- Email: [email protected]
Human body hair—A quantitative study
HUMAN
BODY
PRABHAKER (From
The Indian
HAIR-A QUANTITATIVE STUDY N. SHAH, M.D.,* NEW YORK, N. Y. Cancer
Research
Centrc,
Bombay
18,
India)
VARYING degree of hypertrichosis is a common clinical finding in women of the active reproductive age. Debarring rare cases where pathological lesion in ovary or adrenal is found, no definite factors can be iml~licated as causal agent,s in the large majority of such women. Attempts have been made, however, to establish causal relationship with a disturbance of endocrine function in this large group of cases of “idiopathic” hirsutism but it is only recently that a number of investigator+ *I lo presented biochemical (~vi&nce of a probable abnormal adrenocortical function. Among these authors Jailer and Vander Wiele8 are perhaps the only ones who had a large series of cases and they were unable to demonstrate steroid abnormality in the large majority of their patients. These authors rightly commented on the dificulty of defining the term hirsutism and it is possible that some of the casesstudied may have had hair growth comparable to that in the higher range of normal variation. The present study was instituted with the primary object of elaborating a method of measuring body hair quantitatively, with a hope that this might enable the clinician to distinguish hirsute women in whom detailtcl endocrine work-up was indicated. Such a method would also allow comparison of normal hair growth in various ethnic groups and might be of considerable value in elucidating any striking inherited differences in the distribution and the pattern of hair growth if applied to different endogamous gt+oups of India’3 or elsewhere. Perusal of the literature disclosed that few studies have been made of t,hc quantitative estimation of body hair. The pioneer study of body hair contlucted by Trotter and Danforth*, 3, l5 has been followed by the recent investigations of Pedersen,ll Dupertuis and associates,*Beek,l and Garn.6 These investigations have developed standardized methods for rating coarse or terminal hair, both directly and from photographs. It is necessary to st.ate that the ratings done by these workers were on certain specified areas and the criterion employed was the presence or absence of terminal hair on these regions, with the only exception perhaps of Garn, who tried to quantitate the body hair. 5’01, this Garn devised a rating system based on the density of hair which varied on a scale of O-4 on each region. He also determined a minimum number of hair regions, which should be studied separately, defining a region as 2111 area of the body where hair growth is, at least, partially independent from
A
and 32.
N.
*Fellow Gynecology, Y.
of
the Rockefeller College of
Foundation. Physicians
and
Pr’esent Surgeons,
1255
address : Columbia
Department T’niversity,
of
Obstetrics
Ne\v
York
13.-g;
Am. I. Obsr. & Gym.
June, 1”5:
The tlil t.a 1)~YYWII~ bdy
hair
in
WOIHC’II
~1
h tkrC
~cp~~sc~nt,
sn~~~~osecl
to
have
our mow
etY~rt.S or
to
abnormal
~ne:tSuve hair
quantit,atively 011 certain
parts
body. In the absence of standards by which one can judge what is normal variation of hair growth, a comparative study of hair growth in data a])parrntly nonhirsute women and men was also made. Such comparative from the point of view of quantity of body hair, as fa,r as we are awaTt!, a1.e of
lilil.tlt’
the
iIVZlilkLblC\
pCl’llFlpS
1’01’
the
first
Method The method used very much modified.
time.
and Material
here is based on features from Garn’s procedure The salient features of this method are :
but it is
1. Ratings were made directly on the subjects (only a small loin cloth was allowed) from the closest possible distance and under 1,500 watts of illumination. 2. The study considers only terminal hair of minimal 0.5 cm. in length. 3. The body was divided into nine regions (Fig. 1). The regions, upper arm and thigh, lower arm and leg were numbered separately, for these regions In view of the smallness appeared to be fairly independent for hair growth. of the ear, middigital, lumbosacral, and lower back regions compared to the other regions considered, they were excluded in this study. Thus the total area studied was almost the sa,me as in Garn’s investigation. 4. In order to have a better idea regarding the quantity of hair in each region, three factors, namely, the quality, density, and the proportion of the By quality was area of the region covered by h;Gr, wcrc taken int,o account. meant the thickness of hair and this was rated on a scale of l-3 by palpation. The clensity was rated on a sculc of O-3 for each specified region; the absence of hair or the presence of a few hairs in any region was indicated by zero. When the growth was very clc~~, it was indicated by the figure 3 and the intermediate range was divided into 2. The total quantity of hair for a particular region was obtained by multiplying the numerals for quality, density, and the fraction of the arca of the particular region covered by hair. For example. if on a lower arm of an individual, the quality of hair rated was l., t,hc density was 1, and the dorsal surfacr only was covered by hair, then the quantity of hair for the lower-arm region would be 1 by 1 by l/z = 0.5. For the sake of brevity a round number was taken for counting. The final numerical hair growth score, obtained by adding the respective numerals for the nine regions, was taken as a m(xsurc of body hair. 5. After the rating scale had b~cn developed on a small pilot group, it was tested by two independent persons at the same time on 90 subjects. As their 94 results were fairly comparabl(A, the met,hod was applied to the further persons by the author alone. 6. In all, 184 persons were rated. Their distribution according to age is shown in Table I. They fall into thrrtl groups : (1) Women who came with complaints other than abnormal hairiness There were 100 in all, ranging in age formed the group of nonhirsute women. from 1% to 48 years, the mean age being 27.2 yenrs.
