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Folliculitis

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Folliculitis



Introduction

Hirsutism is when a woman has excessive hair growth. The hair is usually thick and dark, rather than fine and fair.

Excess hair may appear on the:



face – such as the upper lip or chin



neck



chest



tummy – in a line from your belly button down to your pubic hair



anal and genital area



the front of your thighs



Hirsutism is often associated with other symptoms, including:



oily skin



acne – a skin condition that causes spots to develop on your face, back and chest



hair loss (alopecia)



a receding hair line around the front of your hair



an enlarged clitoris (the small soft bump in front of the entrance to the vagina)



voice changes – such as a deeper voice



When to see your GP

It's important to see your GP if you have hirsutism – especially if you have severe or unusual symptoms – as it can cause psychological harm, including depression, embarrassment and lack of self-confidence.

Your GP will assess the severity of your hirsutism and ask you about any other symptoms before suggesting the best treatment.

What causes hirsutism?

Hirsutism is caused by an excess of male sex hormones called androgens, or an increased sensitivity to androgens.

In most cases, this is caused by polycystic ovary syndrome (PCOS). However, in around 10% of cases there are no obvious causes.

Treating hirsutism

There is no cure for hirsutism, but there are treatments to manage the condition.

There are a number of hair-removal methods that may help, such as:



shaving



plucking



waxing



bleaching



In some cases, these can lead to irritated skin or inflamed hair follicles (folliculitis). Folliculitis usually takes a few weeks to resolve itself and may mean you can't continue removing hair until it clears up.

In some cases (in women who have not yet started the menopause), taking a contraceptive pill may control hirsutism.

There are also a number of unlicensed medications (medicines that have not been specifically tested for this purpose) that are known to be effective.

As the life cycle of hair is around six months, treatment can take this long to work, so it's important to start treatment as soon as possible.

Who is affected?

Hirsutism may affect between one and three women in every 20 who have not yet started the menopause (when a woman’s periods stop).

After the menopause, the change in the balance of hormones can make excess hair more common. Up to three-quarters of older women may have slightly increased facial hair. Hirsutism in post-menopausal women is also known as ovarian hyperthecosis.

Causes of hirsutism 

Hirsutism is caused by an increase in male sex hormones called androgens, or an increased sensitivity to them.

There are several different types of androgens. The most well known is testosterone.

In men, testosterone is involved in making sperm and in the development of male sexual characteristics, such as the voice getting deeper. Testosterone is also found in small amounts in women, where it may:



increase your sex drive



affect your periods (menstrual cycle)



affect your fertility



Testosterone levels may be normal in around half of all women with hirsutism. 

Other androgens include:



dehydroepiandrosterone



androstenedione



These are precursors of testosterone, which means they will go on to become testosterone.

Premenopausal women

There are a number of different causes that may explain hirsutism in women who have not yet started the menopause (when a woman’s periods stop).

However, in around 23% of hirsutism cases, there are no obvious causes. This is known as idiopathic hirsutism.

Polycystic ovary syndrome (PCOS)

Most of the excess androgen activity in premenopausal women is due to an underlying condition known as polycystic ovary syndrome (PCOS).

PCOS is thought to be the cause of hirsutism in around 72% of cases.

PCOS is a condition in which women have a number of small, fluid-filled sacs (cysts) around the edge of their ovaries (the pair of reproductive organs that produce eggs and sex hormones in women).

As well as causing excessive hair growth, PCOS can also cause:



irregular periods



weight gain



acne



Many women with PCOS have an imbalance of male sex hormones, which can include high levels of testosterone.

Increased sensitivity

Just under a quarter of premenopausal women with hirsutism have normal androgen levels. It is thought that if your androgen levels are normal, your body may be more sensitive to them, meaning they have a greater effect on your body.

Other causes

In a small number of cases, hirsutism in premenopausal women may be caused by:



Cushing’s syndrome – a rare hormonal disorder that causes sudden weight gain and bloating around the chest and stomach



congenital adrenal hyperplasia – an inherited condition that affects the adrenal glands (two glands above the kidneys that produce steroid hormones, and male and female sex hormones)



a tumour (growth) that produces androgens



medicines – such as anabolic steroids (drugs that are often used illegally to build muscle and improve athletic performance)



acromegaly – a hormonal disorder that causes the body to produce too much growth hormone, causing abnormal growth of the hands and feet



being overweight or obese – you will be advised to lose weight



Menopausal women

Menopausal women are those who have started the menopause (when a woman’s periods stop) and have not had a period for a year. During the menopause, several of your body's hormones change, which can cause symptoms such as hot flushes.

For some women, as hormone levels change, there will be a high amount of testosterone (an androgen) left in the body, which can cause hirsutism. Hirsutism in post-menopausal women is also known as ovarian hyperthecosis. 

