Chapter 55. Hirsutism

• Excess coarse body hair in sex hormone–dependent areas
• Only in women and children
• Ferriman–Gallwey score ≥8 (Fig. 55–1)
• Adult male distribution pattern
• Testing for elevated androgens is not recommended in mild cases.
• Main causes are polycystic ovary syndrome, idiopathic, congenital adrenal hyperplasia, androgen-secreting tumors, Cushing syndrome, acromegaly, drugs.
• Topical and/or systemic treatments control hirsutism in most cases.
• Allow 4–6 months for any treatment to be effective.

Hirsutism, unwanted hair growth, is a common and distressing condition that, although often thought to be a cosmetic problem, significantly affects psychologic well-being. In Western society, excessive facial or body hair in women is unacceptable. Women who do not conform to a prevailing feminine ideal of physical appearance because of hirsutism may feel unattractive and suffer from low self-esteem, and such women may find social interactions difficult. Hirsutism is however, more than a cosmetic problem because it usually represents a hormonal imbalance, resulting from a subtle excess of androgens that may be of ovarian origin, adrenal origin, or both. The underlying cause of hirsutism is usually polycystic ovary syndrome (PCOS). It is important to differentiate idiopathic hirsutism from other causes. Physicians should be familiar with therapies for these conditions.

Hair Growth Cycle

The hair growth cycle comprises 3 phases: anagen (growth phase), catagen (involution phase), and telogen (rest phase). Hormonal regulation plays an important role in the hair growth cycle in a site-specific pattern. Androgens increase hair follicle size, hair fiber diameter, and the proportion of time terminal hairs spent in the anagen phase. Androgen excess in women leads to increased hair growth in most androgen sensitive sites, but will manifest with loss of hair in the scalp region, in part by reducing the time scalp hairs spends in the anagen phase.

The Sebaceous Glands

The sebaceous glands are microscopic glands in the skin that secrete an oily/waxy matter, called sebum, to lubricate the skin and hair. They are found in greatest abundance on the face and scalp, though they are distributed throughout all skin sites except the palms and soles.

Types of Hair

Hair can be categorized as either vellus (fine, soft, and not pigmented) or terminal (long, coarse, and pigmented). Follicle size and type of hair can change in response to numerous factors, particularly androgens. Nonetheless, the number of hair follicles does not change over an individual's lifetime.

The Role of Androgens

Androgens are necessary for terminal hair and sebaceous gland development and mediate differentiation of pilosebaceous units into either a terminal hair follicle or a sebaceous gland. In the former case, androgens transform the vellus hair into a terminal hair; in the latter, the sebaceous component proliferates and the hair remains vellus.

Male-Pattern Hair Growth

Male-pattern hair growth occurs in sites where relatively ...