Compounding Ideas for Patients with Excessive Facial Hair (Hirsutism)

Cost-effective options, including topical metformin and other compounding approaches

What is Hirsutism?

Hirsutism can be defined as excessive body hair in women, often in areas of the body where hair is unwanted.¹

Women who suffer from facial hirsutism often avoid social situations and may experience symptoms of anxiety and depression. This creates a real need for affordable, practical solutions for undesired facial hair.

The term “Hirsutism” is of Latin origin, meaning excessive growth of stiff hair, or simply hairiness. Clinically, it refers to women with excess growth of stiff, pigmented “terminal hair” in a male pattern. Common sites include the lips, chin, and chest.

In approximately 90% of hirsute females, the condition is associated with underlying polycystic ovarian syndrome (PCOS) or is idiopathic (unknown cause).¹ Sometimes women or prescribers suspect hormonal imbalance related to menopause.

Cost-effective Options

Regardless of the cause, many patients are looking for cost-effective options for unwanted hair. Even when commercial products are available, costs can be prohibitive. While addressing hormones and metabolic factors is important, many patients also want a practical option they can discuss with a prescriber sooner.

Unfortunately, commercial products can be very expensive and may come with unwanted side effects. For example, a common brand topical cream for excessive facial hair may cost nearly $200 for one 45 g tube.³ Laser may only work for certain hair colors, and electrolysis can be painful and requires multiple sessions—leaving many lighter-haired women without great options.

One option may be topical metformin. Metformin is well known for reducing circulating androgens, which may decrease excess hair in women. Combined with dermatology research suggesting local cutaneous effects of metformin (e.g., hyperpigmentation pathways), it may be reasonable to hypothesize that topical metformin could help inhibit terminal hair growth.

Metformin

Metformin is used off-label in PCOS because it can reduce circulating insulin, which may reduce the concentration of free androgens. A few studies have examined the influence of metformin on hirsutism as a primary endpoint. Kelly and Gordon demonstrated a modest reduction in hirsutism after therapy in a randomized, double-blind, placebo-controlled crossover trial.⁴

In a six-month randomized controlled trial of 70 PCOS patients, metformin plus intense pulsed light (IPL) for hair removal was superior to IPL alone.⁵

Other evidence comes from dermatological research. Metformin has been explored in cutaneous disorders such as hormonal acne, hidradenitis suppurativa, and acanthosis nigricans.² Systemic metformin has also shown promise in psoriasis and cutaneous malignancies in some studies.²

Interestingly, topical approaches have been explored for pigmentation, including mechanisms related to protein kinase C beta (PKC-β). One study found that topical application of a PKC inhibitor reduced skin and hair pigmentation.⁶

There is also evidence linking insulin to follicular behavior. Hair follicles exposed to high insulin levels may show higher growth rates, while follicles maintained without insulin or at typical levels may enter a catagen-like state (a transition phase where growth stops and melanin production decreases).⁷

Other Options

This research and a new perspective on topical metformin may be helpful when combined with other more established options. Here are common options that may be discussed with a prescriber:

Finasteride Compounded Cream and Combinations

Finasteride is a competitive inhibitor of 5α-reductase and is often considered a second-line option for hirsutism.¹² Some guidelines suggest oral contraceptives as first-line and adding finasteride after six months if response is suboptimal. One study comparing finasteride 0.25% cream to placebo found mean hair counts decreased significantly at finasteride sites after six months, with no significant change at placebo sites.¹²

Example Formulas to Discuss with Your Prescriber

• Metformin HCl 5% / Progesterone 1% / Azelaic Acid 1% / Spironolactone 5% Topical Cream
• Metformin HCl 5% / Progesterone 1% / Azelaic Acid 1% Topical Cream
• Finasteride 0.25% Facial Cream

Note: Compounded medications require prescriber involvement and individualized assessment.

References

1. Yildiz, B. O., Bolour, S., Woods, K., Moore, A., & Azziz, R. (2010). Visually scoring hirsutism. Human Reproduction Update, 16(1), 51–64. https://doi.org/10.1093/humupd/dmp024
2. Bubna, A. K. (2016). Metformin – For the dermatologist. Indian Journal of Pharmacology, 48(1), 4–10. https://doi.org/10.4103/0253-7613.174388
3. Bristol-Myers Squibb. (2000). Labeling: Vaniqa. https://www.accessdata.fda.gov/drugsatfda_docs/label/2000/21145lbl.pdf
4. Kelly, C. J., & Gordon, D. (2002). The effect of metformin on hirsutism in polycystic ovary syndrome. European Journal of Endocrinology, 147(2), 217–221. http://www.eje-online.org/content/147/2/217.long
5. Rezvanian, H., Adibi, N., Siavash, M., Kachuei, A., Shojaee-Moradie, F., & Asilian, A. (2009). Increased insulin sensitivity by metformin enhances intense-pulsed-light-assisted hair removal in PCOS. Dermatology, 218(3), 231–236. https://doi.org/10.1159/000187718
6. Park, H. Y., Lee, J., González, S., Middelkamp-Hup, M. A., Kapasi, S., Peterson, S., & Gilchrest, B. A. (2004). Topical application of a protein kinase C inhibitor reduces skin and hair pigmentation. Journal of Investigative Dermatology, 122(1), 159–166. https://doi.org/10.1046/j.0022-202X.2003.22134.x
7. Philpott, M. P., Sanders, D. A., & Kealey, T. (1994). Effects of insulin and IGFs on cultured human hair follicles. Journal of Investigative Dermatology, 102(6), 857–861.
8. McCoy, N. L. (2001). Female sexuality during aging. In Hof, P. R. & Mobbs, C. V. (Eds.), Functional Neurobiology of Aging (pp. 769–779). Academic Press.
9. Stamatiadis, D., Bulteau-Portois, M. C., & Mowszowicz, I. (1988). Inhibition of 5 alpha-reductase activity in human skin by zinc and azelaic acid. British Journal of Dermatology, 119(5), 627–632.
10. Sachdeva, S. (2010). Hirsutism: Evaluation and treatment. Indian Journal of Dermatology, 55(1), 3–7. https://doi.org/10.4103/0019-5154.60342
11. Lehraiki, A., Abbe, P., Cerezo, M., Rouaud, F., Regazzetti, C., Chignon-Sicar, B., … Rocchi, S. (2014). Inhibition of melanogenesis by the antidiabetic metformin. Journal of Investigative Dermatology, 134(10), 2589–2597. https://doi.org/10.1038/jid.2014.202
12. Lucas, K. J. (2001). Finasteride cream in hirsutism. Endocrine Practice, 7(1), 5–10. http://dx.doi.org/10.4158/EP.7.1.5
13. Compounding Ideas for Patients with Excessive Facial Hair (Hirsutism). Michael Schmidt, PharmD Candidate 2017, Creighton University. Preceptor: Bruce Biundo, RPh, FACA, PCCA Pharmacy Consultant.