Volume Number
73 6
HUMAN
BODY
HAIR-QUANTITATIVE
STUDY
1257
(2) Women who were referred to us from several private clinics for abnormal or excessive hair growth constituted this group. There were 34 in all. Their ages ranged from 15 to 41 years, with a mean age of 22.2 years. (3) Fifty men constituted this group, ranging from 20 to 53 years of age, with a mean age of 28 years. Most of t,hern were the workers at the Indian Cancer Research Centre. A few, however, were &se relatives of the hirsute women.
Fig.
I.-The (4)
body hair regions upper arm, (6) lower
as deflned arm, (6)
in the text: thigh, (7) leg,
(1) (8)
face. buttocks,
(2)
abdomen, (9) upper
(3) back.
chest,
It is important to state that, though the division of nonhirsute and hirsute women is only arbitrary, yet it is of significance because it is rare for a woman to be hairy and still not be concerned about her hair growth. Further questioning of the hirsute group of women regarding the motivation for visiting
an physician disclosctl, in orclrr (4 t’~~luc~ncy. that ( I ) they 01’ their t.(!l:iti\rchs t’olt that, such hair growth would jeoparclizcl the possibility ot’ n1;1rt+lge; (2) t.hcy thought t.hcy were changing sex; (3) the husbantls had startcat to tlislikc them ever since they began to grow hair in (a(art:lin regions: (1) th(xv w(‘t’c’ it)terrstctl in knowing whether investigation of th(arn woultl help in prtxventing similar hair growt,h in their offspring who were thcln in the prepuhertal age.
(6)
Fig.
2.-Frequency
of awxx~~~ce
of terminal
hair
(7)
in specified
I61
I91
regions.
Observations Nonshirsute Women.-Thirty-one of 100 subjects had absence of terminal hair in all the regions studied by us. In the remaining 69 cases, as shown in Fig. 2, the commonest site for hair growth was the leg and in order of frequcncy the lower arm, thigh! buttocks, upper arm, and ahdomcn were found to have hair. It brcomes evident from the histogram that, in nonhirsutc women. the presence of hair on the fact. chest. and upper hack is absolutely “unusual,” while it,s presence on abdomen, upper arm. and buttocks is relatively “unusual. ’ ’ When the individuals were grouped from the point of view of t,hc number of regions showing growth of ha,ir, it was found that the large majority (93 per cent) did not show hair in more than three regions and, of the remaining ‘7, 6 showed it in four regions and 1 in five regions (Fig. 3). During our study it was realized that the presence of hair on the leg, not necessarily in a measurable quantity, was a prerequisite for hair on other parts of the body. There were also marked variations in the proportion of the area covered by hair. By and large, the total quantity of growth of hair on the leg was more than that seen in other regions of the same individual. The growth
HUMAN
BODY HAIK-QUANTITATIVE:
STUDY
1259
of hair on the thigh, though slight, was of measurable quantity in a small percentage of this group. The total hair growth score in the large majority (97 per cent), as shown in Fig. 4, did not exceed ‘7.
4 3 Rmcu*
Fig.
%.-Growth
.-6
of
hair
“e4Io**
by
> 6
number
of
l?x010**
regions.
too 00 00 70 00 00 40 lo SO lo
NcNlrwb
100
Fig.
4.-Frequency
I
t
LI
distribution
nlrrut* 34
of
J N.” 50
total
amount
of
hair.
Hirsute Women.-All the 34 subjects had hair on the leg where hair was common1.y found in the nonhirsute subjects; the difference, however, was in the quantity, more marked in most of the hirsute women. Unlike the nonhirsute ones, hair was found to be present in a measurable quantity on the thigh
in 29 and on the Jouw umt itr 38 01 3-j sal)jects. Along wit,11 the st,riking differrnce in 111~frcquc:ney of appcarancn of hair OII t,hc thigh, there ~vas also an illcrease in all t,hcx thr~c quart1 itati\-c n~~~asurcs, viz., the quality, drnsity, and the area ~vc~tl by hair. The rtinlaining regions in this order of frequent>., buttocks! upper arm, Cac(L,abdomell, c:ljc?st,ant1 ~~ppcr back, \VPYCf’ormtl to lli~v<~hair (Fig. 2). WllCll the sul,jcrts wTr!x 1 gronpcd Cwin tlic point cut’vicv of the nmnher of i-f’gions showing the growt’h of hair, the largc9t single group was the 0n(1showing 4 to 6 regions (Fig. 3). It is pertinent to mention that not a single subject showefl growth of hair in all the “unusu~tl” regions; the maximum nunrbcr of suc~h regions was 5 and the most uncom~no~~regions in order of frequency were the chest and upper back. Rcgardin g the density of hair in the “L~IIUSUR~” IW gions, it varied from person to person and in tlifferent regions of the same individual ; for examp1c, the hair on the chest ranged from circun~at~eolar ant1 sternal tuft to mat confluent with that, of the region abdomen. The tot,al hair growth SCOWTaried from that seen in nonhirsute women to t,he score of 28. Although the total hair growth WOW in 17 of 34 hirsute women did not show any appreciable difcrcncc from that of the nonhirsute subjects, yet. 6 of the 17 hacl a ~neasut~al~l~~ quautity of hair on 1 to 2 “nnusual” regions ( Fig. 4). .ln t.hc remaining 17 hirsute, subjects, the total score in individual sul)j&s bore no relation to the number of regions showing growth of hair nor had it anything to do with t,he selection of the “unusua1” rcbgions. In other words. two persons having similar hair growt,h score ha;1 ib (1ifFerent number of regions showing growt,h of hair.
