Background 21 Cosmetic Procedures

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Cosmetic procedures may be very helpful in controlling mild-to-moderate degrees of unwanted hair and are virtually always required as an adjunct in women being treated medically to remove existing terminal hair. Reduction in the frequency with which women use cosmetic procedures is also reliable evidence of drug efficacy. In general, these procedures are time-consuming and may be expensive. Complications include pain, discomfort, dyspigmentation, and scarring.

Several different techniques may be used, according to the characteristics of the individual patient (Table 2). Shaving does not increase the rate of hair growth, as erroneously thought by many patients, but it leaves an unpleasant sharp stubble. Therefore, other procedures are generally preferred. Waxing and plucking may be effective, but there is the risk of folliculitis and in-grown hairs. Furthermore, skin irritation may sometimes induce a paradoxical increase in local hair growth. In addition, these complications may subsequently make more difficult the removal of hairs by electrolysis. For these reasons, several authors strongly discourage their use, in particular in women with clinically significant degrees of hirsutism.

Electrolysis and laser photothermolysis appear to be the most effective procedures, although with these methods hair removal should not be considered permanent. Moreover, multiple treatments are usually necessary because of the nature of the hair growth cycle. Electrolysis uses an electric current transmitted through a fine needle inserted into the hair follicle. This results in destruction of the follicle. There are different electrolysis techniques using direct (galvanic), high-frequency alternating current, or a combination (7). Pain is common, and scarring may occur if the operator is unskilled or if the current used is too high.

Laser and light-assisted hair removal is based on the principle of selective photothermolysis. Selective absorption by hair chromophores of energy from lasers and broadband light sources may result in destruction of hair follicles while leaving the skin undamaged, although there are significant differences according to the specific characteristics of the patients and techniques used (8). In general, laser therapy is more effective in women with darker hair and lighter skin. Efficacy is lower and complications are more common in women with darker skin. Transient erythema and edema are common after laser therapy, and blistering, crusting, or alterations in skin pigmentation may also occur.

Evidence regarding the efficacy of these procedures is mostly anecdotal, and there are a few controlled studies supporting their efficacy. Laser treatment was effective in reducing, over 6 months,

Table 1

Main Characteristics of Peripheral-Acting Drags Used for Hirsutism Therapy

Drugs ( schedule)




Cyproterone acetate Large experience

(2-100 mg/day, usually on cycle days 5-14) Licensed for this use"


(50-200 mg, continuously)


(62.5-500 mg/day, continuously)

5a-reductase inhibitors


(1-5 mg/day, continuously)

Large experience Low cost

May improve menses

Pure antiandrogen

No adverse effect on ovulation

Well tolerated

No adverse effect on ovulation

Combination with estrogens needed

Frequent side effects, usually mild (e.g., metabolic abnormalities, mood changes, weight gain, edema, headache, and rare liver toxicity) Necessary to avoid pregnancies if not used in oral contraceptive form Necessary to avoid pregnancy

Frequent side effects, usually mild (e.g., polymenorrhea, diuresis, mastodynia, abdominal discomfort, and rare hyperkalemia) Necessary to avoid pregnancy Usually mild side effects (dry skin) Rare but occasionally severe liver toxicity

Necessary to avoid pregnancy

"Available in several countries for use in women, as a combination oral contraceptive pill containing 2 mg cyproterone acetate and 35 (Xg of ethinylestradiol.

Table 2

Chief Cosmetic Procedures for Symptomatic Management of Hirsutism


Depilatory creams





Laser photothermolysis self-reported severity of facial hair and time spent on hair removal in a randomized controlled trial carried out in 88 women with PCOS (9). A retrospective study assessed 242 patients with hirsutism who received diode laser treatments over 4 years (10). After an average of two treatments (range 16), a sufficient reduction in terminal hairs was achieved for a mean period of 8 months, and the hair-plucking interval was raised from a mean of 3.7 days before treatment to 15.2 days after laser epilation. The procedure was well accepted by about 80% of the subjects. At least in the short term, ruby, alexandrite, and diode lasers or the intense pulsed light resulted in similar success rates. The long-pulsed diode and Nd:YAG wavelength-based laser systems are best suited to treat patients with darker skin.

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