HIRSUTISM
Hair removal and pharmacologic treatment
Treatment for hirsutism is unnecessary if no abnormal etiology can be diagnosed, and
the patient does not find the hirsutism cosmetically objectionable. Treatment should be
offered, however, if an underlying disorder is identified or if the patient is troubled by the
hair growth. Management depends on the underlying cause. For example, nonandrogen-dependent excess hair, such as hypertrichosis, is treated primarily with
physical hair removal and medical antiandrogen therapy. (Before attempting electrolysis
or laser epilation, androgen excess should be ruled out because hair will grow back after
treatment.
As an alternative to hair removal, simple bleaching of hair is an inexpensive method that
works well when hirsutism is not too excessive. Bleaches lighten the color of the hair so
that it is less noticeable. Several types of commercial hair bleaching products are
available. All contain hydrogen peroxide as their active ingredient. These products are
generally safe if used as directed.
HAIR REMOVAL
DEPILATION
Depilatories remove hair from the surface of the skin. Depilatory methods include
ordinary shaving and the use of chemicals.
Shaving removes all hairs, but is immediately followed by growth of hairs that were
previously anagen, which produce rough stubble as they grow in. There is no evidence
that shaving increases the growth or coarseness of subsequent hair growth. Most
women however, prefer not to shave their facial hair.
Chemical depilation may be best suited for treatment of large hairy areas in patients
who are unable to afford more expensive treatments, such as electrolysis and laser
epilation. Chemical depilatories separate the hair from its follicle by reducing the sulfide
bonds that are found in abundance in hairs. Irritant reactions and folliculitis may result.
TEMPORARY EPILATION
Epilation involves the removal of the intact hair with its root.
Plucking or tweezing is widely performed. This method may result in irritation, damage
to the hair follicle, folliculitis, hyperpigmentation, and scarring.
Waxing entails the melting of waxes that are applied to the skin. When the wax cools
and sets, it is abruptly peeled off the skin, removing the embedded hair with it. This
method is painful and sometimes results in folliculitis. Repetitive waxing may produce
miniaturization of hairs, and, over the long run, it may permanenetly reduce the number
of hairs.
Certain natural sugars, long used in parts of the Middle East, are becoming popular in
place of waxes. They appear to epilate as effectively as, but less traumatically than,
waxing.
Threading, a method used in some Arab countries, is a technique in which cotton
threads are used to pull out hairs by their roots. Home epilating devices that remove hair
by a rotary or frictional method are available. Both of these methods may produce
traumatic folliculitis.
Radiation therapy was a popular method of hair removal in the past. However, it has
Fallen out of favor and is no longer acceptable.
PERMANENT EPILATION
Techniques of permanent expiation include electrolysis, thermolysis, and laser epilation.
Electrolysis and thermolysis: Hair destruction by electolysis, thermolysis, or a
combination of both is performed with a fine, flexible electrical wire that produces an
electrical current after being introduced down the hair shaft. Thermolysis (diathermy)
employs a high frequency alternating current and is much faster than the traditional
electrolysis method, which uses a direct galvanic current. Electrolysis and thermolysis
are slow processes that can be used on all skin and hair colors but multiple treatments
are required. There are no good controlled studies evaluating electrolysis and
thermolysis, and there is a great variation in the skill of operators. Also, there is little
state-to-state standardization of licensing requirements for practitioners. Electrolysis and
thermolysis can be uncomfortable and may produce folliculitis, pseudofolliculitis, and
postinflammatory pigmentary changes in the skin.
Laser epilation: Lasers can treat larger areas and are able to do it faster than
elecrolysis and thermolysis. They have skin-cooling mechanisms that minimize
epidermal destruction during the procedure. Skin and hair color often determine if a laser
should be used.
Lasers work most effectively on dark hairs on fair-skinned people. In such patients,
lighter skin does not compete with darker hairs for the laser, which selectively targets the
pigment melanin.
In dark-skinned people, a newer approach that delivers more energy to the hairs over a
longer period may prove safe and effective.
As with electrolysis and thermolysis, multiple treatments are necessary for long-term hair
destruction. Folliculitis, pseudofolliculitis, discomfort, and pigmentary changes may result
from laser therapy. It remains to be proved whether lasers are more effective in
permanent hair removal than the more traditional methods. They are certainly more
costly.
NONLASER TREATMENT
Flash lamps, which use an intense pulsed light, are a new epilating method still in the
experimental stage. This photodynamic therapy uses a topical application of Oaminolevulinic acid that is followed by red light exposure.
PHARMACOLOGIC TREATMENT
In general, pharmacologic treatments of hirsutism are selected based on the underlying
cause. Medications (antiandrogens) are often administered while cosmetic hair removal
techniques are being utilized. All of these drugs must be given continuously because
when they are stopped, androgens will revert to their former level. These medications
are all absolutely contraindicated
for use during pregnancy because there is a risk of feminization of a male fetus. Ovarian
suppression (oral contraceptives), androgen-receptor blockade and inhibition
(spironolactone, flutamide, and cyproterone acetate), adrenal suppression (oral
corticosteroids) and a 5α-reductase inhibition (finasteride) can be used alone or in
combination.