TOTAL AMOUNT
F -
0
-
7
8 -
14
IS -
21
22
- 28
29
-
35
36
-
42
43
-
S6
NO. OF “UNUSUAL’
REGIONS
0
II
-
Fig.
5.-Number
of “unusual”
regions
showing
the
growth
of hair
in 34 hirsute
women.
From this study, selection of a group of women with considerable amount of hair growth was found to be practicable if, along with the total score, the number of “unusual” regions was taken into account. Arbitrarily, we selected subjects with a total score of 8 or above and more than two ’ ‘ unusual ’ ’ regions, or with a total score 01 15 or above and more than one “unusual” region to represent the abnormal group (Fig. 5). Thus 20 of the 34 women who originally complained of abnormal hair growth did not satisfy these criteria. In the remaining 14 women, it was interesting t,o note that there was a group of women who had hair on the face and other regions except the chest, and there was another group of women who had a considerable amount of hair on the chest and neck and other regions but the face (Figs. 6 and 7). A small group of women, however, had the combination of these two types. In these cases where there was familial hirsutism, it is interesting to note that the selection of region, namely, face or chest and neck, was identical in the female siblings who showed excessive hair growth.
Volume Number
73 6
HUMAN
BODY
HAIE--QUANTITATIVE
1261
STUDY
Men.-All the 50 subjects had hair in the regions, lower arm, thigh, and leg. Seven of these had hair in all the nine regions while in one there was absence of hair in a measurable quantity on the face. The other regions represented in order of frequency were fact, buttocks, chest, abdomen, upper arm, and upper back (Fig. 2). When individuals were grouped by the number of regions showing hair, the largest single group was the one that showed more than 6 regions (Fig. 3). The quality of the hair varied in different regions in the same individual and it seemed that, by and large, the hair on the lower extremity and chest was coarser than that seen on the upper extremity. The total hair growth score went from one extreme, .amounting to that seen in the nonhirsute women, to the other extreme, showing profuse growth of hair a1110 unting to a score of 54 (Fig. 4).
Fig.
6.
Fig.
7.
Comment Besides age and sex,ly I2 and granting that humoral control occurs, the final product of each individual follicle is largely genetically determined differences in the hair follicle itself.3 this, there is .a good body of evidence that there is no difference of hair follicles per unit area on the face in men and women dividuals of different races, yet there is certain1.y a difference and the degree of hair growth.14 For example, the classical
of hair growth dependent on To substantiate in the number or between inin the extent hair growth in
womw of the wtivc rcl,l,o’ltlc~tivc. ago ili SW(\PII ‘I is lilnit(vl to I II<>walp, q-(‘llrwws. c>yeiashes, asilla ry ;111(1pubic: wgiola. H111 L so~ltctimcs thc~~c~ is SWII il. slight, hair gtdowth in thcb ll>tI’cs, cbsttxl*11;1 I odiws 01 I 11(~(‘iI 1’s. arltl t ht! perianal ~~cgiou. The lmbic hair hils a lllarkt’(l tril~ls\-(~~*sc~ lilrlit cloc3 Ilot IYhilch further than to the i~lgbi~l :~ltl gcauif O~‘VIMII*;II t’olcls. [tIa,ir growth outsitlc these regions, according to Pedersca, ‘I is regarded as hypertrichosis, provided the minimal length of the hair is O..F VIII. According to this definition, hypertrichosis of the forearm or leg was MYW in 60 per cent of Swedish womtbtl and of the breast in % per c*cnt. In colltrilst to this group, of otherwise normal women of the Unit4 States 26.8 pear cent had facial hypertrichosis,‘* 35 per cent had more 01 less terminal hair on the trunk,” and the extent of pubic hair was found to be what is described as “sagitt,al” in pattern in IO per cent of normal white girls abort the age of 19 years.’ AS suggested by Reek.’ it, iltltl
Fig.
