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What is madarosis?

Madarosis is the medical term for loss of eyelashes or loss of eyebrows.

Madarosis is a clinical sign caused by several disorders including, malnutrition, infections, genetic factors, autoimmunity and systemic diseases. The term madarosis includes both temporary loss of eyelashes or eyebrows and also permanent destruction of hair follicles. Depending upon the causative factor, madarosis can be scarring (permanent) or non-scarring.

Identification of the predisposing disorder may help in taking action to reverse madarosis. In scarring loss, the hair follicles are permanently damaged and are not capable of regeneration. Close observation in such madarosis will reveal, tissue damage, inflammation, atrophy and loss of follicular openings. Such situations require surgical management. Eyebrow grafts and follicular unit transplantation are some of the effective surgical procedures for eyelash loss.

The non-scarring type of eyebrow or eyelash loss, can be reversed with proper diagnosis and treatment. It is important to note that the hair of eyelashes and eyebrows go through the growth phases similar to scalp and other body hair.

Causes of madarosis

The loss of eyebrows or eyelashes may occur due to several causes, including malnutrition, infections, trauma, medications, cancer treatment, ophthalmic conditions and systemic conditions. Some of these madrosis causing factors are briefly discussed here.

Malnutritional madarosis

Chronic protein deficiency is associated with madarosis and telogen effluvium. Zinc is vital for hair health and its deficiency is known to cause general hair loss and madarosis in particular. Acrodermatitis enteropathica, a genetic autosomal recessive disorder, affects the ability of intestines to absorb zinc. It is characterized by dermatitis of natural orifices and limbs. Apart from gastrointestinal problems, this disorder causes loss of hair from scalp, eyebrows and eyelashes. Biotin and iron deficiencies show symptoms like loss of eyebrows and eyelashes.

Madrosis in infections

Loss of hair including eyelashes and eyebrows is the characteristic of lepromatous leprosy. Madarosis occurs in lepromatous leprosy due to histiocytic infiltration of hair follicles. Unilateral madarosis may occur in tuberculoid leprosy in the eyebrow/eyelash region due to granulomatous infiltration of hair follicles leading to their destruction and loss. Bacterial infections like secondary and tertiary syphilis can cause madarosis and hair loss.

Viral infections like herpes zoster and HIV/AIDS are known to cause alopecia of eyelashes and eyebrows. Paracoccidioidomycosis (also known as "Brazilian blastomycosis) is a fungal infection caused by the fungus Paracoccidioides brasiliensis and is associated with madrosis. Periocular tinea is another fungal infection involving eyes and is known to cause loss of eyelashes. Tinea capitis is a fungal infection of scalp and it can cause eyebrow loss.

Parasites and madarosis

Demodex folliculorum and Demodex brevis are species of face mites existing as commensals inside hair follicles and sebaceous glands. During a severe infestation, they may cause inflammation, facial hair loss and madarosis. Phthiriasis palpebrarum is an infection of the eyelids caused by the pubic louse (Phthirus pubis) leading to madarosis. Heavy infestation may cause loss of eyebrows and eyelashes.

Medications

Several medications can cause hair loss. The medications may simultaneously cause madarosis also. The medicines causing eyelash and eyebrow loss include, antithyroid drugs, anticoagulants, retinoids, propranolol, heparin, anti-cholesterol drugs, angiotensin-converting enzyme inhibitors and bromocriptine. Chronic hypervitaminosis of vitamin A is known to cause madarosis and hair loss. Entry of thallium, arsenic, bismuth, gold, quinine, and mercury into body can cause loss of eyelashes and eyebrows.

Radiotherapy and madarosis

Radiotherapy for malignant tumors often causes hair loss, including eyelashes and eyebrows. The anagen phase of hair growth is disturbed by the radiation. In most cases the madarosis is reversible.

Chemotherapy

Chemotherapy for malignant tumors often causes hair loss, including eyelashes and eyebrows. The anagen phase gets abruptly gets terminated and without telogen resting phase the hair strand weakens and breaks. After completing chemotherapy, the madarosis condition ends and new hair start growing.

