Hirsutism is a word derived from the Latin word 'hirsutus' meaning 'hairy' or 'shaggy' and is a term used for excess facial and body hair growth.It occurs in about 5-15% of women between the age of 18 and 45 and is more common in Southern European and South Asian women. It is a distressing condition and often leads to avoidance of social situations, anxiety and depression. The main sign of hirsutism is coarse and pigmented body hair, which appear on areas of the body where hair is not commonly found in women, particularly the face, chest and back.Treatment of hirsutism is usually a combination of medical and physical procedures.

Hirsutism

Around 5-15% of women between the age of 18 and 45 suffer from hirsutism. Globally, it is more common in Southern European and South Asian women. The condition is distressing and often leads to avoidance of social situations, anxiety and depression. It is mainly a cosmetic and psychological condition but may also be a sign of a more serious underlying condition, especially if it develops rapidly {1, 2}.

What is Hirsutism?

Hirsutism is a word derived from the Latin word 'hirsutus' meaning 'hairy' or 'shaggy' and is a term used for excess facial and body hair growth. It refers to male pattern distribution of hair mostly found in women, and is a problem with potential medical, social, and physiological implications for millions of women. Hirsutism is both a cosmetic and physiological condition which can affect your everyday life {1}.

The human hair structure

Body hair is a complex structure and consists of a shaft, root and a follicle. The most common theory is that hair evolved from the scales of a reptile. However there is no evidence to suggest that this took place as hair and scales preserve very well and there is no fossil record which has been found even after centuries of searching {3} .

Another theory suggests that primates known as apes were our ancestors and we have evolved over centuries to become the humans we are today. However if this was the case then why are apes still around today? And how did we get rid of all the fur on primate's bodies? {3}.

Hair is comprised of mainly proteins (88%). These proteins are of a hard fibrous type known as keratin. The keratin protein is comprised of polypeptide chains which are made up of many amino acids. Peptide bonds hold these amino acids together in pairs. The polypeptide that forms the keratin protein found in human hair is referred to as the a (alpha) helix. In the organization of a single strand of hair 3 alpha helices are twisted together to form a "protofibril". This is actually the first fibril structure of the hair {4}.

Types of hair

Generally, there are 3 types of hair:

1. Lanugo is soft hair covering skin of foetus

2. Vellus is soft and short hair covering hairless areas of the body

3. Terminal is longer and coarse in texture. For example the eyebrows, eyelashes, scalp hair, pubic and axillary hair in both sexes, and much of the body and facial hair of men.

Facial and body hair of women are mainly of the vellus type, and hirsutism is a vellus to terminal hair transformation {1}.

What stimulates hair growth?

Hair is made up of keratin and other protein fibers, and grows in cycles which is not synchronised in human beings. Each hair enters phases of the growth cycle at different times. There are three phases of the hair growth cycle: anagen, catagen and telogen. Anagen is the phase of active hair growth. The hair remains in this phase from 2 to 6 years, depending on skin region. After anagen is completed, the hair enters the catagen phase; this phase usually lasts around 2-3 weeks where the matrix cells gradually stops dividing and eventually keratinizes (develops keratin). When full keratinisation is achieved, the hair enters the last phase of the cycle, telogen. The telogen phase lasts around 3-4 months during which the keratinized hair falls out, and a new matrix is gradually formed. A new hair is born and the follicle is back in anagen phase {5}.

Causes of Hirsutism

Hirsutism is caused by an excess production of androgens {6}. Androgens are hormones in our body, which are responsible for distribution of body hair and are also responsible for the rate of hair growth. They facilitate the transformation of vellus to terminal hairs in androgen-sensitive areas, including: non-sexual, ambosexual and sexual areas.

• Non-sexual skin areas are typically independent of the effect of androgens, and include eyelashes, eyebrows, lateral and occipital aspects of the scalp.

• Ambosexual skin areas, for example, lower pubic triangle and axillae, are quite sensitive to androgens. Minimal increases of adrenal androgens observed in early puberty are sufficient for the development of terminal hair in these areas.

• Sexual skin areas respond only to high concentrations of androgens. These areas include the face, chin, chest, lower abdomen, lower back upper thighs, upper arms, and upper pelvic triangle. Terminal hairs in these areas are typically masculine, but in females constitute hirsutism.

Severe hirsutism is usually caused by high level of androgen, which can be brought about by a number of medical conditions. These include:

1. Idiopathic Hirsutism is the most common form of hirsutism, where the cause of excessive hair growth is unknown. This form of hirsutism is thought to be hereditary and as such, there would be a family history of the condition. Women who suffer from idiopathic hirsutism typically have no other symptoms associated with other forms of hirsutism apart from excessive hair growth.

2. Polycystic ovary syndrome (PCOS) , a common condition caused by an imbalance in sex hormones, causing irregular periods, infertility, obesity, and oftentimes multiple cysts on the ovaries. PCOS is known to be the most common identifiable cause of hirsutism and is present in about 70 to 80% of women suffering from hirsutism {1, 7}.

3. Late-onset congenital adrenal hyperplasia , which is an inherited condition involving an abnormal production of steroid hormones, such as androgen and cortisol, and is an underlying cause of hirsutism in 2-5% of women with hirsutism.

4. Cushing's syndrome , which occurs when the body is exposed to an excess of cortisol over a long period of time. Cortisol is a steroid hormone, involved in the body's response to stress. An increase in cortisol levels disrupts the balance of sex hormones in the body; this can lead to hirsutism {7}.

5. Tumours , particularly androgen secreting tumours of the ovary or adrenal, although these rarely cause hirsutism {8}.

6. Medications , such as danazol, used in the treatment of women with endometriosis, can cause hirsutism in susceptible individuals {7, 8}.

