Unwanted facial and body hair is a common problem that can be a source of distress for both men and women.
Hirsutism is the excessive hairiness on women in those parts of the body where terminal hair does not normally occur or is minimal – for example, a beard or chest hair. It refers to a male pattern of body hair (androgenic hair) and it is therefore primarily of cosmetic and psychological concern. Hirsutism is a
medical sign rather than a disease and may be a sign of a more serious medical condition, especially if it develops well after puberty.
Signs and symptoms
Hirsutism affects women and sometimes men, since the rising of androgens causes a male pattern of body hair, sometimes excessive, particularly in locations where women normally do not develop terminal hair during puberty (chest, abdomen, back and face). The medical term for excessive hair growth that affect both men and women is hypertrichosis.
Hirsutism can be caused by either an increased level of androgens, the male hormones, or an oversensitivity of hair follicles to androgens. Male hormones such as testosterone stimulate hair growth, increase size and intensify the growth and pigmentation of hair. Other symptoms associated with a high level of male hormones include acne, deepening of the voice, and increased muscle mass.
Growing evidence implicates high circulating levels of insulin in women for the development of hirsutism. This theory is speculated to be consistent with the observation that obese (and thus presumably insulin resistant hyperinsulinemic) women are at high risk of becoming hirsute. Further, treatments that lower insulin levels will lead to a reduction in hirsutism. It is speculated that insulin, at high enough concentration, stimulates the ovarian theca cells to produce androgens. There may also be an effect of high levels of insulin to activate insulin-like growth factor 1 (IGF-1) receptor in those same cells. Again, the result is increased androgen production.
Signs that are suggestive of an androgen-secreting tumor in a patient with hirsutism is rapid onset, virilization and palpable abdominal mass.
The following may be some of the conditions that may increase a woman’s normally low level of male hormones:
- Polycystic ovary syndrome (PCOS), the most common cause
- Congenital adrenal hyperplasia, in turn mostly caused by 21-α hydroxylase deficiency
- Cushing’s disease
- Growth hormone excess (acromegaly)
- Tumors in the ovaries
- adrenal gland cancer, Von Hippel–Lindau disease
- Insulin resistance
- Stromal hyperthecosis (SH) – in postmenopausal women
- Obesity: As there is peripheral conversion of androgens to estrogen in these patients, this is the same mechanism as polycystic ovary syndrome, PCOS.
- Use of certain medications such as tetrahydrogestrinone, phenytoin, minoxidil
- Porphyria cutanea tarda
Diagnosis of patients with even mild hirsutism should include :
- Assessment of ovulation and ovarian ultrasound (because of the high prevalence of polycystic ovary syndrome),
- Assessment of 17-hydroxyprogesterone (because of the possibility of finding nonclassic 21-hydroxylase deficiency).
Other blood value that may be evaluated in the workup of hirsutism include:
- The androgens testosterone and dehydroepiandrosterone sulfate
- Thyroid-stimulating hormone
- If no underlying cause can be identified, the condition is considered idiopathic.
Many women with unwanted hair seek methods of hair removal. However, the causes of the hair growth should be evaluated by a physician, who can conduct blood tests, pinpoint the specific origin of the abnormal hair growth, and advise on the treatment.
Pharmacological treatments include:
- Spironolactone: Antialdosterone antiandrogenic compound.
- Cyproterone acetate: A progestin that also has strong antiandrogenic action. In addition to single form, it is also available in some formulations of combined oral contraceptives.
- Finasteride: 5 alpha reductase inhibitor that inhibits conversion of testosterone to more active 5 alpha hydroxy testosterone
- Metformin: Antihyperglycemic drug used for diabetes mellitus. However, it is also effective in treatment of hirsutism associated with insulin resistance (e.g. polycystic ovary syndrome)
- Eflornithine: Blocks putrescine that is necessary for the growth of hair follicles
- Flutamide: Androgen receptor antagonist. The most effective treatment that was tested is the oral flutamide for one year. Seventeen of eighteen women with hirsutism treated with combination therapy of flutamide 250 mg twice daily and an oral contraceptive pill had a rapid and marked reduction in their hirsutism score. Amongst these, one woman with pattern hair loss showed remarkable improvement.
