Management of Unwanted Facial Hair

Michelle Withers, MD, FRCPC

Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada

Reprinted from Skin Therapy Letter FP 7(2):6-7 (April 2011) due to content update

Introduction

Unwanted facial hair is a common, frustrating condition that affects up to 25% of women. For many individuals, it significantly impacts their quality of life. Treatment options include physical methods such as shaving, waxing, threading, bleaching, electrolysis, and laser therapy. Pharmacologic methods include chemical depilatories, oral hormonal therapy (i.e., spironolactone and contraceptive pills), and topical enzyme blockade (eflornithine).

Overview of Hirsutism

Hirsutism is defined as excessive growth of terminal hair in women in androgen-sensitive areas of the body (face, neck, chest, etc.).¹ This is to be differentiated from hypertrichosis, which is generalized excessive hair growth. The primary androgen responsible for hair growth is dihydrotestosterone (DHT), which is synthesized from testosterone by the activity of 5-alpha-reductase type 2. Hirsute females have increased 5-alpha-reductase activity in the hair follicles.²

Unwanted facial hair is a common, chronic, life-affecting problem for many women. A European study of female college students showed that up to 26% of women had facial hair growth and in 9% it was markedly noticeable.³ Self-esteem and quality of life can be significantly altered by excessive facial hair.⁴ Hirsutism can often be accounted for by ethnicity or genetics, but in a small percentage of people it can be a sign of underlying disease.

Signs of Androgen Excess ^{5, 6}

• Hirsutism
• Acne
• Seborrhea
• Menstrual irregularities or infertility
• Alopecia

Causes of Androgen Excess and Hirsutism ⁵

• Polycystic ovarian syndrome (1-4% of all females of reproductive age)
• Androgen-producing tumours (ovarian or adrenal)
• Congenital adrenal hyperplasia
• Cushing’s disease
• Exogenous steroid use or other drugs

Clinical Considerations

• To determine if a patient needs a work-up for hirsutism, clinical assessment in the form of a thorough history and physical exam are the most important tools.
• If hirsutism is associated with significant acne, menstrual irregularities or signs of androgenization, such as deepening of the voice, clitoromegaly or other, hormonal work-up is warranted.

Blood-work to Assess for Androgen Excess ^6,7

• Total and free testosterone
• Dehydroepiandrosterone sulfate (DHEA-S)
• +/- 17 hydroxy-progesterone
• +/- prolactin
• +/- 24-hour urine cortisol

Psychological Sequelae

• Studies have shown that women with unwanted facial hair can exhibit significant levels of emotional distress.^4,8
• The dissatisfaction with their appearance and persistent pattern of hair removal practices can become obsessive and intrusive on the daily lives of affected individuals, resulting in substantial psychosocial burden.
• The social and emotional impacts of hirsutism, especially among women, are commonly overlooked. Hence, assessment for such disturbances is helpful in guiding therapeutic recommendations.

Treatment Overview

Once underlying pathology causing the hirsutism is ruled out, many women will want to pursue removal of their unwanted facial hair. While there is still no permanent method of hair removal, any one or a combination of the following treatment options can be used to improve the cosmetic outcome. The more common hair removal modalities include:

• Physical removal (e.g., shaving, waxing, plucking, electrolysis)
• Bleaching agents
• Chemical depilatories
• Laser assisted removal
• Oral hormonal blockade
• Topical enzyme blockade

Treatment Options for Unwanted Facial Hair

Physical Removal

Physical removal methods are common, inexpensive, and often home administered, excepting electrolysis. Drawbacks to physical removal include discomfort, resultant folliculitis, rapid regrowth, and the possibility of scarring or hyperpigmentation.

• Only electrolysis is potentially permanent.⁵
• Bleaching is effective for lightening the hair shaft, but it does not affect hair length or growth. Irritant dermatitis is a common drawback.
• Chemical depilatories use thioglycolic acid to dissolve the hair shaft. This is effective at removing both the surface hair as well as hair just below the skin surface, but not down to the depth of the follicle. Irritant dermatitis is again a common side-effect.⁶
• Pseudofolliculitis barbae is a common chronic inflammatory skin condition that is caused by the habitual removal of unwanted hair through physical means. This persistent practice can contribute to a foreign-body reaction surrounding the ingrown hair, which can produce papules and pustules that result in hyperpigmentation and keloidal scars.

