Can idiopathic androgenic alopecia and idiopathic hirsutism occur in obese patients with hidradenitis suppurativa, particularly in females with regular menses and a history of Polycystic Ovary Syndrome (PCOS)?

Idiopathic Androgenic Alopecia and Hirsutism in Obese Patients with Hidradenitis Suppurativa and History of PCOS

Idiopathic androgenic alopecia and idiopathic hirsutism can indeed occur in obese patients with hidradenitis suppurativa, including females with regular menses who have recovered from PCOS, as these conditions share common pathophysiological mechanisms related to androgen sensitivity and metabolic dysfunction. 1

Definitions and Pathophysiology

Idiopathic Androgenic Alopecia

• A non-scarring pattern hair loss condition characterized by progressive miniaturization of hair follicles in androgen-dependent areas of the scalp, occurring without identifiable hormonal abnormalities in blood tests 1
• Results from increased sensitivity of hair follicles to normal circulating androgen levels, particularly dihydrotestosterone (DHT) 2

Idiopathic Hirsutism

• Defined as the presence of terminal (coarse) hairs in females in a male-like pattern, with normal ovulatory function and normal circulating androgen levels 3
• Represents less than 20% of all hirsute women when strictly defined 3
• Pathophysiology involves increased 5α-reductase activity in the skin, which converts testosterone to the more potent DHT 3

Relationship with Hidradenitis Suppurativa (HS)

Shared Pathophysiological Mechanisms

• HS is a chronic inflammatory skin disease affecting hair follicles in apocrine gland-bearing areas 1
• Both HS and androgenic skin conditions involve follicular dysfunction and can be mediated by androgens 4
• A study of 42 women with HS found higher concentrations of total testosterone and free androgen index compared to controls, suggesting an androgenic basis for the disease 4

Obesity Connection

• Obesity is highly prevalent in HS patients, with studies showing 5.9% to 73.1% prevalence 1
• Meta-analysis found that patients with HS had 3.5 times higher odds of obesity compared to control individuals 1
• Obesity exacerbates both androgenic skin conditions and HS through:
  • Increased peripheral conversion of androgens in adipose tissue 2
  • Promotion of inflammatory cytokines 1
  • Insulin resistance and hyperinsulinemia 1

PCOS and Its Relationship to These Conditions

PCOS and HS Connection

• Women with HS have twice the adjusted odds of having PCOS compared to control individuals (aOR: 2.14) 1
• A recent large-scale propensity-score-matched cohort study found that PCOS patients have a significantly increased risk of developing HS (HR: 2.061) 5
• The highest risk was observed in younger women (aged 18-39) and those with BMI less than 30 5

PCOS Recovery and Persistent Symptoms

• Even after normalization of menstrual cycles and resolution of polycystic ovarian morphology, women may continue to experience androgenic symptoms 1
• This occurs because:
  • Underlying insulin resistance may persist 1
  • Androgen receptor sensitivity in target tissues remains heightened 3
  • Skin 5α-reductase activity may remain elevated 3

Clinical Presentation and Diagnosis

Key Clinical Features to Assess

• Pattern of hair loss: diffuse thinning of crown with preservation of frontal hairline in women 1
• Distribution of excess hair growth: upper lip, chin, chest, abdomen, and back 3
• Presence of comedones in apocrine sites (a key early diagnostic sign for HS) 4
• Assessment of inflammatory nodules, abscesses, and sinus tracts in intertriginous areas 1

Diagnostic Approach

• Exclude other causes of hyperandrogenism through hormonal evaluation:
  • Total and free testosterone, DHEA-S, androstenedione 1
  • Luteinizing hormone and follicle-stimulating hormone 1
• Assess ovulatory function even in women with regular menses, as up to 40% of eumenorrheic hirsute women may be anovulatory 3
• Evaluate for metabolic abnormalities: fasting glucose, lipid profile, blood pressure 1

Management Considerations

For Androgenic Alopecia

• Topical minoxidil is the first-line treatment 1
• Anti-androgens (spironolactone, finasteride) may be considered with appropriate contraception 1
• Low-dose oral contraceptives containing anti-androgenic progestins can be beneficial 1

For Hirsutism

• Mechanical hair removal (shaving, waxing) and/or laser therapy for immediate cosmetic improvement 1
• Topical eflornithine hydrochloride cream is FDA-approved for facial hirsutism 1
• Combined medical interventions (anti-androgen plus ovarian suppression) are most effective 1

For Hidradenitis Suppurativa

• Weight loss and smoking cessation are important lifestyle modifications 1
• Adalimumab is recommended as first-line treatment for moderate to severe HS unresponsive to antibiotics (NNT: 4) 1
• Surgical interventions (deroofing, local excision) may be necessary based on scarring extent 1

Addressing Obesity

• Weight loss of as little as 5% can improve both metabolic and reproductive abnormalities 1
• Anti-obesity medications may be considered as adjuncts to lifestyle modification 1
• Regular exercise program is beneficial even without weight loss 1

Important Clinical Considerations

• These conditions can significantly impact quality of life, causing depression, anxiety, and stigmatization 1
• Regular screening for metabolic comorbidities is essential in these patients 1
• Treatment response may be slower in patients with multiple overlapping conditions 1
• Multidisciplinary management involving dermatology, endocrinology, and gynecology may be necessary 1