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Don't Miss the Diagnosis in Cases of Excess Hair : Women who seek laser hair removal should be screened for systemic disease.


 

From the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons

NAPLES, FLA. — Many women with hirsutism have already removed their excess, unwanted hair before they present. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, to identify important medical conditions associated with excess hair growth.

“Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings.” Accurate diagnosis also optimizes dermatology treatment. “Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result],” Dr. Olsen said at the meeting.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum levels of dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. “You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone.” In addition, she added, “I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases.”

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

“One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease,” Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said.

To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls.

These girls also will have advanced bone age but premature closure of epiphyses, “so, ultimately, they have short adult stature,” she said. In adult women, it is important to include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. “If someone is suddenly developing hirsutism, that should be in the back of your mind.”

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the U.S. Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair.

“It decreases the rate of hair growth and amount of shaving a woman has to do,” Dr. Olsen said. “It's a decrease in the rate of hair growth only” and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

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