Management of Hirsutism

By Dr Anita Sturnham / 01 Feb 2016

Dr Anita Sturnham discusses the causes of excessive facial hair in women and explains her methods of treating patients with this concern

Our skin contains hair follicles over almost the entire body, apart from the palms of the hands, soles of the feet and on the lips. Throughout one’s life, hair follicles will produce varying types and quantity of hair. The subject of too much or too little hair amongst aesthetic patients is therefore commonplace.

As a skin specialist, I often advise patients with hair-related conditions. Whether it be too much or too little hair, the concerns one sees are often subjective. Patients are influenced by cultural factors and society’s idea of the ‘norm’. Modern-day women are often under pressure to have no or reduced facial/body hair, to conform with the ‘ideal’ image portrayed in the media, of flawless, hairless supermodels. Sadly, for some women, being ‘too hairy’ can have a devastating affect on body confidence and even result in an increased incidence of anxiety and depression.

Hair growth

For the purpose of this article I will focus on ‘excessive’ facial hair (hirsutism) in women. To simplify my thoughts on the management of excessive facial hair, it is useful to understand the hair growth cycle and the types of hair present on the body. Hair growth goes through three main phases, the anagen or growing phase, the catagen or transition phase, followed by the telogen shedding or resting phase. Patients with excessive facial hair, tend to have a disturbance in this pathway, resulting in a prolonged or altered anagen phase.1,2

Figure 1: The phases of hair growth1,2 

Figure 2: The hair growth cycle 


Hair types

Lanugo: downy hair, without pigment, found on fetuses and is usually shed in the womb. It can be found on malnourished children and adults.1,2

Vellus: soft, short hairs with very little pigment. Found on most parts of the body. It appears after lanugo hair is shed. When a person reaches puberty some sites of vellus hair are concerted to terminal hairs, such as hair in the armpits and pubic regions.1,2

Terminal: longer, thicker, darker and coarser hairs.1


Identifying a cause

If a patient presents to my clinic with excessive facial hair, my first task is to establish whether there has been a sudden increase in the growth of hair, a change in its character (more likely to have an underlying medical cause) or whether it has always been that way (more likely to be genetic). If the case is the latter, although an underlying medical aetiology is unlikely, it is still important to understand why the patient is suddenly presenting with this complaint and not to dismiss it.

The second task is to ascertain the underlying cause. If the hair in question is thick, dark terminal hair, in a male distribution, this is likely to be hirsutism.4 If the patient has generalised excessive hair growth all over the body then this is more likely to be hypertrichosis.

Hirsutism is thought to be either the result of an increase in production of the androgen hormone testosterone or an increased sensitivity of the androgen receptors at the level of the hair follicle.5 Up to 80% of a female’s androgen production comes from the ovaries or the adrenal glands,5 the rest comes from the conversion of precursors dehydroepiandrosterone (DHEA) and androstenedione in peripheral organs such as the liver, adipose tissue and also in the skin.

Polycystic ovary syndrome (PCOS) and idiopathic hirsutism account for approximately 90% of hirsutism, a condition that effects up to 10% of women.6,7 PCOS typically presents around puberty, however the exact aetiology is unknown.7 PCOS is a common endocrine condition, which can affect up to 10% of women of childbearing age.6 Females with this condition may present with weight gain, irregular periods and menstrual abnormalities. Hormonal imbalance is generally a feature, with raised insulin and testosterone levels. As such, PCOS is linked to the pathophysiology of hirsutism.6,7 

Not all testosterone is ‘biologically active’. For it to be active it needs to be in its ‘free form’ and this typically accounts for 1-2% of our testosterone.6 The rest in its ‘inactive’ form is bound to steroid hormone binding globulin (SHBG) albumin and other proteins.3 As such, we may question how this free testosterone causes hair growth. An enzyme called 5-alpha reductase is present in the sheath of hair follicles. This enzyme converts testosterone to dihydrotestosterone (DHT). DHT prolongs the anagen hair growth phase and results in lanugo and vellus hair being converted into thicker, coarser, darker and longer terminal hairs.4,6Hirsute women typically present with concerns about increased growth of terminal hair in a male distribution. These tend to be the sites of androgen dependent hairs such as the chin, jawline, upper lip, shoulders, upper back and abdominal regions. There are no standardised assessment tools to assess the severity of hirsutism, however many practitioners find the Ferriman and Gallwey score helpful.8 This score was utilised in their study of 161 women aged 18 to 38 years old,3,4 in which the density of terminal hair was graded in nine body areas, with a rating score from 0 (absence of terminal hairs) through to 4 (extensive terminal hair growth). The study concluded that hirsutism was represented by a score of 8 or more.

