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Home , Hirsutism

Depilation for Hirsutism

Policy

NHS NWL CCGs will fund depilation only when the following criteria are met:

Facial There is an existing endocrine medical condition and severe facial hirsutism Ferriman Gallwey Score of 3 or more per area requested Medical treatments such as suppression therapy has been tried for at least one year and failed. Patients with a BMI>30 should be in a weight reduction programme and should at least 5% of their body weight.

Peri Anal Removal of excess in the peri anal area will only be funded as part of treatment for pilonidal sinuses.

Other Area Have undergone reconstructive surgery leading to abnormally located hair- bearing skin

Laser treatment for excess hair (hirsutism) will only be funded for 6 treatment sessions and only at NHS commissioned services.

Hair depilation for sites other than the above is not routinely funded and may be available via the IFR route under exceptional circumstances.

These polices have been approved by the eight Clinical Commissioning Groups in North West London (NHS Brent CCG, NHS Central London CCG, NHS Ealing CCG, NHS Hammersmith and Fulham CCG, NHS Harrow CCG, NHS Hillingdon CCG, NHS Hounslow CCG and NHS West London CCG).

Background

Hirsutism is excessive hair growth in women in areas of the body where only to develop coarse hair, primarily on the face and neck area.1 Unwanted and excessive hair growth is a common problem and considerable amounts of time and money are spent on . It affects about 5-10% of women, and is often quoted as a cause of emotional distress. Possible underlying causes Ovarian Syndrome (PCOS), (a condition of unknown cause characterised by reduced fertility, ovarian and increased production), other rare hormone disorders and some forms of medication. Traditional treatments include , and plucking. Most endocrine causes of hirsutism respond to hormone suppression therapy with a 7 8 contraceptive pill containing an anti-androgen or an anti-androgen alone. Hirsutism also improves with weight loss.

Hair depilation (for the management of – code L68) involves permanent removal/reduction of hair from face, neck, legs, armpits and other areas of body usually for cosmetic reasons. It is usually achieved by electrolysis or laser therapy. Although evidence on the use of laser in hirsutism is currently limited, it is advised that laser treatment should not be used by dark-skinned women and there is evidence that it is less effective with blond, red or white hair. Light-skinned women with dark hair get the best results from laser treatment and the benefits are greater for large areas of hair. Most types of are considered safe if performed properly, but recent studies suggest other skin structures can be adversely affected by laser irradiation and the long- term consequences of this are yet unknown. Hair re-growth is common, hence the need for repeated treatments.

Latest version of the policy is available at: http://www.hounslowccg.nhs.uk/what-we-do/individual-funding-requests.aspx Version 3.3 (November 2014)

Background (continued)

The benefits of using laser treatment can include:

• Minimal pain experienced • Improved appearance • Improved satisfaction with results from patients

Common side effects include pigmentary changes, occasional blistering and rare scarring, along with other untoward effects were observed. These included: de- novo growth of hair outside the area treated by laser, potentiation of co-existing in the treatment area, induction or aggravation of , -like rash, premature greyness of hair, tunnelling of hair under the skin, prolonged diffuse redness and oedema of the face, focal hypopigmentation of the lip, angular cheilitis, allergic reaction to the cooling gas, and inflammatory and pigmentary changes of pre-existing nevi.1. It has been noted that burning and sequelae, leukotrichia, paradoxical hypertrichosis and are four major side effects of the use of Lumina IPL system and Vasculight-SR multi-functional laser and IPL system when used to treat hair removal in hirsute patients.1 In addition pain, skin redness, swelling, burned hairs and pigmentary changes were infrequently reported adverse effects.1

The Steer report found no evidence to compare effects of different laser techniques. Case series evidence suggests that after laser depilation, hair growth is reduced for a period of weeks to months, but that multiple treatments may be required to achieve complete .

Acceptable indications for Intervention

For those patients who:

Have undergone reconstructive surgery leading to abnormally located hair- bearing skin Have a proven underlying endocrine disturbance resulting in severe hirsutism (e.g. polycystic syndrome) Are undergoing treatment for pilonidal sinuses to reduce recurrence

Figure illustrating how to score severity of hirsutism using The Ferriman Gallwey score.

Latest version of the policy is available at: http://www.hounslowccg.nhs.uk/what-we-do/individual-funding-requests.aspx Version 3.3 (November 2014)

References

Patient Information Leaflet http://www.nhs.uk/conditions/hirsutism/Pages/introduction.aspx http://www.patient.co.uk/health/Polycystic-Ovary-Syndrome.htm

References

1. Azziz R, Carmina E and Sawaya M. (2000): Idiopathic Hirsutism. The Endocrine Society, Endocrine Reviews 21 (4): 347-362 2. Rasheed AI. Uncommonly reported side effects of hair removal by long pulsed-alexandrite laser. Journal of Cosmetic , December 2009, vol./is. 8/4(267-74), 1473- 2130;1473-2165 (2009 Dec) 3. Haedersdal M, Gøtzsche PC. Laser and photoepilation for unwanted hair grow h Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004684. DOI:10.1002/14651858. CD004684. pub2.

4. Radmanesh M, Azar-Beig M, Abtahian A, Naderi AH. Burning, paradoxical hypertrichosis, leukotrichia and folliculitis are four major complications of intense pulsed light hair removal therapy Journal of Dermatological Treatment, 2008, vo is. 19/6(360-3), 0954-6634;1471- 1753 (2008) 5. Haedersdal M, Gøtzsche PC. Laser and photoepilation for unwanted hair grow h Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004684. DOI:10.1002/14651858. CD004684. pub2. 6. Ferriman D, Gallwey JD: Clinical assessment of growth in women. Journal o Clinical 1961; 21 1440-1447 7. Carmina, E, Anti- for the treatment of hirsutism, Expert Opin Investig Drugs, 2002, 11(3):357- 63 8. Bernasconi D et al, The impact of on hormonal parameters in hirsute and nonhirsute women, Metabolism, 1996, 45(1):72-5 9. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of hyperandrogenic disorders https://www.aace.com/files/hyper- androgenism-2001.pdf

Latest version of the policy is available at: http://www.hounslowccg.nhs.uk/what-we-do/individual-funding-requests.aspx Version 3.3 (November 2014)