eMedicine Specialties > Dermatology > Diseases of the Adnexa
Hirsutism: Treatment & Medication
Updated: Jun 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Most patients with medically significant hirsutism have polycystic ovarian syndrome (PCOS), and the most important interventions are to address the risk of endometrial hyperplasia and cardiac risk factors. Treatment of the hirsutism itself is only necessary if the patient finds the excess hair cosmetically objectionable.
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.
Hair removal
Depilation
Depilatories remove hair from the surface of the skin. Depilatory methods include ordinary shaving and the use of chemicals, such as thioglycolic acid.
Shaving removes all hairs, but it is immediately followed by regrowth of hairs that were previously in anagen; as these hairs grow in, they produce rough stubble. No evidence suggests that shaving increases the rate 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 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 applying melted wax to the skin. When the wax cools and sets, it is abruptly peeled off the skin, and embedded hair is removed with it. This method is painful and sometimes results in folliculitis. Repetitive waxing may produce miniaturization of hairs, and, over the long term, it may permanently 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, waxes.
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 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
Hair destruction by electrolysis, thermolysis, or a combination of both is performed with a fine, flexible electrical wire that produces an electrical current after it is introduced down the hair shaft. Thermolysis (diathermy) uses 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. Electrolysis and thermolysis can be uncomfortable and may produce folliculitis, pseudofolliculitis, and postinflammatory pigmentary changes in the skin.
Lasers can treat larger areas and can do so faster than electrolysis and thermolysis. They have skin-cooling mechanisms that minimize epidermal destruction during the procedure. Skin and hair color often determine whether a laser should be used. Lasers are most effective 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.3
Pharmacologic treatment
In general, pharmacologic treatments for hirsutism are selected based on the underlying cause. Medications (antiandrogens) are often administered while cosmetic hair removal techniques are being used. All these drugs must be given continuously because when they are stopped, androgens revert to their former levels. The following medications are all absolutely contraindicated for use during pregnancy because of the risk of feminization of a male fetus:
- Estrogen-progestin oral contraceptives - Ovarian suppression
- Antiandrogens (eg, spironolactone, flutamide, cyproterone acetate) - Androgen receptor blockade and inhibition4,5
- Oral corticosteroids - Adrenal suppression
- Finasteride - 5-Alpha-reductase inhibition
These agents can be used singly or in combination.6
New treatments
Eflornithine hydrochloride cream 13.9% (Vaniqa) is a prescription topical cream that acts as a growth inhibitor, not a depilatory. The agent inhibits ornithine decarboxylase, an enzyme required for hair growth. It is indicated for the reduction of unwanted facial hair in women. Continued twice-daily use for at least 4-8 weeks is necessary before effectiveness is noted. It can be combined with laser treatments for enhanced effects.7
Metformin (Glucophage) reduces insulin levels, and this change, in turn, reduces the ovarian testosterone levels by competitive inhibition of the ovarian insulin receptors. This drug is effective in treating hirsutism in women with PCOS.
Management depends on the underlying cause. For example, non–androgen-dependent excess hair, such as hypertrichosis, is treated primarily with physical hair removal methods. In contrast, patients with androgen-dependent hirsutism require a combination of physical hair removal and medical antiandrogen therapy.
Hormonal treatment of hirsutism resulting from androgen excess is long term, because the sources of excessive androgen rarely can be eliminated permanently. Consequently, the patient must understand that discontinuation of antiandrogen therapy usually results in the recurrence of hirsutism.
See Laser-Assisted Hair Removal and Nonlaser Hair Removal.
Surgical Care
If virilizing adrenal or ovarian tumors are found to be responsible for excess body hair, removal of the tumor often alleviates the condition. Unfortunately, many tumors are malignant and fatal.
Diet
Although many women with hirsutism are obese, the relationship of adipose tissue and hair growth is undefined. Clinically, it is recognized although undocumented that weight loss in women with hirsutism who are obese and have menstrual irregularities (eg, women with PCOS) may result in the regulation of menses and diminution of hirsutism.
A 2008 study found that women with PCOS experienced a significant decrease in hirsutism after undergoing 16 weeks of therapy with oral essential amino acids. This therapy also resulted in a significant decrease in the levels of fasting insulin, luteinizing hormone, follicle-stimulating hormone, and total testosterone. This research suggests that a diet supplemented with essential amino acids may reduce hirsutism in patients with PCOS.8
Medication
Usually, pharmacologic treatments for hirsutism are selected based on the underlying cause. Medications (antiandrogens) often are administered simultaneously while cosmetic hair removal techniques are performed. All of these drugs must be administered continuously, because when they are discontinued, androgens revert to their former levels. These medications are absolutely contraindicated for use during pregnancy, because a risk exists of feminization of a male fetus.