Laser Hair Removal

• Laser light uses selective thermolysis to cause thermal uptake by the pigmented hair shaft. The heat absorbed by the hair shaft will cause disruption or destruction of the hair follicle.^9,10
• Various lasers and light sources (e.g., intense pulsed light, alexandrite, diode, Nd:YAG)^9,10 have been used for this treatment and results vary depending on the skin type of the patient, the colour of the hair (i.e., it is ineffective on light-coloured hair), the growth phase of the hair, and the operator.
• Complications can include burning, edema, blistering, hyperpigmentation, scarring, and paradoxical hypertrichosis (~1-4%).^9-11
• The possibility of permanent hair reduction can be attained through laser therapy.

Oral Hormonal Blockade

• Anti-androgen therapy using oral contraceptives can suppress adrenal and ovarian androgen production and increase sex-hormone binding globulin to reduce circulating testosterone.
• Cyproterone acetate (50-100 mg on days 1-10 of the menstrual cycle) alone or in lower doses in Diane-35® inhibit 5-alpha reductase, preventing the transformation of testosterone to DHT, which is required for hair growth.¹²
• Spironolactone (100-200 mg/day) acts as an androgen receptor blocker, again preventing the interaction of DHT in the hair follicle.⁶
• Side-effects may include menstrual irregularities, breast tenderness, weight gain, and with spironolactone, hyperkalemia and feminization of a male fetus.⁶
• Rare side-effects of contraceptive pills include cerebrovascular events, heart attack, or venous thromboembolism.⁶
• Much less commonly used oral therapies include flutamide and finasteride, as they have more potential toxic effects.

Topical Enzyme Blockade

• Eflornithine hydrochloride (HCl) cream 13.9% (Vaniqa®) is a novel product that is commercially available by prescription only.
• Eflornithine is an irreversible inhibitor of ornithine decarboxylase.
• It does not remove hair, but rather inhibits cell division and other cellular functions, thus slowing, but not stopping, hair growth, and shortens both the length and mass of hair.¹³s
• Topical eflornithine HCl is effective against all causes of excessive facial hair, regardless of hair colour.
• Pivotal trials showed twice daily application for up to 24 weeks is effective at reducing hair growth in 58% of women, with 32% being considered a “clincial success”; improvement was seen as early as 8 weeks.¹³
• Side-effects include a potential for irritant contact dermatitis.¹⁴
• Unlike lasers, it can be used to treat lighter vellus hairs.
• Topical eflornithine is effective alone or can serve as a useful adjunct to other hair removal techniques.
  • Studies have shown that it increases the efficacy of laser hair removal.¹⁵ A randomized bilateral vehicle-controlled study of women with facial hirsutism comparing eflornithine HCl cream + laser treatment with laser alone demonstrated topical eflornithine provided an additive effect in enhancing the rate and degree of hair reduction on the upper lip.¹⁵
  • Eflornithine improved the reduction in unwanted facial hair until the sufficient number of laser treatments (due to a lag in response time) produced the desired long-term effects.
  • The study medication was well tolerated and no device/ drug interactions were observed.

Conclusion

Facial hair can be a distressing, chronic problem for many women. Assessment for underlying abnormalities should be guided by clinical findings. Treatment options are varied in effectiveness, side-effects, and costs. Combination therapy with multiple modalities of treatment may afford the most effective results.

References

1. Kvedar JC, et al. J Am Acad Dermatol 12(2 Pt 1):215-25 (1985 Feb).
2. Kopera D, et al. Int J Trichology 2(1):30-5 (2010 Jan).
3. McKnight E. Lancet 1(7330):410-3 (1964 Feb 22).
4. Fava GA, et al. Psychother Psychosom 51(2):96-100 (1989).
5. Escobar-Morreale HF. Ann N Y Acad Sci 1205:166-74 (2010 Sep).
6. Harrison S, et al. Cleve Clin J Med 77(6):388-98 (2010 Jun).
7. Rosenfield RL. N Engl J Med 353(24):2578-88 (2005 Dec 15).
8. Lipton MG, et al. J Psychosom Res 61(2):161-8 (2006 Aug).
9. Shenenberger DW, et al. Am Fam Physician 66(10):1907-11 (2002 Nov 15).
10. Lapidoth M, et al. Dermatology 221(1):34-42 (2010 Aug).
11. Alajlan A, et al. J Am Acad Dermatol 53(1):85-8 (2005 Jul).
12. Liew SH. Dermatol Surg 25(6):431-9 (1999 Jun).
13. Wolf JE, Jr., et al. Int J Dermatol 46(1):94-8 (2007 Jan).
14. Hickman JG, et al. Curr Med Res Opin 16(4):235-44 (2001).
15. Hamzavi I, et al. J Am Acad Dermatol 57(1):54-9 (2007 Jul).