DermatologyTier 1Disease (DEADMAN)

Cutaneous manifestations of systemic diseases - hirsutism

Description

Excess terminal hair growth in a male pattern (face, chest, back, abdomen) in women - androgen-dependent
Distinguish from hypertrichosis (generalised excess hair growth, non-androgen-dependent, non-sexual pattern)

Affects ~5-10% of women; PCOS accounts for the large majority (~70-80%) of cases

Androgen excess (ovarian or adrenal) or increased peripheral sensitivity of hair follicles to normal androgen levels (idiopathic hirsutism)
PCOS - ovarian hyperandrogenism + insulin resistance
Other causes: congenital adrenal hyperplasia (non-classic), androgen-secreting ovarian/adrenal tumour (rapid onset/virilisation - red flag), Cushing's syndrome, drugs (danazol, testosterone, valproate)

Ferriman-Gallwey score quantifies severity/distribution
Rapid onset, severe, or associated virilisation (clitoromegaly, voice deepening, temporal balding) - red flag for an androgen-secreting tumour, needs urgent imaging
Bloods: total/free testosterone, DHEAS, 17-OH progesterone (non-classic CAH), consider pelvic ultrasound (PCOS, ovarian tumour), adrenal imaging if adrenal source suspected

Treat the underlying cause where identified (e.g., CAH, tumour resection)
Combined oral contraceptive pill first-line pharmacological therapy - suppresses ovarian androgen production, raises SHBG
Anti-androgen (spironolactone, cyproterone acetate) added if COCP alone insufficient after ~6 months - contraception mandatory given teratogenic feminisation risk to a male fetus
Cosmetic/physical hair removal (laser, electrolysis) - effective adjunct, does not address the underlying hormonal driver
Weight loss and metabolic management in PCOS-associated hirsutism - improves insulin resistance and androgen levels

PCOS - metabolic syndrome, infertility, endometrial hyperplasia risk
Insulin resistance, acanthosis nigricans
Rapid-onset hirsutism with virilisation - androgen-secreting tumour until excluded

Chronic course if underlying cause (usually PCOS) is not addressed
Response to hormonal therapy is gradual - visible improvement takes several months given the hair growth cycle
Tumour-related hirsutism resolves with successful resection of the androgen source

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