Medical treatment of hirsutism

Bachmann-Bupp syndrome and treatment

Bachmann-Bupp syndrome (BABS) is a neurodevelopmental disorder characterized by developmental delay, hypotonia, and varying forms of non-congenital alopecia. The condition is caused by 3'-end mutations of the ornithine decarboxylase 1 (ODC1) gene, which produce carboxy (C)-terminally truncated variants of ODC, a pyridoxal 5'-phosphate-dependent enzyme. C-terminal truncation of ODC prevents its ubiquitin-independent proteasomal degradation and leads to cellular accumulation of ODC enzyme that remains catalytically active. ODC is the first rate-limiting enzyme that converts ornithine to putrescine in the polyamine pathway. Polyamines (putrescine, spermidine, spermine) are aliphatic molecules found in all forms of life and are important during embryogenesis, organogenesis, and tumorigenesis. BABS is an ultra-rare condition with few reported cases, but it serves as a convincing example for drug repurposing therapy. α-Difluoromethylornithine (DFMO, also known as eflornithine) is an ODC inhibitor with a strong safety profile in pediatric use for neuroblastoma and other cancers as well as West African sleeping sickness (trypanosomiasis). Patients with BABS have been treated with DFMO and have shown improvement in hair growth, muscle tone, and development.

A Systematic Review of the Psychosocial Impact of Polycystic Ovarian Syndrome Before and After Treatment

While polycystic ovarian syndrome (PCOS) is one of the most common hormonal endocrine disorders among women of reproductive age, the psychosocial impact of PCOS has not been evaluated across different quality of life (QoL) indicators. We rigorously analyzed available evidence pertaining to the psychosocial burden of PCOS in women of reproductive age and compared validated QoL scores of women with and without PCOS before and after treatment. We searched and considered publications from PubMed, PsychINFO, Embase, and Cochrane Library that evaluated the association between diagnosed PCOS and QoL by standardized and validated questionnaires at baseline and after treatment. Reviewers assessed the risk of bias using established Cochrane and Newcastle-Ottawa Scale guidelines. A total of 33 studies were included in the review: 14 randomized controlled trials and 19 observational studies. The 36-Item Short Form Survey and World Health Organization Quality of Life - BREF questionnaire both revealed that the diagnosis and life experience of PCOS had a disability score that was similar to or surpassed that of heart disease, diabetes mellitus, or breast cancer. QoL scores, associated with mental health issues, infertility, sexual dysfunction, obesity, menstrual disorder, and hirsutism, were lower at the baseline than after treatment in the majority of instruments measuring these variables in women with PCOS. PCOS is associated with significant psychosocial stress and reduced QoL across baseline measures and in comparison, to other diseases. Evidence suggests that treatment with therapy, medications, and lifestyle management decreased psychosocial burdens and alleviated QoL experienced by women with PCOS.

Das schöne, glatte Bein: Haarentfernung durch Laser und lichtbasierte Verfahren

Die Fotoepilation zählt zu den meistgefragten nichtchirurgischen Eingriffen in der ästhetischen Dermatologie. Haarlose, glatte Beine gelten dabei als Schönheitsideal.

Fotoepilation mittels Laser oder hochenergetischer Blitzlampen (sog. Intensed-Pulsed-Light-Geräte) stellt ein sicheres und effektives Verfahren dar. Der Wirkmechanismus beruht auf dem Prinzip der selektiven Fotothermolyse, wobei eine gezielte thermische Schädigung pigmentierter Haarfollikel unter Schonung des umliegenden Gewebes erfolgt. Melaninpigment des Haarschaftes absorbiert als Zielchromophor Licht eines speziellen Wellenlängenspektrums und führt durch Wärmediffusion zur Schädigung der für das Haarwachstum wichtigen Stammzellen im äußeren Haarwurzelschaft.

Patienten müssen über die Notwendigkeit wiederholter Behandlungen sowie den häufig nur partiellen und temporären Haarverlust aufgeklärt werden. Dunkle Terminalhaare bei hellen Hauttypen lassen sich effektiv entfernen. Bei dunklen Hauttypen besteht aufgrund des erhöhten epidermalen Melaninvorkommens ein erhöhtes Risiko für Nebenwirkungen wie Verbrennungen, Dyspigmentierungen und Narben. Sehr feine, helle oder rote Haare lassen sich kaum mit konventionellen Fotoepilationsverfahren entfernen. Haarentfernungsgeräte für den Heimgebrauch sind eine kostengünstige, einfach anzuwendende Alternative, weisen aber im Vergleich zur professionellen Fotoepilation eine geringere Effektivität auf.

Das schöne, glatte Bein: Haarentfernung durch Laser und lichtbasierte Verfahren

Die Fotoepilation zählt zu den meistgefragten nichtchirurgischen Eingriffen in der ästhetischen Dermatologie. Haarlose, glatte Beine gelten dabei als Schönheitsideal.

