Interventions for hirsutism excluding laser and photoepilation therapy alone: abridged Cochrane systematic review includingGRADEassessments

Abstract

Hirsutism is a common disorder with a major impact on quality of life. The most frequent cause is polycystic ovary syndrome. Effects of interventions (except laser and light-based therapies) were evaluated, including Grading of Recommendations Assessment, Development and Evaluation assessments. Searches included Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, Medline, Embase and five trials registers to June 2014. We included 157 randomized controlled trials (RCTs) with 10 550 participants. The majority were assessed as having a 'high risk' of bias (123 of 157). The quality of evidence was rated moderate to very low for most outcomes. Pooled data for an oral contraceptive (OCP) (ethinyl oestradiol and cyproterone acetate) compared with another OCP (ethinyl oestradiol and desogestrel) demonstrated that both treatments were effective in reducing Ferriman-Gallwey scores, but the mean difference (MD) was not statistically significant [-1·84, 95% confidence interval (CI): -3·86-0·18]. Flutamide was more effective than placebo in two studies (MD -7·60, 95% CI: -10·53 to -4·67 and MD -7·20, 95% CI: -10·15 to -4·25), as was spironolactone (MD -7·69, 95% CI: -10·12 to -5·26). Spironolactone appeared to be as effective as flutamide (two studies) and finasteride (two studies). However, finasteride and the gonadotropin-releasing analogues showed discrepant results in several RCTs. Metformin was ineffective. Cyproterone acetate combined with OCPs demonstrated greater reductions in Ferriman-Gallwey scores. Lifestyle interventions reduced body mass index but did not show improvement in hirsutism, and although cosmetic measures are frequently used, no RCTs investigating cosmetic treatments were identified. RCTs investigating OCPs in combination with antiandrogens or finasteride vs. OCP alone, or the different antiandrogens and 5α-reductase inhibitors are warranted.

Hirsutism management needs to be more patient oriented

“…Hairless and smooth skin has been seen as the epitome of femininity, causing major psychological distress for hirsute women, and generates great demand for treatment. The presence of hirsutism suggests underlying absolute or relative hyperandrogenism, best represented by polycystic ovary syndrome . Accordingly, the management of hirsutism requires well‐coordinated endocrinological investigation, with variable outcomes.…”

“…Accordingly, the management of hirsutism requires well‐coordinated endocrinological investigation, with variable outcomes. A large number of remedies have been developed for this annoying condition; however, it remains unclear which are the most advantageous . Hair cycle varies among different anatomical locations and treatment of hirsutism needs to be continuous .…”

“…Hair cycle varies among different anatomical locations and treatment of hirsutism needs to be continuous . Thus, long‐term safety needs to be assessed for each intervention, which has been insufficiently evaluated …”

“…In this issue of the BJD , van Zuuren et al . provide a concise summary of a Cochrane review evaluating the effects of interventions (except for laser and light‐based therapies alone) for hirsutism, originally consisting of 655 pages!…”

“…Effects of interventions were evaluated using major repositories, including the Cochrane Skin Group Specialized Register, and the CENTRAL, MEDLINE and Embase databases. The authors found 157 randomized clinical trials but the majority were assessed as having a ‘high risk’ of bias . Importantly, the authors set the primary outcomes as: participant‐reported improvement of hirsutism; change in health‐related quality of life; proportion of participants reporting an adverse event.…”