8.-Nonhirsute Hirsute Men A-
women 0 - __ 0 -- women 0 - - - 0 - - A ----A
0 0
is conceivable that there arc no typical male or female regions of hair growth but we feel that unless a reasonably accurate method for quantitative measurement of body hair is evolved, it is going to bc difficult to draw a base lint between a variation of normal and abnormal hair growth in women of various ethnic groups. In a study of extensive body surface such as this, the only way to assess roughly the weight of the body hair was to ta.ke into account the known variables for weight, viz., length, thickness, density, and the fraction of the area of the region covered by hair. In view of the fact t.hat no two
1264
f3;IIAH
\I,, I (&\I. & G>lll~C. June, I":7
il~tl,jaccl~t hairs in any region arc exactly similar in length, thus l~rrsctice 1.1 I terminal hair of a Ininimnm of 0.5 cm. in length was made obligatory for rating. In order to check critically the rough assessmentmade by this met,hcod and to give us a more accurate determination of body hair in the future, WC arc planning at present. to employ a procedure similar to that tlescribecl independently by Hamilton’ and Kinscll and associates.” Obviously such a tc,st is practicable in one or two regions in a few volunteers only. Finally, it is important to stress that although t,he observations recorded here are cncouraging and suggestive, we nerd larger series of both the sexes to validate these initial findings. The concept of the “unusual” regions in women derived from this study is only relative and is dependent on the difference in frequency of appcarancc of hair growth on the specified regions found between the two sexes. Such information can be of immense value if differentiat,ion between normally hairy or hypertrichotic women and abnormally hairy or hirsute women be made out conveniently on such basis. When the distribution of subjects showing ha,ir growth was plotted against the specified regions arranged anatomically, the curves of the nonhirsute women and men were found to be of different patterns, while the curve of the hirsute women was. roughly, t,he mean of the two with the exceptions that t,hc face, chest. and thigh approximate much more closely the pattern seen in men (Fig. 8). Wc then felt that if w’c split up the group of the so-called hirsute women on the basis of two criteria, namely, the t,otal hair growth score and the number of the “unusual” regions showing hair, we might be in a position to select a group of women for further investiga.tion. Arbitrarily we selected individuals who had the total hair growth score of 8 (i.c., above the highest score found in nonhirsut,e women) or above, and more than 2 “unusual” regions (i.e., above the highest number of regions seen in nonhirsute women), or those having the score of 15 or above and more than one “unusual” region, to represent the abnormal group. Thus 20 of the 34 women who originally complained of abnormal hair grnwth did not satisfy these criteria. This difference was very well brought out when the frequency of appearance of body hair in specified regions of these two groups was compared with the standard curves obtained for the nonhirsute women and men, respectively (Fig. 9). In ot,her words. 20 of the 34 subjects appeared to have body ha,ir at a higher range of normal variation, i.e., hypertrichosis, and we may call them hairy but normal women. The curve of the remaining 14 constituting the so-called abnormal group had the male pattern and these may be called hirsute or abnormally hairy women. The latter group if subjected to detailed investigations may show some interesting findings. This does not mean that hypertrichosis may not require treatment for cosmetic or psychological reasons, but it does indicate that the problem is essentially that of controlling normal hair growth on any other part of the body.
summary 1. An attempt is made to develop a practical measurement of body hair.
method for quantitative
Volume Number
,‘6
HUMAN
BODY
HAIR-QUANTITATIVE
STUDY
1265
2. The importance of checking the observations obtained by this method on larger series should be emphasized. Such study will materially aid in an understanding of the normal variation in various ethnic groups or in endogamous groups in India or elsewhere. 3. The results of the investigation show that : (1) excessive amount of hair growth on the thigh is perhaps the first sign of developing hypertrichosis in women; (2) the method is found useful in differentiating hypertrichosis from abnormal hair growth in women and may also help to set up objective criteria to evaluate the effect of treatment on hair growth. I am grateful to Dr. V. R. Khanolkar for his interest and support of this work. My sincerest thanks are due to Dr. L. D. Sanghvi for advice and criticism during the course of this study. I also wish to express appreciation to Dr. Emanual A. Friedman and Dr. Raymond Vader Wiele for assistance and advice.
References 1. Beek, C. H.: Dermatologica 101: 317, 1950. 2. Danforth, C. II., and Trotter, M.: Am. J. Phys. Anthropol. 5: 259, 1922. 3. Danforth, C. H.: Hair With Special Reference to Hypertrichosis, Chicago, 1925, American Medical Association. 4. Dupertuis, C. W., Atkinson, W. B., and Elftman, H.: Human Biol. 17: 137, 1945. 5. Gardner, L. I.: J. Clin. Endocrinol. 13: 1054, 1953. 6. Garn, 8. M.: Ann. New York Acad. Se. 53: 498, 1951. 7. Hamilton, J. B.: Ann. New York Acad. SC. 53: 585. 1951. 8. Jailer, J. W., and Vander Wiele, R. L.: Gynaecologica 138: 276, 1954. 9. Kinsell, L., Bryant, D., and Labright, F.: J. Clin. Endocrinol. 14: 897, 1954. 10. Kappas, A., Pearson, 0. H., West, C. D., and Gallagher, T. F.: S. Clin. Endocrinol. 16: 517, 1956. 11. Pedersen, J.: Acta dermat-venereol. 23: 1, 1942. 12. Reynolds, E. L.: Ann. New York Acad. SC. 53: 576, 1951. 13. Sanghvi, L. D.: Am. J. Phys. Anthropol. 2: 385,1953. 14. Trotter, M.: A Study of Facial Hair in the White and Negro Races, Washington Univ. Studies, Scientific Series 9: 273, 1922. 15. Trotter, M., and Danforth, C. H.: i2m. J. Phys. Anthropol. 5: 391, 1922.