Oral contraceptives are often the initial treatment for hirsutism caused by ovarian hyperandrogenism and idiopathic hirsutism. Oral contraceptives also help enhance antihirsutism effects and prevent adverse effects of menstrual irregularity caused by spironolactone and other antiandrogen therapy. Finasteride, a 5-alpha reductase inhibitor approved for use in benign prostatic hypertrophy and in male-pattern alopecia, blocks conversion of testosterone to its more active metabolite, dihydrotestosterone. Currently, finasteride is being evaluated for use in hormonal treatment of acne accompanied by hirsutism. For androgen-excess syndromes, such as PCOS, the following medications are used, often in combination with oral contraceptives.
Antihypertensives
May have properties that improve symptoms of hirsutism.
Spironolactone (Aldactone)
Effective for hormonal acne and hirsutism. May cause menstrual irregularities (usually metrorrhagia). Normal menses may resume with a reduction of dosage. Do not administer in patients already receiving antihypertensive medications, cardiac drugs, or diuretics. Not recommended in patients with renal insufficiency.
Adult
50 mg PO bid; may increase to 200 mg/d prn
Pediatric
1.5-3.5 mg/kg/d PO in divided doses q6-24h
May decrease effect of anticoagulants; potassium and potassium-sparing diuretics may increase toxicity of spironolactone
Documented hypersensitivity; anuria; renal failure; hyperkalemia
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal and hepatic impairment
Antiandrogens
Block active androgen production.
Flutamide (Eulexin)
Nonsteroidal antiandrogen that inhibits androgen uptake or binding of androgen to target tissues. Approved for treatment of prostate cancer.
Adult
250 mg/d PO in divided doses
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Advise patients not to discontinue therapy without physician's advice; may elevate LFT results (order blood tests frequently); when used in combination with oral contraceptives, adverse effects include dry skin, hot flashes, headaches, increased appetite, fatigue, nausea, dizziness, breast tenderness, and decreased libido
Cyproterone (Diane-35)
Steroidal androgen-receptor blocker and potent progestin available in the United States only for compassionate use. Acts as competitive inhibitor of testosterone and DHEA-S at level of androgen receptors.
Powerful antiandrogen usually administered with estrogens to maintain regular menstruation and to prevent conception. Contains a combination of cyproterone acetate and ethinyl estradiol.
Adult
50-100 mg/d PO, administered with 0.05 mg/d of ethinyl estradiol
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Adverse effects include weight gain, fatigue, loss of libido, mastodynia, nausea, headaches, and depression
Dermatologic agents
May inhibit cell growth and proliferation.
Eflornithine (Vaniqa)
Recently approved by the FDA. Prescription topical cream that acts as a growth inhibitor, not a depilatory. Inhibits ornithine decarboxylase, an enzyme required for hair growth. Reportedly takes up to 2 mo to work in approximately 30% of patients.
Adult
Apply thin film bid to areas of hair growth
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adverse effects include minor skin irritation, folliculitis, stinging, burning, tingling, acne, or rash
Glucocorticoids
For classic CAH, systemic corticosteroids are used. Corticosteroids are effective in reducing serum androgen levels, but contradictory reports exist regarding their therapeutic effect on hair growth.
For late-onset CAH and PCOS, oral contraceptives and spironolactone are used. In addition, small doses of dexamethasone may be helpful in reducing androgen production in late-onset CAH; however, changes suggesting Cushing disease may develop in patients receiving long-term corticosteroids.
Dexamethasone (Decadron, Dexasone)
Decreases immune reactions by suppressing migration of PMN leukocytes and reducing capillary permeability.
Adult
0.25-1 mg PO qd
Pediatric
0.08-0.3 mg/kg/d PO or 2.5 mg-10 mg/m2/d PO divided q6-12h
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor DHEA-S levels and morning cortisol levels; increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering; abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications
Prednisone (Deltasone, Sterapred, Orasone)
May decrease immune reactions by reversing increased capillary permeability and suppressing PMN activity.
Adult
5-7 mg PO qd
Pediatric
4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk as symptoms resolve
Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective-tissue infections; fungal or tubercular skin infections
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur
Antidiabetic agents
Insulin-sensitizing agents appear to improve symptoms of hirsutism.
Metformin (Glucophage)
Patients with a clinical diagnosis of persistent anovulation who wish to become pregnant may benefit from use. Effective in treating hirsutism in women with PCOS. Women with PCOS also often receive oral contraceptives and/or spironolactone. If PCOS primarily is considered to be a metabolic syndrome of insulin resistance, perhaps first-line treatment should be with an insulin-sensitizing agent such as metformin.
