Treatment of hirsutism

Dermatology Games

2 years ago

April 6, 2023

Introduction

This article mainly covers the different treatment options of hirsutism. Hirsutism is defined as unwanted excess terminal hair that affects androgen-independent areas in a female patient. The main causes of hirsutism are excess androgen or peripherally increased androgen sensitivity. The most common cause of hirsutism is polycystic ovary syndrome (PCOs), other causes include nonclassic congenital adrenal hyperplasia, idiopathic hirsutism, Cushing disease, and drug-induced hirsutism. Ovarian and adrenal tumors may also induce hirsutism but such cases are not common. Tumors in addition to ovarian hyperthecosis are more common in postmenopausal women.

Treatment options for hirsutism include medications such as oral contraceptives, anti-androgens, and topical creams, as well as hair removal methods like laser therapy and electrolysis.

General instructions

The approach to managing clinically significant hirsutism involves two strategies: pharmacological therapy to reduce the secretion or action of androgens, and the removal of existing terminal hair.
Identifying the cause of hirsutism is essential to choose a suitable plan for management.
Most cases of hirsutism are due to PCOs and idiopathic hirsutism.
History taking and examination should be done precisely to address the source of androgen.
Drugs used to reduce androgens are contraindicated in pregnancy. Pregnancy prevention is required.
The medical treatment may need to be taken for several months before a good result appears.
Lifestyle modifications should be considered especially with PCO patients.

Medical treatment options

Oral contraceptives (OCPs)
- Combination of ethinyl estradiol plus a low androgenic (norgestimate, desogestrel) or antiandrogenic progestin (drospirenone, cyproterone acetate).
  - Yasmin : a combination of two hormones, ethinyl estradiol and drospirenone. Yasmin is taken orally, once daily, at the same time each day for 21 days, followed by a 7-day break where no pills are taken.
Anti-androgens
- Spironolactone
  - 100–200 mg/day.
  - This dose can be increased gradually, up to a maximum of 200 mg per day, based on the individual’s response and tolerance to the medication.
- Cyproterone acetate
  - 50–100 mg/day for 10 days per cycle (e.g. days 1–10 or 5–15).
- Finasteride
  - 2.5 mg daily.
  - Some patients may require higher doses up to 5 mg per day.
- Flutamide
  - 62.5–125 mg daily.
  - Hepatotoxic and teratogenic.
- Bicalutamide
  - 25 mg per day.
  - Hepatotoxic with high doses(50 mg per day).
- Glucocorticoids
  - Dexamethasone : 0.25- 0.5 mg at night.
  - Prednisone : 5 to 10 mg per day.
- Insulin-sensitizing agents
  - Metformin: 1 g twice per day.

Treatment options for hirsutism in patients with PCOS

Lifestyle interventions

Weight loss: Losing weight can help to improve insulin sensitivity and reduce hormone levels in women with PCOS, which may in turn reduce hirsutism.

Diet modifications: Eating a low-carbohydrate, high-protein diet may also help to improve insulin sensitivity and reduce hirsutism in women with PCOS.

Medical treatement

Oral contraceptives (OCPs): Combination of ethinyl estradiol plus a low androgenicity (norgestimate, desogestrel) or antiandrogenic progestin (drospirenone, cyproterone acetate).

Anti-androgens: Spironolactone or cyproterone acetate can be used to block the effects of androgens and reduce excessive hair growth.

Insulin-sensitizing agents: Metformin is commonly used to treat insulin resistance in women with PCOS, and may also help to regulate hormone levels and reduce hirsutism.

Hair removal interventions

Hirsutism in patients with PCOS should be managed in collaboration with a gynecologist.

Treatment options for hirsutism in patients with Non-classical Congenital Adrenal Hyperplasia (NCCAH)

First-line: OCP ± spironolactone or cyproterone acetate.
Second-line or if seeking ovulation induction: glucocorticoids

Treatment options for idiopathic hirsutism

Oral contraceptives
Antiandrogens
Hair removal interventions.

Postmenopausal hirsutism

Spironolactone or cyproterone acetate.

Hair removal treatment options

Topical medications

Topical eﬂornithine (15% cream) twice daily. It works by inhibiting an enzyme called ornithine decarboxylase, which is involved in hair growth.
Topical spironolactone is formulated as a cream or lotion that can be applied directly to the skin. It is typically applied once or twice a day, depending on the specific condition being treated and the severity of symptoms.

Physical interventions

Laser hair removal
- Diode lasers: These lasers are known for their precision and effectiveness in treating a wide range of skin types.
- Alexandrite lasers: These lasers are designed for fast treatment and can be used on larger areas of the body such as the legs and back.
- Nd:YAG lasers: These lasers are best suited for darker skin types and can be used safely on all skin colors.
- IPL (intense pulsed light) devices: These devices use a broad spectrum of light to treat hair follicles and can be used on a variety of skin types.
Electrolysis
- Electrolysis hair removal is a method of hair removal that uses an electric current to destroy hair follicles, thereby preventing future hair growth. It is a permanent solution for hair removal and can be used on various parts of the body, including the face, legs, and underarms.
- During the procedure, a fine, sterile probe is inserted into the hair follicle, and an electric current is delivered to the follicle to destroy it. The procedure can be performed with three different techniques: galvanic, thermolysis, and blend.
Hair bleaching
- Hair bleaching is a cosmetic method that can be used to reduce the appearance of hirsutism in women. It involves using a chemical solution to lighten the color of the hair, making it less noticeable.
Depilation
- Depilation is a method of hair removal that involves removing hair from the skin’s surface, rather than destroying the hair follicle. It is a temporary solution for hirsutism and can be used on various parts of the body, including the face, arms, and legs.
- Depilation is a temporary solution for hirsutism and does not address the underlying cause of the excess hair growth. However, it can be a quick and effective way to manage the appearance of hirsutism and improve self-confidence.
- Some common depilation methods include:
  - Shaving: This method involves using a razor to cut the hair at the skin’s surface. It is a quick and easy solution for hirsutism, but the results are temporary, and the hair will regrow quickly.
  - Waxing: This method involves applying warm wax to the skin and then removing it, along with the hair, using a cloth strip. The results can last up to several weeks, but it can be painful and may cause skin irritation.
  - Depilatory creams: These creams contain chemicals that dissolve hair at the skin’s surface. They are easy to use and can provide temporary hair removal, but they may cause skin irritation and have a strong odor.
Epilation
- Epilation is a method of hair removal that involves removing hair from the root, rather than just cutting it at the skin’s surface. It is a temporary solution for hirsutism.
- Some common epilation methods include:
  - Tweezing: This method involves using tweezers to pluck individual hairs from the skin’s surface. It is a time-consuming process but can provide long-lasting results.
  - Epilators: These handheld devices use multiple rotating tweezers to pull hair from the root. They can be used on larger areas of the body and provide longer-lasting results than shaving or depilation.
  - Sugaring: This method involves applying a sticky paste made from sugar, lemon juice, and water to the skin and then removing it, along with the hair, using a cloth strip. It is a natural and less painful alternative to waxing.
- Epilation is a temporary solution for hirsutism and does not address the underlying cause of excess hair growth. However, it can be a quick and effective way to manage the appearance of hirsutism and improve self-confidence.

References

Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline.
Management of the Female With Non-classical Congenital Adrenal Hyperplasia (NCCAH): A Patient-Oriented Approach.
JL Bolognia, JV Schaffer, L Cerroni – Dermatology. 4th ed. Elsevier, 2018‏.