BODY
PRABHAKER (From
The Indian
HAIR-A QUANTITATIVE STUDY N. SHAH, M.D.,* NEW YORK, N. Y. Cancer
Research
Centrc,
Bombay
18,
India)
VARYING degree of hypertrichosis is a common clinical finding in women of the active reproductive age. Debarring rare cases where pathological lesion in ovary or adrenal is found, no definite factors can be iml~licated as causal agent,s in the large majority of such women. Attempts have been made, however, to establish causal relationship with a disturbance of endocrine function in this large group of cases of “idiopathic” hirsutism but it is only recently that a number of investigator+ *I lo presented biochemical (~vi&nce of a probable abnormal adrenocortical function. Among these authors Jailer and Vander Wiele8 are perhaps the only ones who had a large series of cases and they were unable to demonstrate steroid abnormality in the large majority of their patients. These authors rightly commented on the dificulty of defining the term hirsutism and it is possible that some of the casesstudied may have had hair growth comparable to that in the higher range of normal variation. The present study was instituted with the primary object of elaborating a method of measuring body hair quantitatively, with a hope that this might enable the clinician to distinguish hirsute women in whom detailtcl endocrine work-up was indicated. Such a method would also allow comparison of normal hair growth in various ethnic groups and might be of considerable value in elucidating any striking inherited differences in the distribution and the pattern of hair growth if applied to different endogamous gt+oups of India’3 or elsewhere. Perusal of the literature disclosed that few studies have been made of t,hc quantitative estimation of body hair. The pioneer study of body hair contlucted by Trotter and Danforth*, 3, l5 has been followed by the recent investigations of Pedersen,ll Dupertuis and associates,*Beek,l and Garn.6 These investigations have developed standardized methods for rating coarse or terminal hair, both directly and from photographs. It is necessary to st.ate that the ratings done by these workers were on certain specified areas and the criterion employed was the presence or absence of terminal hair on these regions, with the only exception perhaps of Garn, who tried to quantitate the body hair. 5’01, this Garn devised a rating system based on the density of hair which varied on a scale of O-4 on each region. He also determined a minimum number of hair regions, which should be studied separately, defining a region as 2111 area of the body where hair growth is, at least, partially independent from
A
and 32.
N.
*Fellow Gynecology, Y.
of
the Rockefeller College of
Foundation. Physicians
and
Pr’esent Surgeons,
1255
address : Columbia
Department T’niversity,
of
Obstetrics
Ne\v
York
13.-g;
Am. I. Obsr. & Gym.
June, 1”5:
The tlil t.a 1)~YYWII~ bdy
hair
in
WOIHC’II
~1
h tkrC
~cp~~sc~nt,
sn~~~~osecl
to
have
our mow
etY~rt.S or
to
abnormal
~ne:tSuve hair
quantit,atively 011 certain
parts
body. In the absence of standards by which one can judge what is normal variation of hair growth, a comparative study of hair growth in data a])parrntly nonhirsute women and men was also made. Such comparative from the point of view of quantity of body hair, as fa,r as we are awaTt!, a1.e of
lilil.tlt’
the
iIVZlilkLblC\
pCl’llFlpS
1’01’
the
first
Method The method used very much modified.
time.
and Material
here is based on features from Garn’s procedure The salient features of this method are :
but it is
1. Ratings were made directly on the subjects (only a small loin cloth was allowed) from the closest possible distance and under 1,500 watts of illumination. 2. The study considers only terminal hair of minimal 0.5 cm. in length. 3. The body was divided into nine regions (Fig. 1). The regions, upper arm and thigh, lower arm and leg were numbered separately, for these regions In view of the smallness appeared to be fairly independent for hair growth. of the ear, middigital, lumbosacral, and lower back regions compared to the other regions considered, they were excluded in this study. Thus the total area studied was almost the sa,me as in Garn’s investigation. 4. In order to have a better idea regarding the quantity of hair in each region, three factors, namely, the quality, density, and the proportion of the By quality was area of the region covered by h;Gr, wcrc taken int,o account. meant the thickness of hair and this was rated on a scale of l-3 by palpation. The clensity was rated on a sculc of O-3 for each specified region; the absence of hair or the presence of a few hairs in any region was indicated by zero. When the growth was very clc~~, it was indicated by the figure 3 and the intermediate range was divided into 2. The total quantity of hair for a particular region was obtained by multiplying the numerals for quality, density, and the fraction of the arca of the particular region covered by hair. For example. if on a lower arm of an individual, the quality of hair rated was l., t,hc density was 1, and the dorsal surfacr only was covered by hair, then the quantity of hair for the lower-arm region would be 1 by 1 by l/z = 0.5. For the sake of brevity a round number was taken for counting. The final numerical hair growth score, obtained by adding the respective numerals for the nine regions, was taken as a m(xsurc of body hair. 5. After the rating scale had b~cn developed on a small pilot group, it was tested by two independent persons at the same time on 90 subjects. As their 94 results were fairly comparabl(A, the met,hod was applied to the further persons by the author alone. 6. In all, 184 persons were rated. Their distribution according to age is shown in Table I. They fall into thrrtl groups : (1) Women who came with complaints other than abnormal hairiness There were 100 in all, ranging in age formed the group of nonhirsute women. from 1% to 48 years, the mean age being 27.2 yenrs.