Ophthalmic conditions and madarosis

Ophthalmic diseases, inflammations and trauma can causes madarosis.

Blepharitis and loss of eyelashes

Blepharitis is a common eyelid inflammation, caused by seborrhoea, bacterial infection (staphylococcus) or meibomian gland dysfunction (MGD). The patient may suffer from itching, burning, photophobia and the sensation of the presence of foreign in the eyes. Madarosis may occur due to rubbing of the eyelids, eyelid margin inflammation or folliculitis. Entropion and ectropion of eyelids, stye (chalazion and hordeolum) ocular rosacea, conjunctivitis and cicatricial lagophthalmos can cause eyelid margin inflammation and madarosis.

Madarosis in dermatological conditions

Atopic dermatitis as well as seborrhoeic dermatitis can cause madarosis. In the eyelids, the condition may manifest as lid margin inflammation leading to eyelash loss. Alopecia of the eyebrows occurs due to erythema, pruritus and scaling leading to rubbing and scratching. Other dermatological conditions such as, psoriasis, lamellar ichthyosis, postmenopausal frontal fibrosing alopecia, primary cicatricial alopecias, lichen planopilaris, ulerythema ophryogenes, telogen effluvium, follicular mucinosis and cutaneous sarcoidosis can cause loss of eyelashes and/or loss of eyebrows.

Endocrine disorders and madarosis

Both hypothyroidism as well as hyperthyroidism cause madarosis. Thyroid malfunction is one of the well known cause of eyebrow loss and eyelash loss. Nina van Beek et al, in their study published in 'The Journal of Clinical Endocrinology & Metabolism. 2008 Nov;93(11):4381-8.', concluded that "we present the first evidence that human hair follicles are direct targets of thyroid hormones and demonstrate that T3 and/or T4 modulate multiple hair biology parameters, ranging from hair follicle cycling to pigmentation."

The 'Sign of Hertoghe' (aka Queen Anne's sign) is a thinning or loss of the outer third of the eyebrows which is considered as a sign of hypothyroidism. The thinning, breaking, shortening and loss of hair is one of the signs of hyperthyroidism. Other endocrine disorders like hypopituitarism, hypoparathyroidism and hyperparathyroidism may also cause loss of eyebrows and loss of eyelashes.

Systemic disorders and madarosis

Alopecia areata is a hair-specific autoimmune disease causing patchy loss of hair in the body and madarosis of eyelashes and eyebrows. In alopecia universalis, the eyebrows and eyelashes may be totally lost. Cutaneous lupus erythematosus, an autoimmune disorder, giving rise to scaly lesions and plaques may involve eyebrows, causing madarosis. Frontal linear scleroderma (also known as en coup de sabre) is a linear scleroderma characterized by a linear atrophy and a furrow in the facial skin causing loss of facial symmetry.

Eyebrow and eyelash loss has been reported in frontal linear scleroderma. Graham Little syndrome, possibly an immune disorder, is a rare variant of lichen planopilaris, an inflammatory form of scarring hair loss and madarosis. Familial acanthosis nigricans has been reported to cause alopecia. Parry–Romberg syndrome (also known as progressive hemifacial atrophy) is a rare neurocutaneous syndrome. An autoimmune mechanism is suspected to be the cause. It can cause madarosis. Vogt–Koyanagi–Harada syndrome is an multisystem autoimmune disease which may involve uveitis, poliosis and madarosis.

Psychiatric causes of madarosis

Trichotillomania is an impulse-controlled psychiatric disorder characterized by compulsive plucking or breakage of hair. Affected patients tend to pluck scap hair, pubic hair and eyebrows. They develop patches of alopecia and madarosis. Trichoteiromania yet another type of artificial hair loss, which results from perpetual rubbing of the scalp and othery parts. It may also cause madarosis.

Neoplasms and madarosis

Both benign and malignant tumors can cause loss of hair. Neoplasms causing alopecia include, seborrhoeic keratosis, systemic mastocytosis, cutaneous T-cell lymphoma and epithelioid hemangioendothelioma. Basal cell carcinoma, squamous-cell carcinoma, sebaceous cell carcinoma and sclerosing sweat duct carcinoma are some of the malignant tumors that can cause hair loss and madarosis.

