Hirsutism: An Evidence-Based Treatment Update

Background

Hirsutism has a relatively high prevalence among women. Depending upon societal and ethnic norms, it can cause significant psychosocial distress. Importantly, hirsutism may be associated with underlying disorders and co-morbidities. Hirsutism should not simply be looked upon as an issue of cosmesis. Patients require appropriate evaluation so that underlying etiologies and associated sequelae are recognized and managed. Treatment of hirsutism often requires a multidisciplinary approach, and a variety of physical or pharmacologic modalities can be employed. Efficacy of these therapies is varied and depends, among other things, upon patient factors including the underlying etiology, hormonal drive, and local tissue sensitivity to androgens.

Objective

The objective of this paper is to review and summarize current evidence evaluating the efficacy of various treatment modalities for hirsutism in premenopausal women.

Methods

Online databases were searched to identify all relevant prior systematic reviews and meta-analyses as well as recently published (2012–present) randomized controlled trials (RCTs) on hirsutism treatment.

Results

Four recently published RCTs met criteria for inclusion in our review. In addition, one meta-analysis and one systematic review/treatment guideline were identified in the recent literature. Physical modalities and oral contraceptive pills (OCPs) remain first-line treatments. Evidence supports the use of electrolysis for permanent hair removal in localized areas and lasers (particularly alexandrite and diode lasers) for permanent hair reduction. Topical eflornithine can be used as monotherapy for mild hirsutism and as an adjunct therapy with lasers or pharmacotherapy in more severe cases. Combined OCPs as a class are superior to placebo; however, antiandrogenic and low-dose neutral OCPs may be slightly more efficacious in improving hirsutism compared with other types of OCPs. Antiandrogens are indicated for moderate to severe hirsutism, with spironolactone being the first-line antiandrogen and finasteride and cyproterone acetate being second-line antiandrogens. Due to its risk for hepatotoxicity, flutamide is not considered a first-line therapy. If used, the lowest effective dose should be administered with careful monitoring of liver enzymes. Monotherapy with an insulin sensitizer does not significantly improve hirsutism. While insulin sensitizers improve important metabolic and endocrine aberrations in polycystic ovary syndrome, they are not recommended when hirsutism is the sole indication for use. Lifestyle modification counseling is recommended. Gonadotropin-releasing hormone analogs and glucocorticoids are only recommended in specific circumstances. Additional therapies without sufficient supportive evidence of efficacy are ovarian surgery, statins (HMG-CoA reductase inhibitors), and vitamin D supplementation.

Limitations

In general, most therapies garner recommendations that are weak (where the estimates of benefits versus risks of therapy are either closely balanced or uncertain) and are based on low- to moderate-quality evidence.

Conclusions

Risks and benefits of treatment must be carefully considered and discussed with the patient. Expectations for efficacy should be appropriately set. A minimum of 6 months is required to see benefit from pharmacotherapy and lifelong treatment is often necessary for sustained benefit.     

Allogeneic bone marrow transplantation in a 7-year-old girl with congenital erythropoietic porphyria: a treatment dilemma

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Granulomas in common variable immunodeficiency: a diagnostic dilemma

A 60-year-old man with common variable immunodeficiency presented with a 7-year history of violaceous plaques and papules on the thighs, arms and trunk. In the preceding 2 years he had developed new lesions on both hands. He had been previously diagnosed with sarcoidosis on the basis of skin and visceral histology, but subsequent opinion was that these were sarcoid-like granulomas rather than being representative of true sarcoidosis. Biopsy of the hand lesions showed necrotizing granulomas, and a single acid-fast bacillus (AFB) was identified on Wade-Fite stain. Subsequent repeat tissue biopsies for histology, culture and polymerase chain reaction testing failed to confirm the presence of mycobacterial organisms and it was felt that the organism was a contaminant introduced during tissue processing. The hand lesions responded well to intralesional injections of triamcinolone acetonide 10 mg/mL and oral tetracycline 500 mg b.d. was later introduced with a good clinical response. The diagnostic dilemma of finding granulomatous inflammation in a patient with common variable immunodeficiency, and the significance of a single AFB on histology are discussed. The treatment of sarcoid-like granulomas with tetracycline therapy is also commented on.     

Kikuchi–Fujimoto disease: a diagnostic dilemma

Kikuchi–Fujimoto disease is a benign, self‐limiting condition characterized by lymphadenopathy and fever. Its diagnosis can be challenging, as the disease must be differentiated from lymphoma and systemic lupus erythematosus. Patients can present with nonspecific cutaneous lesions. Adequate clinical and histopathologic correlation can aid in the timely diagnosis of Kikuchi's disease, thus preventing the use of unnecessary diagnostic procedures and inappropriate treatments.     

Scleromyxedema,a therapeutic dilemma

Scleromyxedema is characterized by indurated erythematous papules disseminated on the face, chest and limbs. About twenty cases treated with thalidomide, stem cells, melphalan and immunoglobulin with varying results have been described. We present the case of a 28-year-old male patient diagnosed with scleromyxedema not associated with monoclonal gammopathy, multi-treated with anti-leprosy drugs, UVA1, and thalidomide for 4 years with no improvement.     

Hirsutism, postpartum telogen effluvium, and male pattern alopecia

This paper reviews the interrelating factors affecting hair growth. It presents current data on the development of alopecia and hirsutism in males and females and the newer approaches to treatment.     

Ingrown and pincer nails: evaluation and treatment

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Assessing the severity of allergic reactions: a regulatory dilemma

The identification of chemicals possessing the intrinsic ability to cause sensitization via skin contact or inhalation, commonly referred to as skin and respiratory sensitizers, is a key endpoint in regulatory toxicology. Predictive assays for this purpose exist only for skin sensitizers, but, for both types of sensitizer, human evidence can be used to determine whether a substance should be classified. Furthermore, the use of human evidence for subcategorization according to sensitization potency is also accommodated within the regulations. Normally, this is based on the prevalence of sensitization in relation to the degree of exposure in the context of the size of the population exposed. However, the regulations also indicate that the severity of (allergic) reactions may be taken into account. In this article, we consider whether this is appropriate and whether there is evidence that reaction severity can inform decisions on classification and/or potency categorization. The conclusion drawn is that the severity of an allergic reaction does not correlate with, or serve as an indicator of, the sensitizing potency of a chemical. In reality, it reflects the overall extent of sensitization that an individual has acquired, in concert with the concentration of the causative allergen to which they have been exposed.     

Odontogenic sinus tract to the chin: a diagnostic dilemma

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Hirsutism secondary to topical testosterone: report of two cases and review of the literature

Topical testosterone has been used as a treatment for different vulvar conditions. It is usually well tolerated, although hirsutism and other signs of virilization have been described related to hormonal tests alteration. We report two female patients with vulvar diseases that developed hirsutism after treatment with topical testosterone. Because of its potential virilization, females under this treatment should be closely monitored.     

Naproxen-induced pseudoporphyria presenting a diagnostic dilemma

A case of clinical porphyria cutanea tarda posed a diagnostic dilemma when screening tests for porphyrinuria gave negative results and two skin biopsy specimens failed to show the histologic picture of porphyria cutanea tarda, pseudoporphyria, or epidermolysis bullosa acquisita. The dilemma was resolved when the eruption cleared following elimination of naproxen from the patient's treatment. Subsequent naproxen challenge resulted in new bullae on the dorsum of the hands.