- Combination oral contraceptives
- Laser hair removal
- Lifestyle change, including reducing excessive weight and addressing insulin resistance, may be beneficial. Insulin resistance can cause excessive testosterone levels in women, resulting in hirsutism. One study reported that women who stayed on a low calorie diet for at least six months lost weight and reduced Insulin Resistance. Their levels of Sex hormone-binding globulin (SHBG) increased, which reduced the amount of free testosterone in their blood. As expected, the women reported a reduction in the severity of their hirsutism and acne symptoms.
Hypertrichosis (also called Ambras syndrome) is an abnormal amount of hair growth over the body; extensive cases of hypertrichosis have informally been called werewolf syndrome, because the appearance is similar to the werewolf. The two distinct types of hypertrichosis are generalized hypertrichosis, which occurs over the entire body, and localized hypertrichosis, which is restricted to a certain area. Hypertrichosis can be either congenital (present at birth) or acquired later in life. The excess growth of hair occurs in areas of the skin with the exception of androgen-dependent hair of the pubic area, face, and axillary regions.
Two methods of classification are used for hypertrichosis. One divides them into either generalized versus localized hypertrichosis, while the other divides them into congenital versus acquired.
Congenital forms of hypertrichosis are caused by genetic mutations, and are extremely rare, unlike acquired forms. Congenital hypertrichosis is always present at birth.
Congenital hypertrichosis lanuginosa is noticeable at birth, with the infant completely covered in thin lanugo hair. In normal circumstances, lanugo hair is shed before birth and replaced by vellus hair; however, in a person with congenital hypertrichosis lanuginosa, the lanugo hair remains after birth. The palms of the hands, soles of the feet, and mucous membranes are not affected. As the person ages, the lanugo hair may thin, leaving only limited areas of hypertrichosis.
Acquired hypertrichosis appears after birth.
The multiple causes include the side effects of drugs, associations with cancer, and possible links with eating disorders. Acquired forms can usually be reduced with various treatments.
Hypertrichosis is often mistakenly classified as hirsutism.
The primary characteristic of all forms of hypertrichosis is excess hair. Hair in hypertrichosis is usually longer than expected and may consist of any hair type (lanugo, vellus, or terminal). Patterned forms of hypertrichosis cause hair growth in patterns. Generalized forms of hypertrichosis result in hair
Hypertrichosis is diagnosed clinically via the occurrence of hair in excess of what is expected for age, sex, and ethnicity in areas that are not androgen- sensitive. The excess can be in the form of excessive length or density and may consist of any hair type (lanugo, vellus, or terminal).
There is no cure for any congenital forms of hypertrichosis. The treatment for acquired hypertrichosis is based on attempting to address the underlying cause. Acquired forms of hypertrichosis have a variety of sources, and are usually treated by removing the factor causing hypertrichosis, e.g. a medication with undesired side-effects. All hypertrichosis, congenital or acquired, can be reduced through hair removal. Hair removal treatments are categorized into two principal subdivisions: temporary removal and permanent removal.
Temporary hair removal may last from several hours to several weeks, depending on the method used. These procedures are purely cosmetic. Depilation methods, such as trimming, shaving, and depilatories, remove hair to the level of the skin and produce results that last several hours to several days. Epilation methods, such as plucking, electrology, waxing, sugaring, threading, remove the entire hair from the root, the results lasting several days to several weeks. Permanent hair removal uses chemicals, energy of various types, or a combination to target the cells that cause hair growth.
Laser hair removal is an effective method of hair removal on hairs that have color. Laser cannot treat white hair. The Laser targets the melanin color in the lower 1/3 of the hair follicle, which is the target zone.
Medication to reduce production of hair is currently under testing. One medicinal option suppresses testosterone by increasing the sex hormone-binding globulin. Another controls the overproduction of hair through the regulation of a luteinizing hormone