Removal of Unwanted Facial Hair DONALD W. SHENENBERGER, LCDR, MC, USNR, Naval Medical Center, Portsmouth, Virginia LYNN M. UTECHT, CAPT, MC, USN, Naval Hospital, Rota, Spain Unwanted facial hair is a common problem that is seldom discussed in the primary care set- ting. Although men occasionally request removal of unwanted facial hair, women most O A patient informa- often seek help with this condition. Physicians generally neglect to address the problem if tion handout on removal of unwanted the patient does not first request help. The condition may be caused by androgen overpro- facial hair, written by duction, increased sensitivity to circulating androgens, or other metabolic and endocrine dis- the authors of this orders, and should be properly evaluated. Options for hair removal vary in efficacy, degree article, is provided on of discomfort, and cost. Clinical studies on the efficacy of many therapies are lacking. Short page 1913. of surgical removal of the hair follicle, the only permanent treatment is electrolysis. How- ever, the practice of electrolysis lacks standardization, and regulation of the procedure varies from state to state. Shaving, epilation, and depilation are the most commonly attempted ini- tial options for facial hair removal. Although these methods are less expensive, they are only temporary. Laser hair removal, although better studied than most methods and more strictly regulated, has yet to be proved permanent in all patients. Eflornithine, a topical treatment, is simple to apply and has minimal side effects. By the time most patients consult a physi- cian, they have tried several methods of hair removal. Family physicians can properly edu- cate patients and recommend treatment for this common condition if they are armed with basic knowledge about the treatment options. (Am Fam Physician 2002;66:1907-11,1913-4. Copyright© 2002 American Academy of Family Physicians.) nwanted facial hair is a follicular canal, dehydrate, and form the common condition that growing shaft. The visible hair shaft is com- often goes untreated. Women posed of an outer cuticle, the cortex and, most often seek treatment, sometimes, a core of compact, keratinized but men may also have con- cells, all of which are made of protein.2-5 Ucerns about this problem.1 In most cases, a Hairs that are in the anagen phase during severe underlying medical condition is not removal are more sensitive to the various treat- the cause of unwanted facial hair. Its presence, ment modalities than hairs in the telogen however, causes significant psychologic stress phase. Alteration of matrix cell activity during and may lead patients to resort to uncomfort- anagen, by whatever method chosen, increases able and often expensive means of removal. the amount of time from removal to regrowth. As a result, one of three alterations can occur: Hair Growth Cycle early cessation of anagen causing telogen to The growth of human hair is cyclic, involv- occur, transition into a dystrophic stage of ana- ing phases of active growth (anagen) and qui- gen, or degeneration of the matrix.5-8 escence (telogen). In addition, an intermedi- Depending on the site of the hair, the time ate stage of transition, known as catagen, spent in each phase differs considerably, from occurs between active growth and cessation an anagen phase of two to six years for scalp of growth. Between 85 and 90 percent of hairs hair to one to two months for thigh hair. The are in the anagen phase at any one time, with telogen phase also varies, ranging from one the remainder in telogen.2-4 and one half months for mustache hairs to During the anagen phase, mitotic activity three to six months for leg hairs.5 During tel- in the hair bulb and dermal papilla resumes ogen, growth stops, and the entire structure and forms the new hair shaft, pushing out the rests for a variable period of time, depending See page 1856 for definitions of old inactive hair, or club hair, as the new hair on the site. Once anagen begins, the remain- strength-of-evidence advances. The matrix cells, which form the ing club hair is ejected, and the growth cycle levels. new hair, multiply rapidly and ascend into the continues. NOVEMBER 15, 2002 / VOLUME 66, NUMBER 10 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1907 Women with abnormal hair-growth patterns should be EPILATION/DEPILATION evaluated for overproduction of testosterone and other Epilation, or plucking, is often the first method chosen by patients. The entire hair androgens. shaft and bulb are removed, with results last- ing six to eight weeks.5,10 While this method is probably the least expensive, it is not practical Patterns of hair growth vary greatly for use over larger areas. Unless the hair is depending on whether the patient is male or plucked in anagen, the method generally does female. In addition, ethnicity may also deter- not change the growth rate of hair.11,12 Pluck- mine normal growth patterns that can be ing during anagen may shorten the duration interpreted as abnormal by physicians out- of time