Volume Number
73 6
HUMAN
BODY
HAIR-QUANTITATIVE
STUDY
1257
(2) Women who were referred to us from several private clinics for abnormal or excessive hair growth constituted this group. There were 34 in all. Their ages ranged from 15 to 41 years, with a mean age of 22.2 years. (3) Fifty men constituted this group, ranging from 20 to 53 years of age, with a mean age of 28 years. Most of t,hern were the workers at the Indian Cancer Research Centre. A few, however, were &se relatives of the hirsute women.
Fig.
I.-The (4)
body hair regions upper arm, (6) lower
as deflned arm, (6)
in the text: thigh, (7) leg,
(1) (8)
face. buttocks,
(2)
abdomen, (9) upper
(3) back.
chest,
It is important to state that, though the division of nonhirsute and hirsute women is only arbitrary, yet it is of significance because it is rare for a woman to be hairy and still not be concerned about her hair growth. Further questioning of the hirsute group of women regarding the motivation for visiting
an physician disclosctl, in orclrr (4 t’~~luc~ncy. that ( I ) they 01’ their t.(!l:iti\rchs t’olt that, such hair growth would jeoparclizcl the possibility ot’ n1;1rt+lge; (2) t.hcy thought t.hcy were changing sex; (3) the husbantls had startcat to tlislikc them ever since they began to grow hair in (a(art:lin regions: (1) th(xv w(‘t’c’ it)terrstctl in knowing whether investigation of th(arn woultl help in prtxventing similar hair growt,h in their offspring who were thcln in the prepuhertal age.
(6)
Fig.
2.-Frequency
of awxx~~~ce
of terminal
hair
(7)
in specified
I61
I91
regions.
Observations Nonshirsute Women.-Thirty-one of 100 subjects had absence of terminal hair in all the regions studied by us. In the remaining 69 cases, as shown in Fig. 2, the commonest site for hair growth was the leg and in order of frequcncy the lower arm, thigh! buttocks, upper arm, and ahdomcn were found to have hair. It brcomes evident from the histogram that, in nonhirsutc women. the presence of hair on the fact. chest. and upper hack is absolutely “unusual,” while it,s presence on abdomen, upper arm. and buttocks is relatively “unusual. ’ ’ When the individuals were grouped from the point of view of t,hc number of regions showing growth of ha,ir, it was found that the large majority (93 per cent) did not show hair in more than three regions and, of the remaining ‘7, 6 showed it in four regions and 1 in five regions (Fig. 3). During our study it was realized that the presence of hair on the leg, not necessarily in a measurable quantity, was a prerequisite for hair on other parts of the body. There were also marked variations in the proportion of the area covered by hair. By and large, the total quantity of growth of hair on the leg was more than that seen in other regions of the same individual. The growth
HUMAN
BODY HAIK-QUANTITATIVE:
STUDY
1259
of hair on the thigh, though slight, was of measurable quantity in a small percentage of this group. The total hair growth score in the large majority (97 per cent), as shown in Fig. 4, did not exceed ‘7.
4 3 Rmcu*
Fig.
%.-Growth
.-6
of
hair
“e4Io**
by
> 6
number
of
l?x010**
regions.
too 00 00 70 00 00 40 lo SO lo
NcNlrwb
100
Fig.
4.-Frequency
I
t
LI
distribution
nlrrut* 34
of
J N.” 50
total
amount
of
hair.
Hirsute Women.-All the 34 subjects had hair on the leg where hair was common1.y found in the nonhirsute subjects; the difference, however, was in the quantity, more marked in most of the hirsute women. Unlike the nonhirsute ones, hair was found to be present in a measurable quantity on the thigh
in 29 and on the Jouw umt itr 38 01 3-j sal)jects. Along wit,11 the st,riking differrnce in 111~frcquc:ney of appcarancn of hair OII t,hc thigh, there ~vas also an illcrease in all t,hcx thr~c quart1 itati\-c n~~~asurcs, viz., the quality, drnsity, and the area ~vc~tl by hair. The rtinlaining regions in this order of frequent>., buttocks! upper arm, Cac(L,abdomell, c:ljc?st,ant1 ~~ppcr back, \VPYCf’ormtl to lli~v<~hair (Fig. 2). WllCll the sul,jcrts wTr!x 1 gronpcd Cwin tlic point cut’vicv of the nmnher of i-f’gions showing the growt’h of hair, the largc9t single group was the 0n(1showing 4 to 6 regions (Fig. 3). It is pertinent to mention that not a single subject showefl growth of hair in all the “unusu~tl” regions; the maximum nunrbcr of suc~h regions was 5 and the most uncom~no~~regions in order of frequency were the chest and upper back. Rcgardin g the density of hair in the “L~IIUSUR~” IW gions, it varied from person to person and in tlifferent regions of the same individual ; for examp1c, the hair on the chest ranged from circun~at~eolar ant1 sternal tuft to mat confluent with that, of the region abdomen. The tot,al hair growth SCOWTaried from that seen in nonhirsute women to t,he score of 28. Although the total hair growth WOW in 17 of 34 hirsute women did not show any appreciable difcrcncc from that of the nonhirsute subjects, yet. 6 of the 17 hacl a ~neasut~al~l~~ quautity of hair on 1 to 2 “nnusual” regions ( Fig. 4). .ln t.hc remaining 17 hirsute, subjects, the total score in individual sul)j&s bore no relation to the number of regions showing growth of hair nor had it anything to do with t,he selection of the “unusua1” rcbgions. In other words. two persons having similar hair growt,h score ha;1 ib (1ifFerent number of regions showing growt,h of hair.
