What is the evaluation and management approach for a 10-year-old with hypertrichosis (excessive hair growth) of the upper lip?

Evaluation and Management of Facial Hair Over the Upper Lip in a 10-Year-Old

For a 10-year-old with facial hair over the upper lip, first determine if this represents true hirsutism (androgen-dependent hair growth in a female) versus hypertrichosis (non-androgen-dependent excessive hair growth), as this distinction fundamentally changes the evaluation and treatment approach.

Initial Clinical Assessment

Key Distinguishing Features to Evaluate

• Location specificity: Hirsutism occurs in androgen-dependent areas (upper lip, chin, chest, lower abdomen, inner thighs), while hypertrichosis can occur anywhere 1
• Associated signs of hyperandrogenism: Look for acne, voice deepening, clitoromegaly, increased muscle mass, or rapid progression of hair growth 2, 1
• Medication history: Specifically ask about minoxidil, cyclosporine, diazoxide, or glucocorticosteroids, which cause hypertrichosis 2
• Family history: Determine ethnic background and family patterns of hair growth 3

Modified Ferriman-Gallwey (mFG) Score

• Use the mFG scoring system to objectively assess hair growth in nine androgen-sensitive body areas 1
• A score of 8 or greater is abnormal in premenopausal patients and warrants hormonal evaluation 1

Laboratory Evaluation for Hirsutism

When to Order Labs

If the clinical presentation suggests hirsutism (androgen-dependent pattern) with an mFG score ≥8, obtain a serum total testosterone level 1

Progressive Testing Algorithm

• Initial test: Serum total testosterone 1
• If testosterone is normal but moderate-to-severe hirsutism present: Obtain early morning serum total testosterone AND free testosterone 1
• If total testosterone >1.5 ng/mL: Consider virilizing tumor (ovarian or adrenal) 2
• If DHEA-sulfate >700 μg/dL: Suspect adrenal tumor, especially with hypertension 2

Additional Endocrine Screening (When Indicated)

• 17-OH-progesterone at 8 AM on day 4 of cycle: Detects late-onset 21-hydroxylase deficiency 2
• LH/FSH ratio, fasting insulin: Evaluate for polycystic ovary syndrome (PCOS), the most common cause 2, 1
• Post-dexamethasone cortisol: If Cushing's syndrome suspected 2
• Prolactin level: If hyperprolactinemia suspected 2

Treatment Options

For Hirsutism (Androgen-Dependent)

Pharmacologic Management

• Combination oral contraceptives are first-line pharmacotherapy for hirsutism 1

• Topical eflornithine cream 13.9% (Vaniqa) can be used as adjunctive therapy 4, 5

  • Apply thin layer twice daily at least 8 hours apart to affected areas 4
  • Do not wash treated area for at least 4 hours 4
  • Marked improvement typically seen at 8 weeks, with 32% showing marked improvement or greater at 24 weeks versus 8% with vehicle 4
  • Hair growth returns to pretreatment levels within 8 weeks of discontinuation 4

• Antiandrogens (cyproterone acetate, spironolactone) are effective but require specialist consultation 2, 1

Hair Removal Methods

• Laser hair removal is the most efficient method for long-term hair removal currently available 3
• Temporary methods: Bleaching, trimming, shaving, plucking, waxing, chemical depilatories 3, 1
• Electrolysis: Provides permanent hair removal 3, 1

For Hypertrichosis (Non-Androgen-Dependent)

• No hormonal evaluation needed 2
• Identify and discontinue causative medications if iatrogenic 2
• Hair removal options: Same as for hirsutism (laser, electrolysis, temporary methods) 3
• Topical eflornithine may slow hair growth 3

Referral Considerations

Refer to pediatric endocrinology if:

• Total testosterone >1.5 ng/mL or DHEA-sulfate >700 μg/dL (concern for tumor) 2
• Rapid progression or recent onset with virilization signs 2
• Evidence of PCOS, Cushing's syndrome, or other endocrine disorder 1
• Abnormal screening labs requiring further evaluation 1

Critical Pitfalls to Avoid

• Do not dismiss as "normal variation" without proper assessment: Use objective mFG scoring rather than subjective judgment 1
• Do not miss virilizing tumors: Always check testosterone levels in patients with rapid progression or severe hirsutism 2
• Do not confuse spinal hypertrichosis with facial hair: The guidelines discussing "hypertrichosis" as a cutaneous marker refer specifically to midline posterior spinal tufts ("fawn's tail"), which are completely unrelated to facial hair 6
• Recognize ethnic variation: Non-White patients may have different baseline hair patterns but still benefit from treatment (22% success rate versus 5% vehicle in Black subjects) 4