Dermatologic Manifestations of Hirsutism Treatment & Management

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.^[4]

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 inhibition^{[5, 6]}
• Oral corticosteroids - Adrenal suppression
• Finasteride - 5-Alpha-reductase inhibition

These agents can be used singly or in combination.^[7]

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.^[8]

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.

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.

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.^[9]