Fotoepilation mittels Laser oder hochenergetischer Blitzlampen (sog. Intensed-Pulsed-Light-Geräte) stellt ein sicheres und effektives Verfahren dar. Der Wirkmechanismus beruht auf dem Prinzip der selektiven Fotothermolyse, wobei eine gezielte thermische Schädigung pigmentierter Haarfollikel unter Schonung des umliegenden Gewebes erfolgt. Melaninpigment des Haarschaftes absorbiert als Zielchromophor Licht eines speziellen Wellenlängenspektrums und führt durch Wärmediffusion zur Schädigung der für das Haarwachstum wichtigen Stammzellen im äußeren Haarwurzelschaft.

Patienten müssen über die Notwendigkeit wiederholter Behandlungen sowie den häufig nur partiellen und temporären Haarverlust aufgeklärt werden. Dunkle Terminalhaare bei hellen Hauttypen lassen sich effektiv entfernen. Bei dunklen Hauttypen besteht aufgrund des erhöhten epidermalen Melaninvorkommens ein erhöhtes Risiko für Nebenwirkungen wie Verbrennungen, Dyspigmentierungen und Narben. Sehr feine, helle oder rote Haare lassen sich kaum mit konventionellen Fotoepilationsverfahren entfernen. Haarentfernungsgeräte für den Heimgebrauch sind eine kostengünstige, einfach anzuwendende Alternative, weisen aber im Vergleich zur professionellen Fotoepilation eine geringere Effektivität auf.

Probenecid increases renal retention and antitumor activity of DFMO in neuroblastoma

BACKGROUND

Neuroblastoma (NB) is the most common extracranial solid tumor in children. Interference with the polyamine biosynthesis pathway by inhibition of MYCN-activated ornithine decarboxylase (ODC) is a validated approach. The ODC inhibitor α-difluoromethylornithine (DFMO, or Eflornithine) has been FDA-approved for the treatment of trypanosomiasis and hirsutism and has advanced to clinical cancer trials including NB as well as cancer-unrelated human diseases. One key challenge of DFMO is its rapid renal clearance and the need for high and frequent drug dosing during treatment.

METHODS

We performed in vivo pharmacokinetic (PK), antitumorigenic, and molecular studies with DFMO/probenecid using NB patient-derived xenografts (PDX) in mice. We used LC-MS/MS, HPLC, and immunoblotting to analyze blood, brain tissue, and PDX tumor tissue samples collected from mice.

RESULTS

The organic anion transport 1/3 (OAT 1/3) inhibitor probenecid reduces the renal clearance of DFMO and significantly increases the antitumor activity of DFMO in PDX of NB (P < 0.02). Excised tumors revealed that DFMO/probenecid treatment decreases polyamines putrescine and spermidine, reduces MYCN protein levels and dephosphorylates retinoblastoma (Rb) protein (p-Rb^Ser795), suggesting DFMO/probenecid-induced cell cycle arrest.

CONCLUSION

Addition of probenecid as an adjuvant to DFMO therapy may be suitable to decrease overall dose and improve drug efficacy in vivo.

Application of Hantzsch reaction for sensitive determination of eflornithine in cream, plasma and urine samples

Eflornithine (EFN) is an anti-Trypanosoma brucei agent for the medication of sleeping sickness and widely distributed for the treatment of hirsutism (unwanted facial hair in women). The presented work demonstrates a comprehensive analytical approach for the spectrofluorometric determination of EFN in commercial cream samples and various biological samples. The proposed method is based on the formation of a highly yellow-green fluorescence dihydropyridine derivative after the interaction between EFN and acetylacetone/formaldehyde reagent in a slightly acidic medium. Furthermore, the optimal variables such as reagent volumes, pH of the medium, heating time, buffer volume, heating temperature and diluting solvent were carefully selected to achieve the maximum fluorescence activity. The fluorescence activity for the formed derivative was measured at λ emission = 477 nm after λ excitation = 418 nm. Concerning linearity, accuracy, sensitivity, precision and robustness, the presented method was validated and verified according to ICH guidelines. Moreover, the proposed work offered a selective determination for EFN in various brands of pharmaceutical cream without any interference from excipients. Eventually, the current approach was assured to be successful in the estimation of EFN in urine and plasma samples with acceptable recovery results.