TOTAL AMOUNT
F -
0
-
7
8 -
14
IS -
21
22
- 28
29
-
35
36
-
42
43
-
S6
NO. OF “UNUSUAL’
REGIONS
0
II
-
Fig.
5.-Number
of “unusual”
regions
showing
the
growth
of hair
in 34 hirsute
women.
From this study, selection of a group of women with considerable amount of hair growth was found to be practicable if, along with the total score, the number of “unusual” regions was taken into account. Arbitrarily, we selected subjects with a total score of 8 or above and more than two ’ ‘ unusual ’ ’ regions, or with a total score 01 15 or above and more than one “unusual” region to represent the abnormal group (Fig. 5). Thus 20 of the 34 women who originally complained of abnormal hair growth did not satisfy these criteria. In the remaining 14 women, it was interesting t,o note that there was a group of women who had hair on the face and other regions except the chest, and there was another group of women who had a considerable amount of hair on the chest and neck and other regions but the face (Figs. 6 and 7). A small group of women, however, had the combination of these two types. In these cases where there was familial hirsutism, it is interesting to note that the selection of region, namely, face or chest and neck, was identical in the female siblings who showed excessive hair growth.
Volume Number
73 6
HUMAN
BODY
HAIE--QUANTITATIVE
1261
STUDY
Men.-All the 50 subjects had hair in the regions, lower arm, thigh, and leg. Seven of these had hair in all the nine regions while in one there was absence of hair in a measurable quantity on the face. The other regions represented in order of frequency were fact, buttocks, chest, abdomen, upper arm, and upper back (Fig. 2). When individuals were grouped by the number of regions showing hair, the largest single group was the one that showed more than 6 regions (Fig. 3). The quality of the hair varied in different regions in the same individual and it seemed that, by and large, the hair on the lower extremity and chest was coarser than that seen on the upper extremity. The total hair growth score went from one extreme, .amounting to that seen in the nonhirsute women, to the other extreme, showing profuse growth of hair a1110 unting to a score of 54 (Fig. 4).
Fig.
6.
Fig.
7.
Comment Besides age and sex,ly I2 and granting that humoral control occurs, the final product of each individual follicle is largely genetically determined differences in the hair follicle itself.3 this, there is .a good body of evidence that there is no difference of hair follicles per unit area on the face in men and women dividuals of different races, yet there is certain1.y a difference and the degree of hair growth.14 For example, the classical
of hair growth dependent on To substantiate in the number or between inin the extent hair growth in
womw of the wtivc rcl,l,o’ltlc~tivc. ago ili SW(\PII ‘I is lilnit(vl to I II<>walp, q-(‘llrwws. c>yeiashes, asilla ry ;111(1pubic: wgiola. H111 L so~ltctimcs thc~~c~ is SWII il. slight, hair gtdowth in thcb ll>tI’cs, cbsttxl*11;1 I odiws 01 I 11(~(‘iI 1’s. arltl t ht! perianal ~~cgiou. The lmbic hair hils a lllarkt’(l tril~ls\-(~~*sc~ lilrlit cloc3 Ilot IYhilch further than to the i~lgbi~l :~ltl gcauif O~‘VIMII*;II t’olcls. [tIa,ir growth outsitlc these regions, according to Pedersca, ‘I is regarded as hypertrichosis, provided the minimal length of the hair is O..F VIII. According to this definition, hypertrichosis of the forearm or leg was MYW in 60 per cent of Swedish womtbtl and of the breast in % per c*cnt. In colltrilst to this group, of otherwise normal women of the Unit4 States 26.8 pear cent had facial hypertrichosis,‘* 35 per cent had more 01 less terminal hair on the trunk,” and the extent of pubic hair was found to be what is described as “sagitt,al” in pattern in IO per cent of normal white girls abort the age of 19 years.’ AS suggested by Reek.’ it, iltltl
Fig.