Symptoms of Hirsutism

The main sign of hirsutism is coarse and pigmented body hair, which appear on areas of the body where hair is not commonly found in women, particularly the face, chest and back. Where hirsutism is caused by excessively high androgen levels, symptoms may also include acne, balding, decreased breast size, a deepening voice, and increased muscle mass.

Risk factors

These include,

1. Family history

2. Ethnicity – Idiopathic hirsutism is more likely to be found in women of Mediterranean , South Asian and Middle Eastern origin.

3. Lack of ovulation

4. Use of steroid hormones, particularly androgens

5. Disorders of the adrenal glands

Treatment

Treatment of hirsutism must be a combination of medical and physical procedures.

1. Medical treatments help to decrease or slow down excess hair growth. Medications include spironolactone, oral contraceptive pills, finasteride, cyproterone acetate, flutamide, metformin, and eflornithine hydrochloride.

2 Physical methods have been established as the best method for cosmetic hair removal. These include bleaching, plucking, waxing, shaving, depilatory creams and electrolysis.

• Bleaching involves the use of a bleaching product, which will help lighten hair rather than remove it. This method is used to disguise unwanted facial hair in order to achieve an even tone. Bleaching agent hydrogen peroxide and activator ammonium bicarbonate, act together as agents to bleach the hair. The disadvantages of bleaching include skin irritation and temporary skin discolouration.

• Plucking hair using tweezers is an effective way to remove hair but can be very time consuming. The hair shaft must be long enough to grasp with tweezers. This mode of hair removal can be unpredictable, possibly resulting in hyperpigmentation, scarring and ingrown hairs.

• Waxing is an effective method of removing large amounts of hair at one time. In this method wax is warmed or can be used cold. However warm wax allows it to be spread easily over the skin in the direction of the hair growth. A piece of cotton or a waxing strip can then be laid onto the area being treated and then it should be pulled back stripping the hair out of its follicles.

Removing hair by waxing can be painful, and can cause hyperpigmentation and scarring.

• Shaving involves using a razor to remove the tip of the hair shaft that has grown up through the skin. Razors come in a bunch of different forms. There are standard razors that are either completely disposable or have a disposable blade that needs to be replaced regularly, and there are also electric razors.

Shaving can produce adverse effects which include skin irritation, cuts in the skin, the need to shave daily and stubbles.

• Depilatory creams are products which are very strong alkali. They affect the hair by decomposing it at skin level and fractionally, into the mouth of the follicle. This is because being cream it can go a little deeper than a razor giving better results. This technique of hair removal works very well by removing the hair on a temporary basis.

You may also find that depilatory creams include and cause skin irritation, burns, ingrown hairs and allergic reaction like contact dermatitis.

• Electrolysis is another hair removal method. Each individual hair is treated by inserting a tiny surgical probe into the hair follicle and directing a split second impulse of energy down to the root hair. The hair can then be lifted out and the technique can be repeated over and over until the desired area is cleared.

This technique may cause a change in pigmentation and irritation as well as redness . Procedure is painful and there is a possibility of some hair regrowth.

Other methods include,

• Galvanic electrolysis , which uses direct current electrolysis, which means a direct electric current, is passed down a needle into the hair follicle where it creates a chemical reaction. This reaction converts tissue saline into sodium hydroxide, a caustic agent that then destroys the hair bulb.

This technique may cause partial to full regrowth of hair and may cause lasting skin damage and spread of infection.

• Epilation involves the use of an epilator, which is an electrical device used to remove hair by mechanically grasping multiple hairs simultaneously and pulling them out. The way in which epilators pull out hair is similar to waxing as the hair is pulled out from the roots which maybe painful.

The long term effects of epilation on the hair follicle are not known however, you may experience some redness. This may be because epilation attempts to destroy the hair follicle and repetitive epilation may result in permanent matrix damage, resulting in finer or thinner hairs.

• Sugaring , also known as sugar waxing is a popular form of hair removal that works in the same way traditional waxing does. A thick sugary substance similar to caramel is spread on the skin in the direction of hair growth. The hair becomes embedded in the caramel. A cloth or a waxing strip is then patted onto the caramel and then pulled off quickly in the opposite direction of the hair growth, pulling the hairs out of the follicles. The advantage of this method over traditional waxing is the clean up. The sugar substance is water-soluble and can be removed easier than wax by rinsing with water.

Sugaring may also cause adverse effects which include pain, hyperpigmentation and scarring.

• Laser pigment hair removal where the laser uses a beam of light, which penetrates the skin and is absorbed by the pigment colour in the hair where it is converted to heat. The heat travels down the hair shaft to the hair root and destroys it so that further hair cannot grow.

Using this technique of permanent hair removal may cause redness in the area treated. It may also feel very hot and you may notice a few scabs forming a short while after.

3. Alternative treatments include herbal preparations, which contain herbal extracts such as Saw palmetto ( Serenoa repens ); however, like most herbal treatments, there are limited safety data and few controlled trials of their effect {9}.

Tips for prevention

1. Obesity causes severe Hirsutism. Therefore, women should take up weight loss programme which helps in decreasing serum insulin levels and androgen production.

2. For overweight women with PCOS(Polycystic Ovary Syndrome), even a 5% weight reduction can bring about significant improvement in biochemical profile

3. Habits of healthy eating and daily exercise help in controlling excess growth of hair.

4. Mechanical removal of hair by shaving, bleaching, plucking, or chemical depilation. Shaving may result in folliculitis and ingrown hair. Waxing and plucking may be effective, but they carry the risk of skin irritation, folliculitis and ingrown hairs

5. Combination of electrolysis and thermolysis shows efficacy of 15-50% permanent hair loss with repeated treatment.

6. Laser hair removal treatment is safe and effective unless a course of treatment is taken up.