What are the treatment options for hirsutism (excessive hair growth) on the face and chin?

Treatment of Facial and Chin Hirsutism

Start with combined oral contraceptives (OCCs) as first-line pharmacologic therapy, and add spironolactone 100-150 mg daily if inadequate response after 6-9 months, while simultaneously using laser hair removal as an essential adjunct to address both the hormonal cause and cosmetic concerns. 1

Initial Assessment

Before initiating treatment, obtain laboratory evaluation to identify underlying causes and guide therapy:

• Measure free and total testosterone, DHEA-S, androstenedione, LH, and FSH to assess androgen levels and exclude other endocrine causes 1
• Screen for metabolic abnormalities including fasting glucose and lipid profile, as these guide treatment decisions 1
• Calculate BMI and waist-hip ratio, since obesity significantly impairs treatment efficacy 1

First-Line Approach: Lifestyle Modification

Weight loss of as little as 5% of total body weight significantly improves hirsutism by reducing testosterone levels and improving metabolic parameters 1:

• Target an energy deficit of 500-750 kcal/day combined with regular exercise 1
• This approach reduces Ferriman-Gallwey scores by a mean difference of -1.19 points 1
• Weight loss is particularly critical as obesity negatively impacts all other treatment modalities 1

Pharmacologic Treatment Algorithm

Step 1: Combined Oral Contraceptives (First-Line)

OCPs suppress ovarian androgen secretion and increase sex hormone-binding globulin, making them the recommended initial pharmacotherapy 1, 2:

• Use OCPs with antiandrogenic activity as monotherapy for the first 6-9 months 2
• This addresses the hormonal imbalance at its source 3

Step 2: Add Antiandrogen Therapy (If Inadequate Response)

If clinical improvement is insufficient after 6-9 months of OCP monotherapy, add spironolactone 100-150 mg daily 1, 2:

• Spironolactone achieves improvement in 85% of patients, with complete remission in 55% 1
• The combination of an antiandrogen with ovarian suppression is more effective than either alone 4, 3
• Alternative antiandrogens include flutamide (though hepatotoxicity concerns limit use) 5, 3 or finasteride 3, 6

Critical caveat: Adequate contraception is mandatory when using antiandrogens due to teratogenic risk 7

Step 3: Consider Insulin Sensitizers (If Metabolic Abnormalities Present)

Use metformin only when metabolic abnormalities such as insulin resistance or prediabetes coexist with hirsutism 1:

• Metformin improves metabolic parameters but has insufficient evidence for hirsutism as the sole indication 1
• It is effective for hirsutism when combined with hyperinsulinemia and hyperandrogenism, but not for hirsutism alone 2

Essential Adjunctive Treatment: Laser Hair Removal

Laser hair removal is an essential adjunct to systemic therapy and must be combined with medical management to address underlying androgen excess 1:

• Multiple laser treatments are typically needed for optimal results 4
• Laser addresses the cosmetic symptom while medical therapy treats the hormonal cause 4
• Concomitant medical management directed at reducing androgen levels is necessary for best outcomes 4

Topical Adjunctive Therapy

Topical eflornithine 13.9% cream can be used as an adjuvant when combined with systemic medications or laser/photoepilation 2, 3:

• This provides additional cosmetic benefit but is not sufficient as monotherapy 2

Timeline Expectations

All pharmacologic therapies require at least 6 months of treatment before assessing efficacy due to the length of the hair growth cycle 6:

• Hair growth cycles necessitate prolonged treatment before visible improvement 6
• Switching treatments prematurely leads to suboptimal outcomes 6

Special Populations

For women seeking pregnancy, do not use OCPs; instead, use clomiphene citrate as first-line for ovulation induction 1

For severe obesity with inadequate response to lifestyle modification, bariatric surgery may be considered, with over 90% achieving moderate resolution of hirsutism by 1 year post-surgery 1

Common Pitfalls to Avoid

• Do not use monotherapy with mechanical hair removal alone (shaving, waxing, plucking) as these provide only temporary effects and do not address the underlying hormonal cause 6
• Do not prescribe antiandrogens without adequate contraception due to teratogenic risk 7
• Do not switch treatments before 6 months as the hair growth cycle requires this duration to assess efficacy 6
• Do not use metformin for hirsutism alone without documented metabolic abnormalities 1