Allicin, a Potent New Ornithine Decarboxylase Inhibitor in Neuroblastoma Cells

The natural product allicin is a reactive sulfur species (RSS) from garlic (Allium sativum L.). Neuroblastoma (NB) is an early childhood cancer arising from the developing peripheral nervous system. Ornithine decarboxylase (ODC) is a rate-limiting enzyme in the biosynthesis of polyamines, which are oncometabolites that contribute to cell proliferation in NB and other c-MYC/MYCN-driven cancers. Both c-MYC and MYCN directly transactivate the E-box gene ODC1, a validated anticancer drug target. We identified allicin as a potent ODC inhibitor in a specific radioactive in vitro assay using purified human ODC. Allicin was ∼23 000-fold more potent (IC₅₀ = 11 nM) than DFMO (IC₅₀ = 252 μM), under identical in vitro assay conditions. ODC is a homodimer with 12 cysteines per monomer, and allicin reversibly S-thioallylates cysteines. In actively proliferating human NB cells allicin inhibited ODC enzyme activity, reduced cellular polyamine levels, inhibited cell proliferation (IC₅₀ 9-19 μM), and induced apoptosis. The natural product allicin is a new ODC inhibitor and could be developed for use in conjunction with other anticancer treatments, the latter perhaps at a lower than usual dosage, to achieve drug synergism with good prognosis and reduced adverse effects.

A Novel Effect of Acyclovir on Hair Growth in BALB/c Mice: A Promising Future for Finding a New Topical Drug for the Treatment of Hirsutism

PURPOSE

Hirsutism (ie, terminal hair growth on the face and body in a male-like pattern in women) is a common dermatological disorder in women, with psychosocial implications. Consequently, there is demand for finding novel pharmacological treatments and agents that can safely reduce hair growth. This study aimed to investigate the potential effect of topical acyclovir on hair growth in mice.

METHODS

In this study, twenty-four female BALB/c mice were randomly divided into three groups in order to evaluate the hair growth-reducing effects of acyclovir (control group, vehicle group, and acyclovir group). Topical acyclovir 5% was applied on the shaved denuded skin of mice. Topical application onto the backs of the animals was performed twice daily for 28 consecutive days. The time (in days) required for hair growth initiation as well as completion of hair growth in dorsal skin of animals were recorded. On day 28, horizontally cut biopsy samples were removed and the numbers of hair follicles were counted, and the diameter of hair follicles was measured under high-field microscopy by a specialist blinded to the treatments.

RESULTS

Hair growth initiation time was significantly increased with acyclovir, as compared to control and vehicle groups. The time required for complete hair growth in control and vehicle groups were 18±0.68 and 19±1.41 days, respectively; however, the hair growth completion in acyclovir-treated animals was not observed at the end of the experiment. Furthermore, the length of hairs in treatment group was significantly shorter than the control group at the end of the study (P < 0.001). In histologic examination, the count and the diameter of hair follicles in deep subcutis were significantly decreased.

CONCLUSION

The results of this study, for the first time, showed that topical administration of acyclovir might have inhibitory effects on hair growth in experimental animals; however, further studies are required to understand its mechanism.

Dihydrotestosterone Regulates Hair Growth Through the Wnt/β-Catenin Pathway in C57BL/6 Mice and In Vitro Organ Culture

Dihydrotestosterone (DHT) is the most potent androgen that regulates hair cycling. Hair cycling involves cross-talk between the androgen and Wnt/β-catenin pathways. However, how DHT regulates hair follicle (HF) growth through the Wnt/β-catenin pathway has not been well investigated. This study aimed to investigate the roles of DHT in hair growth in vivo and in vitro. Human scalp HFs were treated with different concentrations of DHT (10^-5, 10^-6, 10^-7, 10^-8, and 10^-9 mol/L) for 10 days. The effects of DHT on hair shaft elongation, the proliferation of hair matrix cells, and the levels of β-catenin, GSK-3β, and phosphorylated GSK-3β (ser9) were evaluated in the cultured HFs. The effects of DHT were further investigated in C57BL/6 mice. Moreover, the growth of cultured human HFs was observed after interfering with the β-catenin pathway through inhibitors or activators in the presence or absence of DHT. We found that different concentrations of DHT had different effects on human HFs in vitro and C57BL/6 mice. At 10^-6 mol/L, DHT inhibited HF growth and β-catenin/p-GSK-3β expression, whereas 10^-7 mol/L DHT induced HF growth and β-catenin/p-GSK-3β expression. In addition, a β-catenin inhibitor (21H7) inhibited HF growth in vitro, while a β-catenin activator (IM12) promoted HF growth in vitro and antagonized the inhibition of HFs by high levels of DHT. These results suggest that DHT plays a pivotal role in region-specific hair growth, which may be related to the Wnt/β-catenin pathway.

Androgens in women: Hormone-modulating therapies for skin disease

Androgen-mediated cutaneous disorders (AMCDs) in women, including acne, hirsutism, and female pattern hair loss, can be treated with hormone-modulating therapies. In the second article in this Continuing Medical Education series, we discuss the hormone-modulating therapies available to dermatologists for the treatment of AMCDs, including combined oral contraceptives, spironolactone, finasteride, dutasteride, and flutamide. Available hormone-modulating treatments used for each AMCDs are reviewed, along with mechanisms of androgen modulation, safety profile, contraindications, monitoring parameters, and evidence of efficacy. Medications discussed include those that are approved by the US Food and Drug Administration for certain AMCDs and some that are used off-label. Despite the ubiquity of hormone-modulating therapies used for AMCDs, this review highlights the need for more rigorous studies to evaluate these therapies for acne, hirsutism, and female pattern hair loss.