Causes of hirsutism

Ovarian: polycystic ovarian syndrome (PCOS), ovarian tumour

Adrenal: congenital adrenal hyperplasia (CAH), adrenal tumour

Idopathic (IH): no identifiable cause


Managing the hirsute patient

The importance of taking a good history and examination is key. Examination should consist of a general physical examination, including hair, skin, cardiovascular system, abdomen and urine. Practitioners should then establish the following before offering treatment:

  • Onset of hair growth.
  • Other associated symptoms such as weight gain, skin changes including acne, changes in menstrual cycle, deepening of voice, changes in libido.
  • Drug history; some medications can affect hair growth, such as some anti-epileptic drugs.3
  • Family hair growth patterns: genetic causes.
  • Past medical history, including thyroid disease and diabetes. Thyroid disease can cause weight gain and irregular menstruation and must therefore be excluded. Diabetes is strongly associated with PCOS.

Blood tests

  • Testosterone: may be normal/increased in case of PCOS and CAH if significantly raised (>200ng/ml) consider malignant ovarian/adrenal tumour.3 
  • Dehydroepiandrosterone sulfate (DHEAS): >700?g/do indicates adrenal cause.3 
  • 17-hydroxyprogesterone (take between 7-9am): raised in cases of CAH.4 
  • 24-hour urinary free cortisol (measured if clinical signs of Cushing’s syndrome).4 
  • LH/FSH >3 indicative of PCOS.4 
  • Prolactin raised in hyperprolactinemia (hypothalamic disease or a pituitary tumour).4 
  • Thyroid function tests (TFTS).4 
  • Glucose: metabolic syndrome associated with PCOS.8 

Other tests

  • Pelvic ultrasound: to assess ovarian follicles. The ‘string of beads’ sign reflects a line of pearl-like follicles in the peripheral region. PCOS sufferers are likely to have at least 12 visible follicles and this may increase up to 25 in some cases.7,8 
Figure 3: Terminal hairs in a hirsute female patient before and 12 weeks after four treatments with the Soprano diode, fluence mode II, 38j. Images courtesy of Dr Dhepas, Skin City. Postgraduate Institute of Dermatology, India.

Treatment options

For the purpose of this article I am focusing on the management of excessive facial hair secondary to PCOS or IH. For any other underlying conditions identified at this stage I would seek advice from an endocrinologist. For those with patients with PCOS, I start by advising them to follow a diet and exercise plan, which can help to reduce their BMI and also lower other health disease risk factors.

Studies have identified a directly proportionate relationship between raised BMIs and raised free testosterone levels.7 The same link applies for reduced Sex Hormone Binding Globulin (SHBG) levels. Both factors are thought to contribute to hirsutism.7 I often advise a three to six month programme before looking at drug treatments for confirmed hyperandrogenism. Below I have summarised the medical treatment options that should be considered at this stage.

Oral contraceptives: These are recommended first line and are a popular choice for women who are also looking for contraception.4 The combined pill (COC) containing oestrogen and progesterone, works by inhibiting adrenal androgens and reducing ovarian androgens. The COC also increases levels of SHBG, resulting in lower levels of free androgens.4 Patients should be warned of common side effects such as: mood changes, breast tenderness and weight gain.

Spironolactone: Most will know of this as an antihypertensive, but it is also acts as an androgen blocker, by competing with DHT for androgen binding sites.3 It also has an inhibitory effect on 5-alpha reductase.7 It should be emphasised that it may take four to six months before patients start to see any benefits so it is important to advise the patient of this to encourage compliance. Patients should be warned of common side effects such as: tiredness, increased thirst and constipation.

Cyproterone acetate: This has anti-androgenic properties too; it works by reducing luteinizing hormone (LH) levels.3 Patients should be warned of common side effects such as: tiredness, hot flushes and breast tenderness.

