Indian Journal of Dermatology
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Table of Contents 
Year : 2011  |  Volume : 56  |  Issue : 2  |  Page : 248-249
Author's reply

Vasal Hospital, Jalandhar - 144 022, Punjab, India

Date of Web Publication5-May-2011

Correspondence Address:
Silonie Sachdeva
Vasal Hospital, Jalandhar - 144 022, Punjab
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Source of Support: None, Conflict of Interest: None

PMID: 21716944

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How to cite this article:
Sachdeva S. Author's reply. Indian J Dermatol 2011;56:248-9

How to cite this URL:
Sachdeva S. Author's reply. Indian J Dermatol [serial online] 2011 [cited 2022 Dec 5];56:248-9. Available from:


I thank Ghosh [1] for taking an interest in my article. [2] A review article cannot cover everything that is written on a particular subject. We have a lot of contradictions in literature on almost every subject in dermatology, starting from the definition to the marker values. I maintain this article has not given any wrong information to the IJD readers.

The correspondent states that "the definition of hirsutism stated in the article is perhaps not appropriate." We maintain the definition quoted is not out of place (reference 1, 2 in the original article. Lancet; 1961). This has been the original definition of hirsutism. Of course the density can vary from 0 - 4 on the Ferriman scale, which is mentioned in the article. However, in the algorithm for the evaluation of hirsutism, it is very clearly written that hirsutism is the increased amount of hair in a male pattern distribution.

The correspondent thinks that in the etiology section, the term 'premenopausal' should have been replaced with the term 'perimenopausal'. My response would be that 'perimenopausal' would in anyway mean surrounding menopausal age.

Regarding the correspondent's argument on testosterone levels, I maintain that the values quoted are correct (reference no.4. Lancet, 1997, in the original article). The correspondent should know that the precursor molecules are again synthesized in the ovaries or adrenals and it is just the way of writing things that causes a change in values.

With respect to what the correspondent has to say regarding the Ferriman-Gallwey scoring, we maintain that when we use the word 'subjective' it covers everything and that there is no need to go into the details of what signifies subjectivism. Racial differences or not paying due attention to other androgen-dependent sites also contributes to subjectivism. The Lorenzo system is not popular, so it was not mentioned.

Regarding the correspondent's insinuation about missing points on evaluation, we maintain that in the algorithm on page 2 of the article, there is a point that states that complete history and general and systemic examination should be done. In an article written on hirsutism, it was axiomatic that the pertinent history would include family history and examination would mean looking for skin tags, acanthosis nigricans, galactorrhea, and so on. This is a review article and not a resident corner page where every basic point needs to be described.

We maintain that the cut-off value given for total testosterone, to signify the adrenal or ovarian neoplasm value, is correct (original reference 11 in the article). The excessive increase was to signify the malignant cause, which needed immediate attention compared to the benign neoplasm.

Regarding the correspondent's assertion that there is no mention of free testosterone level and its importance in the whole article, I would like to point out that in the 'etiology' itself, (page 1) it is mentioned that classically hirsutism is considered a marker of increased androgen levels in females (testosterone).The importance has never been overlooked.

We accept the reader's observation regarding the timing of testosterone estimation, which we failed to mention in the article. We appreciate the reader's interest and agree that it would be worth mentioning the timing in an article on hirsutism.

I also appreciate the reader's observation and agree that depilatory and epilatory methods should have been mentioned separately. Regarding the reader's observation on lasers, we hold that it hardly has any bearing on the article. That laser works on the selective photothermolysis principle and destroys the target melanin. This is absolutely true. Nobody can challenge that. Without melanin, there can be no destruction of hair follicles.

Regarding the reader's comment that 'intense pulse light as a tool for hair removal has been overlooked', I would like to respond that in the Indian scenario long pulse Nd : YAG is an accepted treatment in most studies. We have mentioned what is more successful. This is a review article on hirsutism and not on laser hair removal.

We agree with the correspondent's comments on drug therapy in idiopathic hirsutism, but would maintain that the principle is to start drugs when hyperandrogenism is confirmed by various laboratory tests.

Regarding the reader's claim that the importance of the progestins has been overlooked, we would like to point out that cyproterone acetate is adequately mentioned on page 4 of the article, para 2. In fact, a complete paragraph is devoted to it.

Regarding the reader's view on non-classical variants, we would like to point out that we have focused on the basic etiology and treatment. We would also maintain that the main use of corticosteroids has been to treat hirsutism associated with congenital adrenal hyperplasia.

Finally, we appreciate the reader's comments regarding the role and significance of metformin and thiazolidinediones, but our main focus was on the treatment of hirsutism and not other conditions like diabetes associated with polycystic ovary disease (PCOD), although these would be worth mentioning . However, the role of diet and exercise has been emphasized in the beginning of the treatment section, which means that we have indicated that associated symptoms of PCOD should be taken care of.[13]

   References Top

1.Ghosh K. Hirsutism: Evaluation and treatment: A reader's dilemma. Indian J Dermatol 2011;56:237-8  Back to cited text no. 1
2.Sachdeva S. Hirsutism: Evaluation and treatment. Indian J Dermatol 2010;55:3-7.   Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Rosenfield RL. Clinical practice. Hirsutism. N Engl J Med 2005;353:2578-88.  Back to cited text no. 3
4.Redmond GP, Bergfeld WF. Diagnostic approach to androgen disorders in women: Acne, hirsutism, and alopecia. Cleve Clin J Med 1990;57:423-7.  Back to cited text no. 4
5.Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008;93:1105-20.  Back to cited text no. 5
6.Ehrmann DA. Hirsutism and Virilization: Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL editors. Harrison's Principles of Internal Medicine. 16 th ed. New York: McGraw-Hill; 2005. p. 275-8  Back to cited text no. 6
7.Kirschner MA, Bardin CW. Androgen production and metabolism in normal and virilized women. Metabolism 1972;21:667-73.   Back to cited text no. 7
8.Mandt N, Troilius A, Drosner M. Epilation today: physiology of the hair follicle and clinical photo-epilation. J Investig Dermatol Symp Proc 2005;10:271-4.  Back to cited text no. 8
9.Erenus M, Yucelten D, Durmusoglu F, Gurbuz O. Comparison of finasteride versus spironolactone in the treatment of idiopathic hirsutism. Fertil Steril 1997;68:1000-3.  Back to cited text no. 9
10.Lumachi F, Rondinone R. Use of cyproterone acetate, finasteride, and spironolactone to treat idiopathic hirsutism. Fertil Steril 2003;79:942-6.  Back to cited text no. 10
11.Spritzer P, Billaud L, Thalabard JC, Birman P, Mowszowicz I, Raux-Demay MC, et al. Cyproterone acetate versus hydrocortisone treatment in late-onset adrenal hyperplasia. J Clin Endocrinol Metab 1990;70:642-6.  Back to cited text no. 11
12.Emans SJ, Grace E, Woods ER, Mansfield J, Crigler JF Jr. Treatment with dexamethasone of androgen excess in adolescent patients. J Pediatr 1988;112:821-6.   Back to cited text no. 12
13.Kelly CJ, Gordon D. The effect of metformin on hirsutism in polycystic ovary syndrome. Eur J Endocrinol 2002;147:217-21.  Back to cited text no. 13


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