A Prospective Study of Axillary Hair Reduction in Patients Treated With Microwave Technology

BACKGROUND

Removing unwanted body hair is a growing trend in society today, and there are many laser-based devices for hair reduction. There are some limitations to those methods, including the lack of efficacy for lighter color hair.

OBJECTIVE

The objective was to quantify hair reduction in the axillae after treatment with a noninvasive microwave energy device.

MATERIALS AND METHODS

A prospective, multicenter study was performed at 3 private dermatology clinics. Fifty-six adult subjects seeking axillary hair reduction were enrolled and treated with the device in 1 or 2 treatment sessions 3 months apart at various energy levels, and followed for 12 months. The primary analysis was monitoring reduction of hair counts from baseline to follow-up visits. A subject assessment of overall satisfaction, odor ratings, and sweat reduction ratings was provided at follow-up visits.

RESULTS

Fifty-six subjects received treatment, with an average total underarm hair reduction of approximately 70% for both light and dark hair. Percentage of patients with hair reduction of 30% or more was significantly higher than 50% at all follow-up visits. Half of treated subjects reported expected mild transient post-treatment effects such as localized edema, discomfort, and bruising. Other reported events were mild.

CONCLUSION

This clinical study provides evidence for safe and permanent axillary hair reduction, showing stable average reduction that lasted through the year of follow-up. Most notably, the study has shown the treatment's efficacy for reduction of light-colored axillary hair.

Interventions for hirsutism excluding laser and photoepilation therapy alone: abridged Cochrane systematic review including GRADE assessments

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.

A Phase I Trial of DFMO Targeting Polyamine Addiction in Patients with Relapsed/Refractory Neuroblastoma

BACKGROUND

Neuroblastoma (NB) is the most common cancer in infancy and most frequent cause of death from extracranial solid tumors in children. Ornithine decarboxylase (ODC) expression is an independent indicator of poor prognosis in NB patients. This study investigated safety, response, pharmacokinetics, genetic and metabolic factors associated with ODC in a clinical trial of the ODC inhibitor difluoromethylornithine (DFMO) ± etoposide for patients with relapsed or refractory NB.

METHODS AND FINDINGS

Twenty-one patients participated in a phase I study of daily oral DFMO alone for three weeks, followed by additional three-week cycles of DFMO plus daily oral etoposide. No dose limiting toxicities (DLTs) were identified in patients taking doses of DFMO between 500-1500 mg/m2 orally twice a day. DFMO pharmacokinetics, single nucleotide polymorphisms (SNPs) in the ODC gene and urinary levels of substrates for the tissue polyamine exporter were measured. Urinary polyamine levels varied among patients at baseline. Patients with the minor T-allele at rs2302616 of the ODC gene had higher baseline levels (p=0.02) of, and larger decreases in, total urinary polyamines during the first cycle of DFMO therapy (p=0.003) and had median progression free survival (PFS) that was over three times longer, compared to patients with the major G allele at this locus although this last result was not statistically significant (p=0.07). Six of 18 evaluable patients were progression free during the trial period with three patients continuing progression free at 663, 1559 and 1573 days after initiating treatment. Median progression-free survival was less among patients having increased urinary polyamines, especially diacetylspermine, although this result was not statistically significant (p=0.056).

CONCLUSIONS

DFMO doses of 500-1500 mg/m2/day are safe and well tolerated in children with relapsed NB. Children with the minor T allele at rs2302616 of the ODC gene with relapsed or refractory NB had higher levels of urinary polyamine markers and responded better to therapy containing DFMO, compared to those with the major G allele at this locus. These findings suggest that this patient subset may display dependence on polyamines and be uniquely susceptible to therapies targeting this pathway.

TRIAL REGISTRATION

Clinicaltrials.gov NCT#01059071.

Interventions for hirsutism (excluding laser and photoepilation therapy alone)

BACKGROUND

Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen-sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective.

OBJECTIVES

To assess the effects of interventions (except laser and light-based therapies alone) for hirsutism.

SEARCH METHODS

We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism.

DATA COLLECTION AND ANALYSIS

Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses.