Finasteride: 5-alpha reductase inhibitors inhibit DHT production.4 Patients should be warned of common side effects such as: mood swings, weight gain and breast tenderness.3

Figure 4: Summary of assessment protocol for patients with hirsuitism3 

Hair removal

While the medical management is initiated, patients generally do not want to wait for prolonged periods of time to treat their excessive facial hair, so it is important to address this issue at an early stage. Simple at-home options include waxing, shaving and plucking.6 These are somewhat time-consuming methods and can leave redness, inflammation and irritation. In my experience, most patients will have already tried these options before coming to see a specialist and are generally seeking alternatives at this stage.

At my clinic, we offer electrolysis as a solution for hair removal. During this process a fine disposable sterile needle is introduced into the individual hair follicle to the correct depth and a small amount of current is released. This destroys the root of the hair by cutting off the blood supply.6 This ‘old-fashioned’ method is great for hair removal, however it is time-consuming if large treatment areas are required. 

Studies have identified a directly proportionate relationship between raised BMIs and raised free testosterone levels. The same link applies for reduced Sex Hormone Binding Globulin (SHBG) levels 
Figure 5: Treatment of facial hair using Soprano Alexandrite laser. Fluence mode III. 28j. 10 weeks after first treatment. Images courtesy of Dr Dhepas, Skin City. Postgraduate Institute of Dermatology, India.


Laser hair removal

Lasers have gained wide popularity in recent years. They work to reduce hair by causing selective photothermolysis, which aims to destroy the hair follicle.3 The laser target or chromophore is the melanin pigment in the hair. The best clinical results tend to be achieved with a light-skinned patient with darker hair.9 The laser energy acts on only anagen hair follicles, we therefore need to treat the patients every four to six weeks for facial hair and every six to eight weeks for body hair to achieve significant reduction.3 There are many different lasers on the market for hair removal. These include 1064nm Q-switched, 694nm ruby, 755nm long-pulsed alexandrite, Nd: YAG Lasers.9,10 

At my clinic, Nuriss, we use the Soprano ICE, a high fluence dual wavelength laser, with contact cooling, hence the ‘ICE’. The Soprano’s sapphire cooling system allows the energy to be delivered into the hair follicle without damaging the epidermis.9 This allows for more comfortable treatments but also helps to reduce the risk of hypo or hyper pigmentation, secondary to inflammatory changes in the skin.10 

There are many laser hair removal devices on the market. I chose Soprano ICE for my clinic, as I have worked with it for several years and have achieved outstanding results. Many of my colleagues use other devices such as the Gentle Pro systems and Lightsheer. 

At Nuriss, suitability for laser is assessed and risk factors are screened for at the initial consultation. Those with a Fitzpatrick skin type IV-VI are prepped with a melanocyte-stabilising homecare regimen, using cosmeceutical grade products using the actives alpha arbutin, ascorbic acid 20% and retinol 2-3%, for a period of six weeks. The importance of daily SPF 30 is also emphasised, as part of the skin preparation phase. The main reasoning for this skin preparation phase is to reduce post-inflammatory hyperpigmentation that one can see in darker skin tones following laser treatments. 

It is important to assess each patient carefully and ensure that underlying medical causes are addressed and treated accordingly 

At the time of treatment, designated settings are used as per skin type, hair type and body area. To achieve the best results with hirsute facial hair, low-fluence, rapid-pulse width and multiple passes with the Soprano ICE 755nm and 810nm dual wavelength laser seems to be the best approach. As well as noticing this in my practice, a study by Ganesh et al, which compared this strategy with a traditional high-powered, single-pass, Soprano 755nm and 810nm dual wavelength laser system, also suggested this method was more effective.

Once we have achieved the desired end point, we advise our patients to return two to three months later for a review. At this stage, we may recommend additional treatments. Most patients return for several maintenance treatments every 12 to 18 months.

Conclusion

Hirsutism is a condition that all aesthetic practitioners are likely to be presented with. It is important to assess each patient carefully and ensure that underlying medical causes are addressed and treated accordingly. As discussed, PCOS and IH are the most likely causes.3 If pharmacological therapy is required, the combined oral contraceptive pill may be a good first line pharmacological therapy.3,4 This should be reviewed at the six-month stage, where one may consider adding an anti-androgen if necessary.

Most women will also want advice and/or treatment for hair removal. In my experience I have found that laser photoeplilation is often the preferred choice.10 The darker skin types may benefit from a period of skin preparation with melanocyte-stabilising active skincare products before commencing laser therapy, to reduce the risks of adverse effects secondary to the laser. 

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