Overview

Madarosis is a condition that is characterised by the loss of either the eyelashes or eyebrows (superciliary or ciliary madarosis). It may occur unilaterally, on one side of the face, or bilaterally. "Madao", a word coming from ancient Greek which means to “fall off”, is the way the terminology is now used.¹

Eyebrows protect the bones above the eyes; they act like built-in sweatbands and prevent sweat from running down the forehead into the eyes. The eyelashes function as filters; they act as part of the eyes’ natural reflex to blink, protecting the eyes from dust and other small debris found in the air.²

Madarosis is different from normal hair shedding; we all lose some hair or eyelashes each day. A few eyelashes may be on the pillow in the morning, or some hair may be on the washcloth after washing your face. With madarosis, you lose hair more than normal, and in greater quantities or clumps than usual. The term milphosis refers specifically to the loss of only the eyelashes.

Basically, hair around a human head grows based on cycles of growth: some hair grows anew, and old hair falls off. Madarosis and other types of hair loss occur when someone begins to lose hair that the hair follicles can naturally replace.

Madarosis may be scarring. Scarring means that the eyelashes or eyebrows that have been lost are permanently damaged. Non-scarring means temporary loss of hair in the area of the eyelashes or eyebrows.¹

Types

Madarosis can cause two types of hair loss: that of the eyebrows and that of the eyelashes.²

1. Madarosis, which makes the eyebrows fall off, is known as superciliary madarosis
2. Madarosis affecting your eyelashes is known as ciliary madarosis

Causes

Infection

Blepharitis is an inflammation of the eyelids that can lead to the loss of eyelashes. It is caused by infection, trauma,  or allergy.³

1.  During infection with microorganisms, for example, Staphylococcus aureus, thin, honey-colored flakes appear among the eyelashes. Chronic staphylococcal infection leads to loss, whitening and misdirection of eyelashes. Madarosis is commonly associated with leprosy and has been reported in 76% of patients with the disease
   • Ocular involvement is more common in lepromatous leprosy, followed by borderline and tuberculoid leprosy, and shows a higher incidence with the increasing age and time period of the disease
   • Eyelashes can also be lost due to parasitic infestation with the mite Demodex folliculorum. Mites are more abundant in older people, diabetics and people with Staphylococcus aureus infection of the eyelids. They are characterised by "waxy, cylinder-shaped cuffs” at the bases of the eyelashes
   • Systemic fungal infection with paracoccidioidomycosis rarely presents with eyelid involvement. Active lesions present as red patches of madarosis to rank destructive ulcers, which can not be differentiated from malignancies. Inactive lesions present as loss of eyelashes
   • Other infectious causes include chronic ulcerative blepharitis, tuberculosis, severe acute bacterial infections like scarlet fever, and viral infections like herpes zoster, smallpox, measles, hepatitis, and chlamydia trachomatis infection. Syphilis also presents as madarosis with loss of the lateral brow, referred to as Hertoghe sign
2. This trauma may be from rubbing or plucking and may result in unilateral or bilateral loss of lashes. This is also associated with eye cosmetics; waterproof mascara is the most challenging to remove and may result in increased loss of eyelashes
3. Allergy: The loss of lashes could be a result of an allergy to skincare and beauty products. It’s commonly associated with the usage of eye cosmetics like mascara

Autoimmune disorders

Alopecia areata is an autoimmune disorder that presents as hair loss in round patches, but it may also present as loss of eyebrows and eyelashes. Conversely, though the loss of scalp hair occurs with Discoid Lupus Erythematosus, DLE, the first presentation is rarely madarosis. The typical presentation of DLE is with erythematous papules or plaques on sun-exposed areas. 

Involvement of the periocular area, around the eye, is relatively rare and may progress from eyelid erythema to scarring and madarosis. The characteristic periorbital erythema and scarring of DLE may not be present initially, and madarosis can sometimes be the presenting symptom. 

Cases of madarosis have also been reported in systemic lupus erythematosus and scleroderma.

Tumors

Loss of eyelashes may also be seen in chalazion, squamous cell carcinoma, basal cell carcinoma, sebaceous carcinoma, lymphomas, plasma cell tumors of the orbit, sclerosing sweat duct carcinoma of the eyelid, and other benign and malignant tumors.

Endocrine disorders

There is a modification of hair follicle activity in states such as hypothyroidism or hyperthyroidism. Changes in hair growth and hair structure may be the first clinical sign of a thyroid hormonal disturbance due to the influence on the cell cycle kinetics of the hair follicle cells. The signs and symptoms of hyperthyroidism include hair thinning and increased shedding; there is a reduction in hair length, with more loss likely to be seen in patches.