MAIN RESULTS

We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty-eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow-up above 40%.Primary outcomes, 'participant-reported improvement of hirsutism' and 'change in health-related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin-releasing hormone (GnRH) analogues)).Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one-third of studies.The quality of evidence was moderate to very low for most outcomes.There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman-Gallwey scores. The mean difference (MD) was -1.84 (95% confidence interval (CI) -3.86 to 0.18).There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman-Gallwey scores more effectively than placebo (MD -7.60, 95% CI -10.53 to -4.67 and MD -7.20, 95% CI -10.15 to -4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87).Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman-Gallwey scores (MD -7.69, 95% CI -10.12 to -5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD -1.90, 95% CI -5.01 to 1.21 and MD 0.49, 95% CI -1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI -0.58 to 3.56 and MD 0.40, 95% CI -1.18 to 1.98) (low quality evidence).Although there was very low quality evidence of a difference in reduction of Ferriman-Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD -5.73, 95% CI -6.87 to -4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached.Metformin demonstrated no benefit over placebo in reduction of Ferriman-Gallwey scores (MD 0.05, 95% CI -1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements.We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman-Gallwey scores.Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman-Gallwey scores (low quality evidence). Ferriman-Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD -6.30, 95% CI -9.83 to -2.77) (very low quality evidence). Data showing reductions in Ferriman-Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%).Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman-Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs.

AUTHORS' CONCLUSIONS

Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision-making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects.Further research should consist of well-designed, rigorously reported, head-to-head trials examining OCPs combined with antiandrogens or 5α-reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α-reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment.

A simple and sensitive assay for eflornithine quantification in rat brain using pre-column derivatization and UPLC-MS/MS detection

Eflornithine (α-difluoromethylornithine) has been used to treat second-stage (or meningoencephalitic-stage) human African trypanosomiasis and currently is under clinical development for cancer prevention. In this study, a new ultraperformance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS)-based assay was developed and validated for the quantification of eflornithine in rat brain. To improve chromatographic retention and MS detection, eflornithine was derivatized with 6-aminoquinolyl-N-hydroxysuccinimidyl carbamate for 5 min at room temperature prior to injection. Derivatized eflornithine was separated on a reverse-phase C18 UPLC column with a 6-min gradient; elution occurred at approximately 1.5 min. Prior to derivatization, eflornithine was reproducibly extracted from rat brain homogenate by methanol protein precipitation (~70% recovery). Derivatized eflornithine was stable in the autosampler (6 °C) for at least 24 h. This new assay had acceptable intra- and interday accuracy and precision over a wide dynamic range (5000-fold) and excellent sensitivity with a lower limit of quantification of 0.1 µm (18 ng/mL) using only 10 μL of rat brain homogenate. The validated eflornithine assay was applied successfully to determine eflornithine distribution in different regions of rat brain in an in situ rat brain perfusion study.

Dermatosis associated with menopause

Menopause is defined as permanent irreversible cessation of menses brought by decline in ovarian follicular activity. Hormonal alteration results in various physical, psychological, and sexual changes in menopausal women. Associated dermatological problems can be classified as physiological changes, age-related changes, changes due to estrogen deficiency and due to hormone replacement therapy. Dermatosis seen due to estrogen deficiency includes Atrophic Vulvovaginitis, Vulvar Lichen Sclerosus, Dyaesthetic Vulvodynia, Hirsutism, Alopecia, Menopausal Flushing, Keratoderma Climactericum, Vulvovaginal Candidiasis. Dermatologists and gynecologists need to be familiar with the problems of menopausal women, as with increase in life expectancy, women passing through this phase is rising.

Psychotrichology: psychosomatic aspects of hair diseases

Hair growth and hair disorders with changes in hair density or quality not only influence an individual's appearance but also often lead to an enormous emotional burden with low self-confidence, impaired quality of life, and even psychological disorders. Psychosomatic hair diseases cover a wide spectrum of specific psycho-dermatological disease patterns. This review provides an overview and classification of psychosomatic hair diseases based on primary and secondary disorders. Somatoform disorders are among the primary psychiatric diseases, especially body dysmorphic disorder in which patients have an exaggerated and excessive preoccupation of normal and physiological hair loss. Self-inflicted skin diseases as trichotillomania, often with an impairment of impulse control, also belong to this group. Secondary/reactive psychosocial disorders may occur in congenital and acquired hair disorders. These may be accompanied by feelings of disfigurement, depressive and anxiety disorders including social avoidance. Furthermore, psychosomatic comorbidity could complicate coping with hair loss. Psychosomatic therapy and coping are based on an early and accurate differential diagnostic approach to psychosomatic disorders. Psychotrichological disorders need to be treated promptly with psychosomatic basic care, improvement of coping strategies, behavior therapy, depth psychology, and/or appropriate psychopharmacotherapy with antidepressants or anxiolytics.

How to diagnose and treat medically women with excessive hair

Excessive hair growth in women is common and due to a broad spectrum of causes. Management options comprise different pharmaceuticals, epilation methods, and aesthetic approaches. Because excessive hair growth in women may cause psychological and psychosocial problems, a holistic treatment approach, including support and emotional coping strategies, should be recommended. In this article, diagnostic procedures and treatment options for excessive hair growth in female patients are discussed.