If you think you have hirsutism, see your GP as soon as possible. Hirsutism is a common problem that is easily treated, and it's important that your GP looks for any underlying cause.

Your GP will look for excessive amounts of hair on your body, including on your:



face



chest



thighs (upper legs)



buttocks



As some people have more hair than others anyway, there is no clear definition of when excess hair becomes hirsutism. However, if your excess hair is thick and dark instead of fine and fair, then you may have hirsutism.

Assessing the severity

Your GP may assess the severity of your hirsutism by grading the growth of your hair in different areas of your body. This will be done by:



looking at the hair growth in nine different body areas – including the upper lip, chin, chest and upper arms



grading this hair growth from zero to four – with zero meaning no hair and four meaning heavy hair growth



This will then give you a score from zero to a maximum of 36. Generally, a score above 15 is considered moderate to severe hirsutism.

Finding the cause

As well as diagnosing hirsutism and assessing its severity, your GP will try to find out if there is an underlying cause (see causes of hirsutism). They may ask if:



you have other symptoms, such as irregular periods or weight gain – these can be signs of polycystic ovary syndrome (PCOS)



your hirsutism has come on suddenly – this may a sign of a tumour (growth)



you are taking any medication that may cause hirsutism



Further tests

If your symptoms suggest another condition is causing your hirsutism, you may need further tests, such as:



a blood test to check your levels of testosterone (the male sex hormone)



an ultrasound scan (when high-frequency sound waves are used to create an image of your womb) to look for cysts (fluid-filled sacs) if your GP thinks you may have PCOS



testing a urine sample for the stress hormone cortisol if your GP thinks you may have Cushing’s syndrome (a rare hormonal disorder)



If you do not have any other symptoms and your hirsutism is mild, then further tests are not usually necessary.

Treating hirsutism 

Hirsutism can't be cured, but there are treatments to help control the condition. 

There are a number of things you can do yourself that may help. If you are overweight, losing weight can reduce the production of androgens. Check your body mass index (BMI) using our BMI healthy weight calculator.

Hair removal and treatment

There are a number of ways to remove or disguise excess hair. As these are considered "cosmetic" treatments to improve your physical appearance, they are unlikely to be available on the.

Shaving – quick and easy, and will not make the hair grow back quicker or thicker. However, you may find you have to shave everyday, which may cause irritation. There may also be unpleasant stubble growth between shaves.

Bleaching – can make dark hair look better in the short term, but may irritate your skin and is not effective for everyone.

Waxing, plucking or threading – can reduce regrowth if done regularly, but can be painful and may cause scarring or folliculitis (inflammation of a hair follicle).

Electrolysis – when electricity is used to destroy hair cells and remove hair permanently. However, it takes many treatments over a long time; it can also be painful and may cause scarring or changes to your skin colour (check the electrologist is accredited through the British Institute & Association of Electrolysis).

Laser hair removal – involves powerful beams of light (lasers), which destroy the hair. It can last several months and is more effective on women with pale skin and dark hair.  

Your GP can discuss the different methods with you in more detail. The method that you choose will depend on:



what works for you – if your skin becomes irritated because of one of these hair-removal methods, it can be itchy, look unpleasant and make regrowth worse



what you can afford – electrolysis and laser hair removal may only be available in specialist clinics



If your hirsutism is mild, hair removal methods may be all the treatment you need. However, if the hirsutism is affecting your quality of life, you may require further treatment, such as medication.

Oral contraceptives  

If your hirsutism requires further treatment, you may be prescribed contraceptive pills. These are only suitable if you have not yet started the menopause (when a woman’s periods stop).

You may be prescribed either:



a combined oral contraceptive



co-cyprindiol



Both of these may take at least six months to work. This is because hairs that have already grown live for around six months anyway.

Combined oral contraceptive

Combined contraceptive pills that contain drospirenone, such as Yasmin, suppress androgens (male sex hormones). This means they can be used to treat hirsutism. Drospirenone is anti-androgenic, which means it prevents the androgens from working, thereby preventing excess hair growth.

Combined oral contraceptive pills are usually the first choice of treatment in premenopausal women, and are particularly useful if long-term treatment is necessary.

Co-cyprindiol

Co-cyprindiol (Dianette) contains ingredients that make it anti-androgenic (prevents the androgens from working).

It is used to treat both acne and hirsutism. It was initially used as a contraceptive, and you won't need to take another contraceptive method if you start taking co-cyprindiol for hirsutism.

Once the medication has treated your hirsutism, you should stop taking co-cyprindiol after three or four more 28-day cycles. This is because the risk of venous thromboembolism (a blood clot) is higher if you are taking co-cyprindiol than with other types of oral contraceptives.

Co-cyprindiol will not be suitable if you or anyone in your close family has a history of blood clots.

If your hirsutism returns after you stop taking co-cyprindiol, your GP may recommend starting treatment with it again. Alternatively, you can try changing to a combined contraceptive pill.

