What is an alternative to topical eflornithine (Vaniqa) for treating hirsutism?

Alternatives to Topical Eflornithine for Hirsutism

Spironolactone is the most effective alternative to topical eflornithine for treating hirsutism, with doses of 100-200 mg daily showing significant improvement in most women. 1, 2

First-Line Alternatives

Spironolactone

• Dosing: 50-200 mg daily (most effective at 100-200 mg/day)
• Mechanism: Androgen receptor antagonist that decreases testosterone production and inhibits binding of testosterone and dihydrotestosterone to androgen receptors in the skin 1
• Efficacy: 66% of women show clear or marked improvement with 50-100 mg daily dosing 1
• Onset: Visible improvement typically takes 3-8 months 2
• Considerations:
  • Well-tolerated at lower doses
  • Side effects are dose-related: diuresis (29%), menstrual irregularities (22%), breast tenderness (17%) 1
  • Pregnancy category C - concomitant use of oral contraceptives recommended for sexually active women 1

Combined Oral Contraceptives (COCs)

• Efficacy: Superior to placebo for hirsutism treatment 3
• Best options: Antiandrogenic and low-dose neutral COCs
• Mechanism: Reduce circulating androgens and increase sex hormone-binding globulin
• Timing: Improvement may take 3 months to become apparent 1

Second-Line Alternatives

Other Antiandrogens

• Finasteride: Second-line antiandrogen option 3
• Cyproterone acetate: Second-line antiandrogen (not available in some countries) 3
• Flutamide: Not recommended as first-line due to hepatotoxicity risk 3

Adjunctive Therapies

Physical Hair Removal Methods

• Laser therapy: Particularly alexandrite and diode lasers for permanent hair reduction 3
• Electrolysis: Effective for permanent hair removal in localized areas 3

Combination Approaches

• Combining an oral contraceptive with an antiandrogen is recommended if clinical improvement is insufficient after 6-9 months of monotherapy 4
• Spironolactone + COC is particularly effective for moderate to severe hirsutism

Important Considerations

Patient Selection

• Best candidates for spironolactone:
  • Women with moderate to severe hirsutism
  • Those with PCOS or idiopathic hirsutism
  • Patients who failed topical treatments or have widespread hirsutism

Monitoring

• Regular follow-up every 6 months to monitor:
  • Blood pressure
  • Menstrual cyclicity
  • Improvement in hirsutism
  • Potassium levels (though hyperkalemia is rare in young healthy individuals) 1

Precautions

• Avoid in:
  • Pregnancy (teratogenic)
  • Men (risk of feminization) 5
  • Patients with renal insufficiency
  • Those with history of hyperkalemia

Treatment Algorithm

1. Mild hirsutism:

   • COCs as first-line
   • Add spironolactone 50 mg daily if insufficient response after 3-6 months

2. Moderate to severe hirsutism:

   • Start with spironolactone 100 mg daily + COC
   • Increase spironolactone to 200 mg daily if needed after 6 months
   • Consider adding physical hair removal methods (laser/electrolysis)

3. For all patients:

   • Counsel on realistic expectations (minimum 3-6 months for visible results)
   • Continuous treatment required to sustain effect 5
   • Consider temporary cosmetic measures during treatment initiation period

Practical Tips

• Start with lower doses of spironolactone (50 mg daily) and titrate up as needed 2
• Take spironolactone with food to minimize gastrointestinal side effects
• Divide higher doses (>100 mg) into twice daily dosing to improve tolerability
• Inform patients that hair regrowth occurs within weeks of discontinuing treatment

Spironolactone offers a safe, effective, and well-established alternative to topical eflornithine with the advantage of systemic effects for more widespread hirsutism.