Congenital adrenal hyperplasia

Congenital adrenal hyperplasia consists of a heterogenous group of inherited disorders due to enzymatic defects in the biosynthetic pathway of cortisol and/or aldosterone. This results in glucocorticoid deficiency, mineralocorticoid deficiency, and androgen excess. 95% of CAH cases are due to 21-hydroxylase deficiency. Clinical forms range from the severe, classical CAH associated with complete loss of enzyme function, to milder, non-classical forms (NCAH). Androgen excess affects the pilosebaceous unit, causing cutaneous manifestations such as acne, androgenetic alopecia and hirsutism. Clinical differential diagnosis between NCAH and polycystic ovary syndrome may be difficult. In this review, the evaluation of patients with suspected CAH, the clinical presentation of CAH forms, with emphasis on the cutaneous manifestations of the disease, and available treatment options, will be discussed.

Androgen actions on the human hair follicle: perspectives

Androgens stimulate beard growth but suppress hair growth in androgenetic alopecia (AGA). This condition is known as 'androgen paradox'. Human pilosebaceous units possess enough enzymes to form the active androgens testosterone and dihydrotestosterone. In hair follicles, 5α-reductase type 1 and 2, androgen receptors (AR) and AR coactivators can regulate androgen sensitivity of dermal papillae (DP). To regulate hair growth, androgens stimulate production of IGF-1 as positive mediators from beard DP cells and of TGF-β1, TGF-β2, dickkopf1 and IL-6 as negative mediators from balding DP cells. In addition, androgens enhance inducible nitric oxide synthase from occipital DP cells and stem cell factor for positive regulation of hair growth in beard and negative regulation of balding DP cells. Moreover, AGA involves crosstalk between androgen and Wnt/β-catenin signalling. Finally, recent data on susceptibility genes have provided us with the impetus to investigate the molecular pathogenesis of AGA.

An overview of unwanted female hair

Unwanted facial hair (UFH) is an important but often overlooked issue, with over 40% of women experiencing some degree of UFH. In the female population a wide spectrum of unwanted hair concerns is represented - from biologically normal but undesirable to excessive unwanted hair with an underlying pathology. While women may seek to manage unwanted hair across their bodies, UFH is a particular concern, due to its negative impact on perceived femininity. There may not always be a direct correlation between degree of severity diagnosed objectively by the physician and level of concern and impact upon the patient. This review discusses the spectrum of facial hair experience and outlines the clinical approach to unwanted hair management including UFH. It highlights the importance of a treatment regimen which should respond to the causation factors and needs of the individual. This will lead to a holistic treatment approach including evaluation of the implementation of emotional coping strategies and on-going support, lifestyle modifications, pharmacological interventions (to address underlying pathologies) and the use of cosmetic hair removal methods as either a stand-alone or adjunct treatment as appropriate to the individual.

Ornithine decarboxylase is upregulated by the androgen receptor in skeletal muscle and regulates myoblast proliferation

The aim of this study is to determine if the Odc1 gene, which encodes ornithine decarboxylase (ODC), the rate-limiting enzyme in polyamine biosynthesis, is directly regulated by the androgen receptor (AR) in skeletal muscle myoblasts and if Odc1 regulates myoblast proliferation and differentiation. We previously showed that expression of Odc1 is decreased in muscle from AR knockout male mice. In this study, we show in vivo that Odc1 expression is also decreased >60% in muscle from male muscle-specific AR knockout mice. In normal muscle homeostasis, Odc1 expression is regulated by age and sex, reflecting testosterone levels, as muscle of adult male mice expresses high levels of Odc1 compared with age-matched females and younger males. In vitro, expression of Odc1 is 10- and 1.5-fold higher in proliferating mouse C(2)C(12) and human skeletal muscle myoblasts, respectively, than in differentiated myotubes. Dihydrotestosterone increases Odc1 levels 2.7- and 1.6-fold in skeletal muscle cell myoblasts after 12 and 24 h of treatment, respectively. Inhibition of ODC activity in C(2)C(12) myoblasts by α-difluoromethylornithine decreases myoblast number by 40% and 66% following 48 and 72 h of treatment, respectively. In contrast, overexpression of Odc1 in C(2)C(12) myoblasts results in a 27% increase in cell number vs. control when cells are grown under differentiation conditions for 96 h. This prolonged proliferation is associated with delayed differentiation, with reduced expression of the differentiation markers myogenin and Myf6 in Odc1-overexpressing cells. In conclusion, androgens act via the AR to upregulate Odc1 in skeletal muscle myoblasts, and Odc1 promotes myoblast proliferation and delays differentiation.

