and does not constitute medical advice. The content is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article. Reliance on any information provided in this article is solely at your own risk. Specific medical conditions and treatments should be discussed with a healthcare professional. Individual results may vary.
References
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[2] American Academy of Dermatology Association. (n.d.). Acne: Overview. https://www.aad.org/public/diseases/acne/basics/what
[3] Hims. (2025, September 25). Understanding the Testosterone-Acne Connection. https://www.hims.com/guides/testosterone-acne
[4] Healthline. (2023, March 1). How Long Does Testosterone-Related Acne Last? Plus, Treatments. https://www.healthline.com/health/how-long-does-testosterone-acne-last
[5] American Academy of Dermatology Association. (n.d.). Acne: Signs and symptoms. https://www.aad.org/public/diseases/acne/basics/symptoms
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[7] Kim, J., et al. (2025, November 3). Dermatological adverse effects of testosterone replacement therapy. Sexual Medicine Reviews. https://academic.oup.com/smr/article/14/1/qeaf061/8313420
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[11] Dermatology Advisor. (2023, March 27). Acne Common Among Transgender Adolescents on Hormone Therapy. https://www.dermatologyadvisor.com/reports/transgender-adolescent-hormone-therapy-acne/
[12] Healthline. (2023, March 1). How Long Does Testosterone-Related Acne Last? Plus, Treatments. https://www.healthline.com/health/how-long-does-testosterone-acne-last
[13] Thoreson, N., et al. (2021). Incidence and Factors Associated With Acne Among Transgender Individuals Receiving Masculinizing Hormone Therapy. JAMA Dermatology, 157(3), 303-310. https://pmc.ncbi.nlm.nih.gov/articles/PMC7970334/
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[15] Kim, J., et al. (2025, November 3). Dermatological adverse effects of testosterone replacement therapy. Sexual Medicine Reviews. https://academic.oup.com/smr/article/14/1/qeaf061/8313420
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[19] American Academy of Dermatology Association. (n.d.). Salicylic acid: How to use. https://www.aad.org/public/diseases/acne/treat/salicylic-acid
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[22] American Academy of Dermatology Association. (n.d.). Oral antibiotics: How to use. https://www.aad.org/public/diseases/acne/treat/oral-antibiotics
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[29] American Academy of Dermatology Association. (n.d.). Isotretinoin: Who gets it and what to expect. https://www.aad.org/public/diseases/acne/treat/isotretinoin
[30] GameDay Men's Health. (2025, June 18). Managing Acne on TRT: Clearer Skin Without Stopping Treatment. https://gamedaymenshealth.com/blog/managing-acne-on-trt
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[32] TRT Nation. (2025, December 3). Why Your TRT Is Causing Acne (And How to Fix It Without Quitting Testosterone). https://trtnation.com/why-your-trt-is-causing-acne-and-how-to-fix-it-without-quitting-testosterone/
[33] Hims. (2025, September 25). Understanding the Testosterone-Acne Connection. https://www.hims.com/guides/testosterone-acne
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