Eflornithine Cream for Hirsutism/Hypertrichosis in Women of Childbearing Age
Eflornithine hydrochloride 13.9% cream (Vaniqa) should be applied twice daily at least 8 hours apart to affected facial areas and adjacent areas under the chin, as an adjunctive treatment to systemic hormonal therapy and hair removal techniques, not as monotherapy. 1
FDA-Approved Indication and Application
- Eflornithine cream is FDA-approved specifically for reduction of unwanted facial hair in women, with usage limited to the face and adjacent areas under the chin. 1
- Apply a thin layer to affected areas and rub in thoroughly twice daily, at least 8 hours apart. 1
- Do not wash the treated area for at least 4 hours after application. 1
- If using hair removal techniques (shaving, waxing, plucking), apply eflornithine at least 5 minutes after hair removal. 1
- Cosmetics or sunscreens may be applied after the cream has dried. 1
Mechanism and Expected Timeline
- Eflornithine irreversibly inhibits ornithine decarboxylase (ODC), an enzyme necessary for hair follicle polyamine synthesis and hair growth. 2, 3
- Clinical improvement occurs gradually over 4-8 weeks or longer, with 58% of patients showing at least some improvement by 24 weeks compared to 34% with placebo. 2
- Marked improvement occurs in 32% of treated patients versus 8% with placebo. 2
- Hair growth returns to pretreatment rates within 8 weeks of discontinuation, requiring continuous use to maintain benefit. 2
Integration with Systemic Therapy
For women of childbearing age with hirsutism, eflornithine must be combined with systemic hormonal management, not used alone:
- Combined oral contraceptives (COCs) are first-line systemic therapy, suppressing ovarian androgen production and increasing sex hormone-binding globulin. 4, 5
- Avoid COCs containing androgenic progestins (norethisterone derivatives, levonorgestrel) as they worsen hirsutism. 4
- If inadequate response after 6-9 months of COCs alone, add spironolactone 100-150 mg daily, which achieves improvement in 85% of patients. 5
- Weight loss of as little as 5% of body weight significantly improves hirsutism through testosterone reduction and metabolic improvement. 5
Complementary Hair Removal Techniques
- Patients should continue using hair removal techniques (shaving, waxing, plucking, electrolysis, laser therapy) in conjunction with eflornithine. 4, 1
- Laser hair removal is an essential adjunct to systemic therapy, requiring multiple treatments for optimal results. 5
- Laser therapy must be combined with medical management to address underlying androgen excess. 5
Safety Profile
- Percutaneous absorption is minimal (<1%), with low systemic exposure offering a favorable safety profile. 6
- Peak plasma concentrations are only 4.96-10.44 ng/mL, with a terminal half-life of 8-11 hours. 6
- Adverse events are primarily local skin reactions, with burning/stinging/tingling being the most common side effect compared to placebo. 2
- The medication shows a high safety profile with no significant cytotoxicity. 7
Critical Clinical Pitfalls
- Eflornithine addresses the symptom (hair growth) but not the underlying hormonal cause—systemic hormonal therapy is mandatory for women with PCOS-related hirsutism. 8
- Treatment is palliative rather than curative, requiring a combined approach with systemic therapy. 8
- Discontinuation leads to rapid return of hair growth within 8 weeks, so patients must understand this is a maintenance therapy. 2
- Eflornithine has only been studied on facial areas and should not be used on other body sites. 1
Monitoring and Patient Counseling
- Patients should expect gradual improvement over 4-8 weeks, with maximal benefit by 24 weeks. 2, 3
- Eflornithine reduces overall discomfort and bother by 33% versus 15% with placebo based on patient self-assessment. 2
- Hirsutism improvement with systemic therapy typically takes 6-12 months, so eflornithine provides cosmetic benefit during this period. 4