Current standards in the diagnostics and therapy of hair diseases - hair consultation

Hair and scalp diseases present an extensive diagnostic and therapeutic task. Treating them is often a challenge for the physician in daily practice. Unclear diagnoses, chronic conditions with long-lasting therapies and the uncertainty of the patient may often lead to unsatisfying situations for both the patient as well as the doctor. The complaints can be divided into (1) hair loss, (2) increased hair growth and (3) abnormal hair quality. A structured history and the objectification of the clinical findings with the help of standardized diagnostic methods and score systems or classifications enable a diagnosis in most patients already at the first visit. Moreover, such structured processes strengthen the treatment satisfaction and compliance of both the patient and the therapist. In the meantime, diagnostic measures and clinical practice guidelines are available for the most common hair disorders. Expertise in basic psychosomatic care and an empathetic approach to the fears and concerns as well as practical advice for the daily contact with hair disorders should be integrated as separate elements in the management of hair diseases; in most cases they are gratefully welcomed by the patients. The aim of this article is to provide the physician with a guideline for the structured management of a hair patient. An overview of recent new developments and the currently available clinical practice guidelines for diagnosis and therapy of hair disorders is presented.

Spermine synthase activity affects the content of decarboxylated S-adenosylmethionine

dcAdoMet (decarboxylated S-adenosylmethionine) is an essential intermediate in the synthesis of polyamines. Its content is normally very low, amounting to less than 5% of that of S-adenosylmethionine itself. It was found that in mice lacking spermine synthase there was a large increase in dcAdoMet and that overexpression of spermine synthase reduced the amount of this nucleoside. There was also an increase in dcAdoMet in cells derived from patients with Snyder–Robinson syndrome, a rare X-linked recessive human disease caused by SMS gene mutations that greatly reduce the content of spermine synthase. These results suggest that there is an inverse relationship between the amount of spermine synthase protein and the content of dcAdoMet and raise the possibility that some of the abnormalities seen in mammals deficient in spermine synthase might be due to changes in dcAdoMet pools.

Aging well--the role of minimally invasive aesthetic dermatological procedures in women over 65

BACKGROUND

The western world is getting older. Aging well has become the new target of preventative medicine. Aesthetic dermatology can contribute to this quest. Females over 65 represent an important and growing group of consumers of cosmetic procedures. In this group, there is a paucity of scientific evaluation of aesthetic procedures.

OBJECTIVE

To review the use of minimally invasive procedures for facial rejuvenation in women over 65.

METHODS

Drawing from both the literature and personal experience, the opportunities, modifications, and limitations of minimally invasive techniques for facial rejuvenation in older women are considered.

RESULTS

In this older age group, dermal fillers, chemical and laser peels, and nonablative photorejuvenation remain useful and can each be used as stand-alone treatments. In this age group, botulinum toxin (BTX) injections are more often used in combination with other procedures.

CONCLUSIONS

With respect to aesthetic procedures, women over 65 are different from younger women. More scientific investigation is necessary to better meet needs of this growing part of the population. Available data suggest that aesthetic dermatology can make a major contribution to the complex matter of aging well.

Effect of oral contraceptives on markers of hyperandrogenism and SHBG in women with polycystic ovary syndrome

BACKGROUND

This randomized study's aim was to compare the effect of four oral contraceptives (OCs) containing 30 mcg of ethinylestradiol (EE) and different progestogens [drospirenone, (DRSP), chlormadinone acetate (CMA), desogestrel (DSG), gestodene (GSD)] on biochemical and hormonal parameters of hyperandrogenism and sex hormone-binding globulin (SHBG) in women with polycystic ovary syndrome (PCOS).

STUDY DESIGN

Forty women with PCOS (age 16-35 years) were recruited and randomly assigned to one of four treatment groups of 10 women each, treated, respectively, with 3 mg DRSP/30 mcg EE (Yasmin, Bayer Shering), 2 mg CMA/30 mcg EE (Belara, Grunenthal), 75 mcg GSD/30 mcg EE (Minulet, Wyeth Lederle) and 150 mcg DSG/30 mcg EE (Practil 21, Organon Italia). Blood samples were obtained on day 6-8 of the control cycle and day 6-8 of the third treatment cycle for assay of the following hormones: androsteredione (A), total testosterone (T), free T, SHBG, dehydroepiandrosterone sulphate (DHEAS).

RESULTS

In all groups, mean concentrations of free T, total T and A dropped by 40-60%, and concentrations of DHEAS dropped by 20-50%. Formulations with DRSP and CMA caused a greater reduction of androgens and a progressive increase in serum concentrations of SHBG than those with DSG and GSD.

CONCLUSIONS

Clinical studies need to be performed to determine effects of these OCs upon clinical signs of hyperandrogenism.