Side effects

Both combined contraceptive pills and co-cyprindiol can cause side effects, including:



changes in body weight



breast tenderness



mood changes – such as irritability or a low mood



feeling sick



vomiting



headache



Eflornithine

Eflornithine is an alternative medication that can be prescribed to both premenopausal women and menopausal women (women who have started the menopause). You may be prescribed eflornithine if:



you have mild excess hair growth on your face



hair-removal treatments alone are not effective



contraceptive pills are either not suitable for you or have not worked



Eflornithine is a cream that can be applied thinly to your face twice a day to slow hair growth.

It should be thoroughly rubbed in and you can wear make-up on top if you wish. However, you should not wash your face for at least four hours after applying the cream. 

Eflornithine acts on your hair follicles (the small hole in your skin that an individual hair grows out of) to prevent hair growth. You should notice an effect within six to eight weeks. If no benefit is seen after four months, treatment will be stopped.

If eflornithine works you will need to continue using it, as hair growth will return around eight weeks after you stop using it.

Eflornithine is not suitable if you are pregnant or breastfeeding.

Side effects

Eflornithine can cause side effects, including:



a burning or stinging sensation when you apply the cream 



acne



Referral

Your GP may refer you for further treatment with a specialist, such as an endocrinologist (a specialist in hormone conditions), if:



treatment has not worked after 6 to 12 months



the hair growth gets worse despite treatment 



If your GP suspects an underlying cause for your condition (see causes of hirsutism), they may also refer you to a specialist. For example:



A high level of testosterone in your blood or hirsutism that comes on quickly may indicate a tumour (growth) – your GP may therefore refer you to an oncologist, a doctor who specialises in treating tumours.



Sudden weight gain around your face may be a sign of Cushing’s syndrome, a rare hormonal disorder – your GP may then refer you to an endocrinologist.



 Further treatment 

There are several other medications used to treat hirsutism. However, because many are unlicensed for the treatment of hirsutism, they will only be prescribed by a specialist, not your GP.

Unlicensed medication means manufacturers of the medications have not applied for a licence for it to be used in treating hirsutism. In other words, the medication has not undergone clinical trials (research that tests one treatment against another) to see if it is effective and safe in the treatment of hirsutism.

Many specialists will use an unlicensed medication if they think it is likely to be effective, and benefits of treatment outweigh any associated risk. If your specialist is considering prescribing an unlicensed medication, they should tell you it is unlicensed, and should discuss possible risks and benefits with you.

Some possible alternative medications are explained below.

 Anti-androgens 

Anti-androgens are medications that suppress androgens. This means they prevent androgens from working, which prevents excess hair growth. Possible types of anti-androgens include:



cyproterone acetate



spironolactone



Some of these may be prescribed in combination with contraceptive pills (see above).

One review of a number of different studies found weak evidence to suggest that anti-androgens are effective for treating hirsutism. The review also suggested anti-androgens may work best when combined with other medication, such as contraceptive pills.

Side effects were not reported in the studies that this review looked at.

Finasteride

Finasteride is a type of medication known as a 5-alpha-reductase inhibitor. It works by preventing testosterone (an androgen) from turning into a stronger form of testosterone inside your body’s cells. Finasteride is normally used in men to treat an enlarged prostate gland (a small gland, found only in men, located in the pelvis). 

When finasteride is taken for its usual purpose (to treat men) it can cause side effects, such as:



lip and facial swelling



itchiness



rash



loss of libido (sex drive)



breast tenderness 



Few side effects have been reported when finasteride is used in women, so the above may not apply.

Insulin-sensitising medication

Insulin-sensitising medication makes your body more sensitive to insulin. Insulin is a hormone produced by the pancreas, which is a gland located behind the stomach.

A high amount of insulin in the blood (hyperinsulinaemia) is thought to play a role in causing hirsutism. Because insulin-sensitising medication makes your body more responsive to insulin, your body does not need as much insulin, so produces less of it. The level of insulin in your blood should therefore fall, and your hirsutism may improve.

Possible insulin-sensitising mediations include:



metformin



pioglitazone



rosiglitazone



So far, there is only limited research into the benefits of insulin-sensitising medication for hirsutism. Some research found a small benefit, while some suggested that insulin-sensitising medication is no better than alternative medications already available. Conclusions may change in future if more long-term studies are carried out.

Gonadotrophin-releasing hormone (GnRH) analogues

Gonadotrophin-releasing hormone (GnRH) analogues are synthetic (man-made) hormones. They are used to treat hormone-related conditions, such as endometriosis (a condition in which small pieces of the womb lining are found outside the womb).  

Possible GnRH analogues include:



goserelin



leuprorelin



These may causes side effects, such as:



hot flushes



sweating



dryness or bleeding of the vagina 



rashes



itchiness



For a full list of side effects, see the patient information leaflet that comes with your medication.



Folliculitis