spent in this phase and, if repetitive, side of a patient’s native culture. Growth of may permanently damage the matrix.5,6 androgen-sensitive hairs at various regions of Numerous methods are used for epilation, the body (beard, axillae, pubis, chest, and from tweezers to devices that pluck several shoulders, for example) can arouse suspicion hairs at once. Hot or cold waxing is also a of an underlying organic cause.2,3 Overpro- form of epilation. Mixed with the wax is a duction of testosterone and other androgens resin that hardens around the hair shaft and in female patients may cause abnormal aids in pulling out the hair when the wax has growth patterns that can be clinically evident dried. Side effects, which are more common as hirsutism.2,3 All such patients should be when more than one hair is removed at a evaluated for an underlying cause of the hair time, include burns (from hot wax products), growth, whether the unwanted facial hair is folliculitis, pseudofolliculitis, postinflamma- to be treated or not. tory hyperpigmentation, and scarring.5,13 Depilation is the use of a chemical that dis- Methods of Hair Removal solves the hair shaft, with results lasting up to Several methods of hair removal are avail- two weeks.5,14 Composed of thioglycolates able, each with varying degrees of cost, effi- and mercaptans, and mixed with an alkali cacy, and side effects. Methods of hair re- compound (calcium hydroxide or sodium moval are summarized in Table 1. hydroxide), depilatories do not affect the hair bulb.5,14 The thioglycolates disrupt disulfide SHAVING bonds between the cystine molecules found Shaving does not change the thickness or in hair, helping to dissolve the hair shaft.5,14 growth rate of human hair.5,9 Rather, the The addition of an alkali compound in- rough-textured, beveled edge that shaving creases the pH level and can improve the effi- produces (compared with the softer, tapered cacy of the depilatory. tip of uncut hair) may give the appearance of Side effects include chemical dermatitis thickening.5,6 Although shaving is a useful and, occasionally, allergic dermatitis from the and safe method of facial hair removal (and sulfur-containing thioglycolates or fragrance the chief method chosen by men), it is not added to the compound. The thioglycolates popular among women. produce hydrogen disulfide gas, a particularly Side effects of shaving are generally mini- offensive-smelling byproduct.5,14 mal. Irritation, often caused by components of the shaving lubricant, and minor cuts can LASER occur. Pseudofolliculitis barbae, caused by the The use of lasers in hair removal allows selec- ingrowth of curly hair, is also a fairly com- tive targeting of the hair bulb and can diminish mon side effect in some ethnic groups.5 regrowth for at least three months.2,5,6,15,16 [Ref- 1908 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 10 / NOVEMBER 15, 2002 Unwanted Facial Hair erence 15—Evidence level B, nonrandomized damage or absorptive interference with less clinical trial] Evidence of permanent hair effective hair destruction. Patients with dark removal has yet to be established but is under hair and light skin have a relatively higher con- investigation. centration of melanin in the hair compared The basis for laser hair removal is the spe- with the epidermis, allowing for more selective cific targeting of melanin in the hair bulb. absorption of light within the hair bulb, reduc- Melanin absorbs the light emitted by the laser ing damage to or interference by the melanin at a specific wavelength. The energy of the laser in the epidermis. Conversely, gray or white hair converts into heat, causing the selective is a poor target for laser energy. destruction of the hair bulb. However, melanin The most common side effects of laser hair in the surrounding epidermis can also be tar- removal are edema and erythema, which gen- geted, which may limit the success of the pro- erally resolve within 24 hours after treatment. cedure. With too much melanin in the adja- The process itself can be slightly painful cent skin, the laser energy is absorbed into the because of the short burst of heat energy cre- surrounding epidermis, causing epidermal ated. Furthermore, hypopigmentation and TABLE 1 Summary of Hair Removal Methods Method Side effects Permanence Cost Shaving Chemical dermatitis, minor cuts, One to three days Variably inexpensive pseudofolliculitis barbae Epilation: Pain, folliculitis, pseudofolliculitis, Two to eight weeks Least expensive plucking/waxing burns, irritation, postinflammatory hyperpigmentation, scarring Depilation: Chemical dermatitis, occasionally Up to two weeks Variably inexpensive chemical allergic dermatitis Laser Edema, erythema, pain, At least three months Variable but hypopigmentation, approximately six to hyperpigmentation eight sessions (depending on site and skin/hair color), at $75 to $250 per session Electrolysis Edema, erythema, pain, scarring, Considered to be About $18 to $25 keloid formation, postinflammatory permanent but per 15-minute pigment changes.