In hypothyroidism, hair becomes dull, brittle, and coarse with reduced diameter, and the process may involve eyelashes and brows. Other conditions that may also be associated with madarosis include hypopituitarism and hyperparathyroidism.

Congenital causes

Eyelash loss, along with other ocular anomalies, has been documented in congenital ichthyosiform erythroderma, lamellar itchyosis, hereditary ectodermal dysplasia syndrome, inborn atrichia, cryptophthalmos, Ehlers-Danlos syndrome and lid coloboma. A few times, unilateral madarosis and facial alopecia have been reported as idiosyncratic reactions to long-term use of Botulinum A injections, Botox.

Drugs and toxins

Some eye drops, blood thinners, statins and beta blockers are a non-exhaustive list of drugs that can cause loss of eyelashes. The use of cocaine is also reported to induce ciliary madarosis.

Other potential causes of eyelash loss could be intoxication or overdose with arsenic, bismuth, thallium, gold, quinine, and vitamin A.

Psychiatric causes

This also includes trichotillomania, a rather rare form of hair/eyelash loss due to the removal of hair by the individual. It manifests as the compulsive pulling of one's hair, which is associated with tension or an irresistible urge before pulling and pleasure or relief after it. The hairs break at various levels; they can be tufted, crooked, and other hair fibers significantly longer than others. The hair follicles may be prominent.

Miscellaneous

These include dermatological conditions like acanthosis nigricans, which can be associated with other skin diseases, hair, and nails. Familial acanthosis nigricans has been reported as madarosis. Loss of eyelashes has also been reported in association with Vogt-Koyanagi syndrome, epidermolysis bullosa, rosacea, psoriasis, metabolic diseases like mitochondriopathy, adrenoleukodystrophy, and malnutrition; Meige syndrome; sickle cell anemia; infection with HIV; postproton beam irradiation for tumors of the choroid of the eye; eyelid tattooing; thermal injury; and cryotherapy.

Diagnosis

Madarosis can be clinically diagnosed after a history and an examination.⁵ Useful tests may include:

1. Trichoscopy (dermoscopy of hair)
2. Skin swabs are to be sent for culture, bacterial, and viral studies using a polymerase chain reaction
3. Fungal scraping for microscopy and culture
4. Skin biopsy
5. Blood tests to assess thyroid function and vitamin deficiencies

Treatment

The mode of treatment in madarosis is cause-specific; for instance, bacterial infections would have to be treated with antibiotics.⁵ Some non-specific measures could be used in madarosis:

1. Cosmetic Camouflage
2. Eyelashes and eyebrows are false.
3. Tattooing
4. Minoxidil solution
5. Topical prostaglandins, such
6. Hair transplantation and eyelash grafting

Home remedies to prevent madarosis

The condition is also treatable by some alterations in your daily routine, coupled with the treatment options available.¹

1. Castor oil: Massaging the oil soothes inflammation and increases blood flow to the area to support the growth of eyelashes
2. Protein and fatty acids: High-protein diets will stimulate the regrowth of eyelashes and eyebrows. Protein strengthens hair follicles and promotes their growth
3. Makeup care: Put on extra care while applying makeup. Avoid using expired or damaged cosmetic products and maintain a routine to remove makeup, particularly in and around the eyes
4. Aloe vera: This is one of the great natural remedies used for thin eyebrow hair. Just remove the jelly on the inside of a few leaves of aloe vera, massage this lightly over the eyebrows, and let it soak in. It promotes hair growth and skin healing
5. Onions: Onions make eyebrow hair grow faster and thicker. To maximise the use of an onion, grind one and tap the juice onto eyebrows using a cotton ball and wash off after letting it soak
6. Milk: Being rich in proteins, vitamins, and other nutrients, milk and its products feed the scalp and enhance the growth of roots quickly. Just soak a cotton ball in milk and massage it onto eyebrows at night, and voilà

Summary

Madarosis is a state characterised by the deficiency of either eyelashes or eyebrows. It is caused by several factors like infections, malignancy, autoimmune conditions, and some drugs.. It is diagnosed through an extensive history and sometimes by using tests. Treatments range from antibiotics, prostaglandins, and hair transplants to home remedies like castor oil and aloe vera. The management of madarosis aims to treat the underlying condition and make some lifestyle changes.