ORAL CONTRACEPTIVES
These agents are often the initial treatment for idiopathic hirsutism and hirsutism caused
by ovarian hyperandrogenism. They help to prevent the side effects of menstrual
irregularity caused by spironolactone and other antiandrogen therapy, and they enhance
the antihirsutism effect. For androgen-excess syndromes, such as polycystic ovary
syndrome (PCOS), the following medication are used, often in combination with oral
contraceptives.
SPIRONOLACTONE
A nonsteroidal androgen receptor blocker, spironolactone is effective for hormonal acne
and hirsutism. Spironolactone may cause menstrual irregularities (usually metrorrhagia).
Normal menses may resume with a reduction of the dosage. Patients already receiving
antihypertensive medications, cardiac drugs, or diuretics should not be given
spironolactone.
Increased potassium and decreased sodium levels are corrected with increased water
ingestion. Its use is not recommended in patients with renal insufficiency. Spironolactone
should be administered at 50mg twice a day. The dose can be increased up to 200 to
300 mg/d. When combined with low-dose oral contraceptives, spironolactone has
increased efficacy.
FLUTAMIDE
A weak inhibitor of adrenal testosterone synthesis, flutamide is primarily a nonsteroidal
androgen receptor blocker. It is approved for the treatment of prostate cancer. When
flutamide is used in combination with oral contraceptives, the side effects include dry
skin, hot flashes, headaches, increased appetite, fatigue, nausea, dizziness, breast
tenderness, and decreased libido. Flutamide is administered in doses ranging from 125
to 500 mg/d.
CYPROTERONE ACETATE
An acetate steroidal androgen receptor blocker and potent progestin, cyproterone
acetate is currently available in the United States for compassionate use. It acts as a
competitive inhibitor of testosterone and dehydroepiandrosterone at the level of the
androgen receptors and is a powerful antiandrogen.
Cyproterone acetate is usually administered with estrogens to maintain regular
menstruation and to prevent conception. Cyproterone acetate, in doses of 50mg/d to
100mg/d should be administered with 0.05mg/d of ethinyl estradiol. Side effects include
liver toxicity, weight gain, fatigue, loss of libido, mastodynia, nausea, headaches, and
depression. Monitor liver enzymes for patients who take this medication.
Diane-35, an oral contraceptive that is very effective in the treatment of acne but is not
available in the United States, contains a combination of cyproterone acetate and ethinyl
estradiol.
CORTICOSTEROIDS
For classical congenital adrenal hyperplasia (CAH), systemic corticosteroids are
employed. Corticosteroids are effective in reducing serum androgen levels, but there are
contradictory reports regarding their therapeutic effect on hair growth. For late-onset
CAH and PCOS, oral contraceptives and spironolactone are utilized. Small doses of
dexamethasone may be added to help reduce androgen production in late-onset CAH,
however. Changes suggesting Cushing’s disease generally develop in most patients
who are receiving long-term corticosteroids.
FINASTERIDE
This agent is approved for use in benign prostatic hypertrophy and in male-pattern
alopecia. A 5α-reductase inhibitor, it blocks the conversion of testosterone to its more
active metabolite, dihydrotestosterone. Finasteride is currently being evaluated for use in
the hormonal treatment of acne that is accompanied by hirsutism.
NEW TREATMENTS
METFORMIN
Metformin reduces insulin levels which in turn reduces the ovarian testosterone levels by
competitive inhibition of the ovarian insulin receptors. The result is improved glucose
levels, lowered testosterone levels, and improvement of menstrual irregularities. Patients
with a clinical diagnosis of persistent anovulation who wish to become pregnant may
benefit from this agent, which is approved for the treatment of diabetes. Metformin has
recently been found to be effective in treating hirsutism in women with PCOS. The
recommended dosage is 850mg; this dose is usually started at a lower dose given once
a day, then twice a day until the therapeutic range is reached. Lactic acidosis has been
reported rarely. Women with PCOS often also receive oral contraceptives and/or
spironolactone.
EFLORNITHINE HYDROCHLORIDE (VANIQA)
A new drug, eflorithine hydrochloride cream 13.9%, is a prescription cream that acts as a
growth inhibitor, not a depilatory; the agent inhibits ornithine decarboxylase, an enzyme
required for hair growth. Eflornithine hydrochloride (Vaniqa) is indicated for the reduction
of unwanted facial hair in women. Continued twice daily use for at least four to eight
weeks is necessary before effectiveness is noted.
The drug’s action is apparently independent of the etiology of the excess facial hair, the
patient’s skin pigmentation, or the location of the facial hair. Side effects, such as
irritation, acne, and folliculitis, are due to the mandatory shaving, waxing, cutting, or
plucking of hairs required while using the cream. Long-term side effects are unknown.
From WOMEN’S HEALTH Gynecology Edition Vol.1 No. 2/April 2001
By Dr. Goodheart an Assistant Clinical Professor of Medicine in the Division of
Dermatology at Albert Einstein College of Medicine, Bronx, New York. He is also author
of the textbook “A Photoguide of Common Skin Disorders: Diagnosis and Management”.
Updated 01/05/07