Madarosis management

Management of loss of eyelash and eyebrows primarily depends upon treating the causative factor. In conditions where the hair does not grow back and also in scarring madarosis hair transplants and wearing false makeup are the alternatives for cosmetic purposes. In non-scarring madarosis, treatment with topical minoxidil or latanoprost may be tried under medical professional's guidance. Surgical management of the hair loss and madarosis by follicular unit transplantation and eyelash/eyebrow grafting are being successfully carried out.

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What is hypotrichosis?

Hypotrichosis is the presence of less than the normal amount of hair on the head, eyelashes or body. Hypotrichosis disorders are a broad spectrum of hair loss conditions.

They are generally congenital and hereditary. The disorders are present at the time of birth or manifest in infancy and may remain with the affected patients throughout their lives.

In alopecia, the hair which is already present on the scalp or body is lost partially or wholly. However hypotrichosis is a state of hair loss right from the birth. The normal terminal hair may get replaced by soft, short and unpigmented vellus hair. Most of the congenital depilations are caused by defective embryonic growth or genetic aberrations. There is no known standard treatment for these hypotrichosis hair loss conditions.

These hypotrichosis disorders coexist with many other physical or mental problems. Disorders like Graham-Little syndrome, Hallermann–Streiff syndrome, Ofuji syndrome, congenital aplasia, alopecia triangularis, papular atrichia, metaphyseal chondrodysplasia, EEM Syndrome and cartilage-hair hypoplasia, manifest with the symptoms of hypotrichosis. There are hundreds of genetic congenital depilation disorders.

Though these hypotrichosis disorders are commonly generalized, in some cases depilation lesions may occur at single or multiple sites. The severity of the congenital hair loss may vary depending upon the afflicting disorder and the patient's health status.

Hypotrichosis causes

The basic causes of these types of congenital hair loss are defective embryonic growth and genetic aberrations. There are hundreds of genetic hypotrichosis disorders.

Congenital and hereditary hypotrichosis

There are many hereditary and congenital forms of hypotrichosis. We may consider a few of them to understand the complex diversity of these genetic disorders.

Hereditary hypotrichosis simplex (HHS) affected patients have normal hair at birth, but with progress of age hair is diffusely thinned. There is progressive hair follicle miniaturization. This congenital disorder is inherited either as an autosomal recessive trait or as an autosomal dominant trait. There is thinning of body hair, axillary hair, and pubic hair. The hair shafts of the eyebrows, eyelashes and male beard are found to be normal.

Localized autosomal recessive hypotrichosis affects both the scalp and body hair. In this congenital disorder, hairs get sparse, become fragile and break easily. Though scalp, eyebrows and eyelashes may be affected, beard, pubic and axillary hairs are generally spared. The patients may suffer from follicular papules, erythema and pruritus.

Marie Unna type of hypotrichosis (hereditary trichodysplasia) is characterized by the presence of a twisting hair dystrophy. This congenital hereditary disorder was reported by Marie Unna. Hairs of the scalp, body, eyebrows and eyelashes are involved and the disorder can progress into irreversible universal alopecia.

Eyelash hypotrichosis

In this disorder, there is inadequate or absence of eyelash. Loss of eyelash is not merely a cosmetic and aesthetic issue like most of us think, but is a medical condition.

The depilation of eyelashes may be congenital and genetic. Certain diseases, cancer treatment, radiation, chemotherapy and certain neurotic habits can cause the loss of eyelashes. The absence of eyelashes mars the facial appearance. But there is a silver lining. Ophthalmic prostaglandin and prostamide analogs are used in the treatment of glaucoma. Incidentally these ocular hypotensive agents have been found to cause hypertrichosis (excessive growth of hair) of eyelashes. The use of bimatoprost (prostaglandin analog) 0.03% solution was approved by the US Food and Drug Administration (FDA) for the treatment of hypotrichosis of the eyelashes.

Congenital hypotrichosis treatment

There is no standard treatment available for these types of congenital hair loss. Hair loss of the eyelashes has been successfully treated with ophthalmic prostaglandin and prostamide analogs.