Adult
850 mg PO qd initially, increase to bid
Pediatric
Not established
Diuretics, thyroid products, oral contraceptives, phenytoin, calcium channel blocking drugs, and phenothiazines may decrease effects; cimetidine may increase levels
Documented hypersensitivity; acute myocardial infarction; septicemia; renal disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal insufficiency; discontinue therapy before performing surgical procedures; impaired liver function
More on Hirsutism |
| Overview: Hirsutism |
| Differential Diagnoses & Workup: Hirsutism |
 Treatment & Medication: Hirsutism |
| Follow-up: Hirsutism |
| Multimedia: Hirsutism |
| References |
| « Previous Page | Next Page » |
References
Mofid A, Seyyed Alinaghi SA, Zandieh S, Yazdani T. Hirsutism. Int J Clin Pract. Mar 2008;62(3):433-43. [Medline].
Abdel Fattah NS, Darwish YW. Is there a role for insulin resistance in nonobese patients with idiopathic hirsutism?. Br J Dermatol. May 2009;160(5):1011-5. [Medline].
Moghetti P, Toscano V. Treatment of hirsutism and acne in hyperandrogenism. Best Pract Res Clin Endocrinol Metab. Jun 2006;20(2):221-34. [Medline].
Falsetti L, Gambera A, Legrenzi L, Iacobello C, Bugari G. Comparison of finasteride versus flutamide in the treatment of hirsutism. Eur J Endocrinol. Oct 1999;141(4):361-7. [Medline].
Moghetti P, Tosi F, Tosti A, et al. Comparison of spironolactone, flutamide, and finasteride efficacy in the treatment of hirsutism: a randomized, double blind, placebo-controlled trial. J Clin Endocrinol Metab. Jan 2000;85(1):89-94. [Medline].
Bergfeld WF. Hirsutism in women. Effective therapy that is safe for long-term use. Postgrad Med. Jun 2000;107(7):93-4, 99-104. [Medline].
Hamzavi I, Tan E, Shapiro J, Lui H. A randomized bilateral vehicle-controlled study of eflornithine cream combined with laser treatment versus laser treatment alone for facial hirsutism in women. J Am Acad Dermatol. Jul 2007;57(1):54-9. [Medline].
Unfer V, Zacche M, Serafini A, Redaelli A, Papaleo E. [Treatment of hyperandrogenism and hyperinsulinemia in PCOS patients with essential amino acids. A pilot clinical study]. Minerva Ginecol. Oct 2008;60(5):363-8. [Medline].
Morgan J, Scholtz S, Lacey H, Conway G. The prevalence of eating disorders in women with facial hirsutism: an epidemiological cohort study. Int J Eat Disord. Jul 2008;41(5):427-31. [Medline].
Berek JS, Hillard PA, Adashi EY. Novak's Gynecology. 12th ed. Baltimore, Md: Williams & Wilkins; 1996:799-801; 833-52.
Clarke Secor, RM. Hirsutism in women. Clin Rev. 2000;10(2):61-72.
Androgen excess. In: Scott JR, Disaia PJ, et al, eds. Danforth's Obstetrics and Gynecology. 7th ed. Philadelphia, Pa: Lippincott-Raven; 1994:681-93.
de Berker D. The diagnosis and treatment of hirsutism. Practitioner. Jun 1999;243(1599):493-8, 501. [Medline].
Diamanti-Kandarakis E, Bartzis MI, Zapanti ED, et al. Polymorphism T-->C (-34 bp) of gene CYP17 promoter in Greek patients with polycystic ovary syndrome. Fertil Steril. Mar 1999;71(3):431-5. [Medline].
Fauci AS, Braunwald E, Hauser SL, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:292-4.
Friedberg IM, Eisen AZ, Wolff K, eds. Fitzpatrick's Dermatology in General Medicine. Vol 1. 5th ed. New York, NY: McGraw-Hill; 1999:746-9.
Marchell N, Alster T. Evaluation of hair removal methods. Aesthetic Surg Cosmet Surg. 1999;1(1):3-11.
Patel SR, Korytkowski M. Polycystic ovarian syndrome. Women Health Prim Care. 2000;3(1):55-69.
Pugeat M, Ducluzeau PH. Insulin resistance, polycystic ovary syndrome and metformin. Drugs. 1999;58 Suppl 1:41-6; discussion 75-82. [Medline].
Sperling LC, Heimer WL 2nd. Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. I. J Am Acad Dermatol. May 1993;28(5 Pt 1):669-83. [Medline].
Sperling LC, Heimer WL 2nd. Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. II. J Am Acad Dermatol. Jun 1993;28(6):901-16. [Medline].
Waggoner W, Boots LR, Azziz R. Total testosterone and DHEAS levels as predictors of androgen-secreting neoplasms: a populational study. Gynecol Endocrinol. Dec 1999;13(6):394-400. [Medline].
Watts J. Understanding the causes and management of hirsutism. Nurs Times. Feb 21-27 2006;102(8):26-8. [Medline].
Further Reading
Keywords
hirsutism, hypertrichosis, hirsuties, excessive body hair, male-pattern hair growth