Polyamines and hair: a couple in search of perfection

Polyamines (spermidine, putrescine and spermine) are multifunctional cationic amines that are indispensable for cellular proliferation; of key significance in the growth of rapidly regenerating tissues and tumors. Given that the hair follicle (HF) is one of the most highly proliferative organs in mammalian biology, it is not surprising that polyamines are crucial to HF growth. Indeed, growing (anagen) HFs show the highest activity of ornithine decarboxylase (ODC), the rate-limiting enzyme of polyamine biosynthesis, while inhibition of ODC, using eflornithine, results in a decreased rate of excessive facial hair growth in vivo and inhibits human scalp hair growth in organ culture. In sheep, manipulation of dietary intake of polyamines also results in altered wool growth. Polyamine-containing nutraceuticals have therefore been proposed as promoters of human hair growth. Recent progress in polyamine research, coupled with renewed interest in the role of polyamines in skin biology, encourages one to revisit their potential roles in HF biology and highlights the need for a systematic evaluation of their mechanisms of action and clinical applications in the treatment of hair disorders. The present viewpoint essay outlines the key frontiers in polyamine-related hair research and defines the major open questions. Moreover, it argues that a renaissance in polyamine research in hair biology, well beyond the inhibition of ODC activity in hirsutism therapy, is important for the development of novel therapeutic strategies for the manipulation of human hair growth. Such targets could include the manipulation of polyamine biosynthesis and the topical administration of selected polyamines, such as spermidine.

Comprehensive clinical management of hirsutism

Hirsutism is an excessive body and facial hair growth in women in locations where is normally minimal or absent following a hair-male pattern. For this reason is not uncommon that hirsutism raises psychological, cosmetic and social concerns. There are many treatment modalities that can be summarised into two broad groups: pharmacologic and non-pharmacologic treatment. Until now, medical treatment has been designed to interfere with the synthesis of androgen at the ovarian or adrenal level, or inhibit the effect of androgen at the receptor level, although recent progresses test other options such as insulin modulators or ornithine decarboxylase inhibitors. Mechanical treatment includes laser hair removal, electrolysis, depilatory creams, plucking and waxing. This article presents a general overview of hirsutism treatment options.

Tamoxifen-loaded liposomal topical formulation arrests hair growth in mice

BACKGROUND

For several decades, androgens have dominated endocrine research in the domain of hair growth control. However, it has long been known that oestrogens also tend to alter hair follicle (HF) growth and cycling significantly by binding to locally expressed high-affinity oestrogen receptors (ORs). Tamoxifen (TAM) is a selective OR modulator.

OBJECTIVES

The current work aims to investigate the effect of topically applied TAM on the hair growth of mice.

METHODS

Test formulations were applied once daily on the shaved back area of the mice for a period of 5 weeks. The effect of these formulations was studied by visual and histological examinations.

RESULTS

Animals treated with saline and placebo gel formulation showed significant hair growth on the 20th day. The number and length of follicles were also found to be normal. In contrast, no hair growth was observed in the animals treated with TAM gel, even after the termination of treatment. The HFs were found to be arrested in telogen phase with clear signs of follicle dystrophy.

CONCLUSIONS

The hair growth-retarding effect of TAM observed in the current study clearly demonstrates its OR agonistic effect on hair growth. This work also provides a distinct lead towards the possible potential of TAM liposomal gel in the treatment of hirsutism.

Biology of human hair: know your hair to control it

Hair can be engineered at different levels--its structure and surface--through modification of its constituent molecules, in particular proteins, but also the hair follicle (HF) can be genetically altered, in particular with the advent of siRNA-based applications. General aspects of hair biology are reviewed, as well as the most recent contributions to understanding hair pigmentation and the regulation of hair development. Focus will also be placed on the techniques developed specifically for delivering compounds of varying chemical nature to the HF, indicating methods for genetic/biochemical modulation of HF components for the treatment of hair diseases. Finally, hair fiber structure and chemical characteristics will be discussed as targets for keratin surface functionalization.

Female adolescent hair disorders

Hair abnormalities can have tremendous psychosocial impacts on adolescents and young adults, and may cause a great amount of anxiety regarding physical appearance, associated illnesses, and potential clinical course. The pathophysiology of such disorders may vary,with potential congenital, infectious, autoimmune, nutritional, or environmental causes. Hair abnormalities may present as changes in hair appearance or quality, becoming weathered or fractured.An abnormal increase in hair is present in hypertrichosis and hirsutism, whereas a thinning or shedding of hair is evident in patients with telogen effluviumand alopecia areata. Diagnosis is focused on a detailed clinical history and physical exam, in addition to laboratory testing, a variety of clinical diagnostic tests, and scalp biopsy, which may be necessary to confirm some diagnoses. Many hair disorders have no cure, but clinicians can have a positive impact on their patients by identifying the abnormality and educating the patient regarding disease course. However, some conditions such as infectious hair disorders or scarring alopecia should be identified promptly to initiate treatment and ensure clinical improvement or optimal outcome.