Excessive Facial Hair

J. Shapiro, MD, FRCPC and H. Lui, MD, FRCPC
Hair Research and Treatment Centre, and Division of Dermatology, University of British Columbia, Vancouver, British Columbia, Canada

Hirsutism

Excessive facial hair in women, or hirsutism, is a common problem that may be caused by androgen overproduction, increased sensitivity to circulating androgens, or other metabolic and endocrine disorders. Approximately 80% of women are affected by the presence of excessive hair growth in areas usually recognized as places where male secondary sexual characteristics occur. This can be a source of distress, leading to anxiety, depression and a reduced quality of life.

Differential Diagnosis

It is very important to determine the etiology of this condition. Diagnostic evaluation of the potentially hirsute patient first involves confirmation of the presence of hirsutism and then exclusion of associated or etiological abnormalities and disorders. Investigate or rule out underlying conditions that produce excess androgens using tests such as:

• Serum testosterone
• Serum DHEA (Dehydroepiandrosterone)
• Rule out testosterone secreting tumors.

Hair Removal Techniques

Technique	Body Area	Advantages	Disadvantages
Plucking	Face Eyebrows	Inexpensive Regrowth can take weeks	Painful Slow
Waxing	Face Eyebrows Groin Trunk	Regrowth can take weeks	Painful Slow Risk of folliculitis
Depilatories	Extremities Groin Face	Quick	Can be irritating Regrowth in days
Shaving	All areas	Easy Inexpensive	Quick regrowth Risk of folliculitis Time consuming
Electrolysis	All areas, but usually the face	May give permanent removal	Painful Very time consuming Expensive Risk of scarring and skin pigment changes
Laser and Intense Pulsed Light (IPL)	All areas	May give permanent hair reduction Efficient	Painful Repeat treatments needed Dark hair required Expensive Risk of scarring and skin pigment changes Rare reports of paradoxical hypertrichosis [Alajlan A, et al. J Am Acad Dermatol 53(1):85-8 (2005 Jul).]
Eflornithine 13.9% cream	Face Neck	Regrowth can take weeks Minimal adverse effects Can be used in conjunction with other treatments	Must be continued indefinitely to prevent regrowth
Antiandrogens and oral contraceptives	Inhibits androgen		Takes months to show benefit Some adverse effects
Table 1: Methods for removing unwanted hair

Treatment Options

Current methods for removing unwanted hair include plucking, waxing (including the sugar forms), depilatories, shaving, electrolysis, laser, intense pulsed light (IPL), and eflornithine 13.9% cream. All these methods are temporary with the time of regrowth ranging from a few days to a few months. Short of surgical removal of the hair follicle, the only permanent treatment is electrolysis. However, the practice of electrolysis lacks standardization. For hirsutism associated with Polycystic Ovary Syndrome (PCOS), treatments include oral contraceptive pills or antiandrogens, such as spironolactone, flutamide and finasteride.

Patients should be adequately advised of the available treatment modalities for hair removal. No single method of hair removal is appropriate for all body locations or patients, and the one adopted will depend on the character, area and amount of hair growth as well as on the age of the patient and their personal preference.

Women and Hirsutism

Women who have hirsutism will need to be evaluated to rule out causes of elevated androgens. PCOS needs to be excluded if there are suspicious clinical features. Medications such as spironolactone and oral contraceptives, e.g., cyproterone acetate + ethinyl estradiol, can be of value.

Ornithine Decarboxylase (ODC)

ODC is an enzyme that has been associated with the prolongation of the anagen or growth phase of the hair. Thus, when ODC is decreased, the length of time the hair is in the growth phase is also reduced.

Eflornithine HCl 13.9%, rather than removing the hair, is an irreversible inhibitor of ODC, thus it reduces the rate of hair growth. It appears to be effective regardless of whether the unwanted facial hair is hereditary or whether it is due to medical conditions such as an androgen excess disorder, e.g., PCOS.

Combination Therapy

Eflornithine 13.9% cream can slow hair growth and thus reduce the frequency of the need for hair removal by other means, such as lasers and IPL treatments. Studies have shown that the two processes can be started simultaneously, and eflornithine treatment can continue right through laser treatments. [Dawber RP. Curr Med Res Opin 21(8):1227-34 (2005 Aug).] Treatment should be undertaken using combination therapy to possibly include:

1. hormonal suppression, e.g., oral contraceptives, long-acting gonadotropin-releasing hormonal analogues and insulin sensitizers
2. peripheral androgen blockade, e.g., spironolactone, flutamide, cyproterone acetate or finasteride
3. mechanical/cosmetic amelioration and destruction of the unwanted hairs, e.g., electrolysis, lasers, IPL, depilatories, shaving, waxing, etc.
4. application of eflornithine 13.9% topical cream.[Azziz R. Obstet Gynecol 101 (5 Pat 1):995-1007 (2003 May).]

Paradoxical hypertrichosis has, however, been reported in a small number of patients receiving laser or IPL treatment for excess hair removal. [Alajlan A, et al. J Am Acad Dermatol 53(1):85-8 (2005 Jul).]

Conclusion

Hirsutism can cause embarrassment and lead to anxiety and depression. There are a limited number of treatments available that vary in efficacy, degree of discomfort and cost. It is very important to make sure that the patient is aware of all the available treatment modalities, since no one method is effective for all patients or body locations, and results from therapy may not always be satisfactory.

This article has been adapted from an article by Drs. Shapiro and Lui to be published in the November 2005 issue of Skin Therapy Letter®.

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