8.-Nonhirsute Hirsute Men A-
women 0 - __ 0 -- women 0 - - - 0 - - A ----A
0 0
is conceivable that there arc no typical male or female regions of hair growth but we feel that unless a reasonably accurate method for quantitative measurement of body hair is evolved, it is going to bc difficult to draw a base lint between a variation of normal and abnormal hair growth in women of various ethnic groups. In a study of extensive body surface such as this, the only way to assess roughly the weight of the body hair was to ta.ke into account the known variables for weight, viz., length, thickness, density, and the fraction of the area of the region covered by hair. In view of the fact t.hat no two
1264
f3;IIAH
\I,, I (&\I. & G>lll~C. June, I":7
il~tl,jaccl~t hairs in any region arc exactly similar in length, thus l~rrsctice 1.1 I terminal hair of a Ininimnm of 0.5 cm. in length was made obligatory for rating. In order to check critically the rough assessmentmade by this met,hcod and to give us a more accurate determination of body hair in the future, WC arc planning at present. to employ a procedure similar to that tlescribecl independently by Hamilton’ and Kinscll and associates.” Obviously such a tc,st is practicable in one or two regions in a few volunteers only. Finally, it is important to stress that although t,he observations recorded here are cncouraging and suggestive, we nerd larger series of both the sexes to validate these initial findings. The concept of the “unusual” regions in women derived from this study is only relative and is dependent on the difference in frequency of appcarancc of hair growth on the specified regions found between the two sexes. Such information can be of immense value if differentiat,ion between normally hairy or hypertrichotic women and abnormally hairy or hirsute women be made out conveniently on such basis. When the distribution of subjects showing ha,ir growth was plotted against the specified regions arranged anatomically, the curves of the nonhirsute women and men were found to be of different patterns, while the curve of the hirsute women was. roughly, t,he mean of the two with the exceptions that t,hc face, chest. and thigh approximate much more closely the pattern seen in men (Fig. 8). Wc then felt that if w’c split up the group of the so-called hirsute women on the basis of two criteria, namely, the t,otal hair growth score and the number of the “unusual” regions showing hair, we might be in a position to select a group of women for further investiga.tion. Arbitrarily we selected individuals who had the total hair growth score of 8 (i.c., above the highest score found in nonhirsut,e women) or above, and more than 2 “unusual” regions (i.e., above the highest number of regions seen in nonhirsute women), or those having the score of 15 or above and more than one “unusual” region, to represent the abnormal group. Thus 20 of the 34 women who originally complained of abnormal hair grnwth did not satisfy these criteria. This difference was very well brought out when the frequency of appearance of body hair in specified regions of these two groups was compared with the standard curves obtained for the nonhirsute women and men, respectively (Fig. 9). In ot,her words. 20 of the 34 subjects appeared to have body ha,ir at a higher range of normal variation, i.e., hypertrichosis, and we may call them hairy but normal women. The curve of the remaining 14 constituting the so-called abnormal group had the male pattern and these may be called hirsute or abnormally hairy women. The latter group if subjected to detailed investigations may show some interesting findings. This does not mean that hypertrichosis may not require treatment for cosmetic or psychological reasons, but it does indicate that the problem is essentially that of controlling normal hair growth on any other part of the body.
summary 1. An attempt is made to develop a practical measurement of body hair.
method for quantitative
Volume Number
,‘6
HUMAN
BODY
HAIR-QUANTITATIVE
STUDY
1265
2. The importance of checking the observations obtained by this method on larger series should be emphasized. Such study will materially aid in an understanding of the normal variation in various ethnic groups or in endogamous groups in India or elsewhere. 3. The results of the investigation show that : (1) excessive amount of hair growth on the thigh is perhaps the first sign of developing hypertrichosis in women; (2) the method is found useful in differentiating hypertrichosis from abnormal hair growth in women and may also help to set up objective criteria to evaluate the effect of treatment on hair growth. I am grateful to Dr. V. R. Khanolkar for his interest and support of this work. My sincerest thanks are due to Dr. L. D. Sanghvi for advice and criticism during the course of this study. I also wish to express appreciation to Dr. Emanual A. Friedman and Dr. Raymond Vader Wiele for assistance and advice.
References 1. Beek, C. H.: Dermatologica 101: 317, 1950. 2. Danforth, C. II., and Trotter, M.: Am. J. Phys. Anthropol. 5: 259, 1922. 3. Danforth, C. H.: Hair With Special Reference to Hypertrichosis, Chicago, 1925, American Medical Association. 4. Dupertuis, C. W., Atkinson, W. B., and Elftman, H.: Human Biol. 17: 137, 1945. 5. Gardner, L. I.: J. Clin. Endocrinol. 13: 1054, 1953. 6. Garn, 8. M.: Ann. New York Acad. Se. 53: 498, 1951. 7. Hamilton, J. B.: Ann. New York Acad. SC. 53: 585. 1951. 8. Jailer, J. W., and Vander Wiele, R. L.: Gynaecologica 138: 276, 1954. 9. Kinsell, L., Bryant, D., and Labright, F.: J. Clin. Endocrinol. 14: 897, 1954. 10. Kappas, A., Pearson, 0. H., West, C. D., and Gallagher, T. F.: S. Clin. Endocrinol. 16: 517, 1956. 11. Pedersen, J.: Acta dermat-venereol. 23: 1, 1942. 12. Reynolds, E. L.: Ann. New York Acad. SC. 53: 576, 1951. 13. Sanghvi, L. D.: Am. J. Phys. Anthropol. 2: 385,1953. 14. Trotter, M.: A Study of Facial Hair in the White and Negro Races, Washington Univ. Studies, Scientific Series 9: 273, 1922. 15. Trotter, M., and Danforth, C. H.: i2m. J. Phys. Anthropol. 5: 391, 1922.