Overview

Madarosis, a condition characterised by the loss of eyebrows or eyelashes, often follows dermatological disorders like atopic dermatitis.¹ This loss can be distressing and significantly affect one's appearance and self-esteem. Understanding how madarosis is connected to other conditions can help address its underlying causes.

Atopic dermatitis, commonly known as atopic eczema, is one of the most prevalent skin conditions, affecting many individuals worldwide. It manifests as dry, itchy, and inflamed skin, causing significant discomfort. This condition often affects those with a personal or family history of other atopic diseases, such as:

•  Asthma
•  Allergic rhinitis
•  Hay fever
•  Food allergies 

Living with atopic dermatitis can be particularly challenging, as it worsens and increases the likelihood of madarosis by:

• Increasing chronic inflammation and inducing itching
• Compromising the skin barrier 
• Reducing overall skin health  

Understanding these connections can help manage the impact of atopic dermatitis on overall well-being.

Understanding madarosis

Causes of madarosis

Madarosis is a secondary condition that can develop due to several pathologies.¹ These primary pathologies and route causes include but are not limited to the following:

• Dermatological Disorders: These encompass a range of conditions, such as the aforementioned atopic dermatitis, seborrheic dermatitis, lamellar ichthyosis, psoriasis, frontal fibrosing alopecia and many others.
• Ophthalmological Conditions: These affect the eyes and visual system, including chronic eyelid inflammation like blepharitis.
• Autoimmune Diseases: These occur when the immune system mistakenly attacks healthy cells, leading to conditions, such as alopecia areata and discoid lupus erythematosus (DLE).
• Nutritional Disorders: These arise from inadequate nutrient intake, including vitamins and minerals, for example, hypoproteinemia, caused by chronic zinc deficiency.
• Trauma and Mechanical Damage: Conditions like trichotillomania (compulsive hair-pulling), trichoteiromania (hair loss from repeated rubbing), and trichotemnomania (obsessive shaving).¹ 

Symptoms and diagnosis

Madarosis is primarily defined by the loss of eyebrow or eyelash hair, either partially or completely. Secondary symptoms can vary based on the underlying cause. When atopic dermatitis is the underlying cause, thinning of eyebrows and eyelashes, accompanied by redness and inflammation around the eyes, are typical features associated with madarosis.¹

Madarosis is typically diagnosed through a combination of clinical evaluation, thorough medical history review, and specific diagnostic tests. Some of the tests commonly employed include:

• Trichoscopy (A dermoscopy of hair) 
• Skin swabs for bacterial culture identification
• Blood tests (e.g. complete blood count, thyroid function tests and vitamin and mineral analysis) 
• Skin biopsy 
• Fungal scraping (For microscopy and culture analysis) 

Understanding atopic dermatitis

Causes and risk factors of atopic dermatitis 

The root cause of atopic dermatitis remains elusive, but several recognised factors contribute to its development. Atopic dermatitis may arise due to genetic predisposition, environmental triggers, like allergens or irritants, or dysregulation of the immune system.² 

Genetic predisposition

Atopic dermatitis often correlates with a family history of the condition, indicating a significant genetic predisposition. Consequently, individuals with relatives affected by atopic dermatitis are at increased risk of developing the disease.³ 

Genome-wide association studies (GWAS) provide compelling evidence of genetic predisposition to atopic dermatitis. Specific genetic variants identified through these studies are known to heighten the risk of developing the condition. These variants play critical roles in regulating the immune system, maintaining skin barrier function, and modulating inflammatory responses, underscoring the complex interplay of genetics in the onset of atopic dermatitis.⁴ 

Mutations in the filaggrin gene (FLG) represent a crucial genetic factor associated with atopic dermatitis. These mutations impair the skin barrier, rendering individuals more vulnerable to environmental allergens and irritants.³ 

Environmental triggers 

Environmental factors can contribute to the onset and exacerbation of atopic dermatitis by triggering immune responses and promoting skin inflammation. Common factors include:⁵

• Allergens: Dust mites, pollen, hay fever, and pet dander
• Irritants: Certain soaps, detergents, fragrances, and dyes
• Climate and Weather: Dry air or hot, sweaty weather conditions
• Pollutants: Air pollution, such as smog, and tobacco smoke
• Microbial Infections: Bacterial or fungal infections
• Psychological Stress: Emotional stress and anxiety⁵ 

Immune system dysregulation 

Atopic dermatitis can result from a dysregulated immune system that becomes overactive in specific areas of the skin, leading to an inflammatory response and the development of the condition. The resulting inflamed skin can create a positive feedback loop, as the compromised skin barrier becomes more susceptible to environmental triggers, further exacerbating the inflammation and symptoms of atopic dermatitis.⁶ 

Symptoms and affected areas 

Atopic dermatitis can develop on any part of the skin, with symptoms varying significantly from person to person. However, certain characteristics help distinguish it from other dermatological conditions:

• Itchiness 
• Red and inflamed skin 
• Dry and scaly skin 
• Rashes or swollen skin 
• Thickened skin 
• Cracks and fissures 
• Discoloration of the skin

While atopic dermatitis can indeed manifest anywhere on the body, certain areas tend to be common "hotspots" across different age groups:⁷ 

• Infants: Commonly on cheeks, scalp, or extremities (arms and legs)
• Children: Often on the face, neck, flexural regions (elbows and knees), and wrists and ankles
• Adolescents and Adults: Typically on the face, neck, flexural regions, hands and feet, and occasionally upper chest and back⁷ 

The relationship between madarosis and atopic dermatitis

Atopic dermatitis and madarosis exemplify comorbid conditions, linked through mechanisms involving chronic inflammation and itching, as well as a compromised skin barrier.¹ 

Chronic inflammation and itching 

As previously mentioned, atopic dermatitis is characterised by chronic inflammation. This inflammation can spread to the areas around the eyes, damaging hair follicles and leading to hair loss.¹ The overactive immune response in atopic dermatitis releases pro-inflammatory cytokines, which further damage hair follicles and contribute to madarosis.^8,9 

Intense itching, a hallmark of atopic dermatitis, often leads to constant rubbing and scratching of the affected areas. This physical damage to the hair follicles of both, the eyebrows and eyelashes, exacerbates hair loss. The mechanical trauma induced by this behaviour further worsens madarosis in these regions.¹ 

Compromised skin barrier 

As previously mentioned, mutations in the filaggrin gene result in a weakened skin barrier, making the skin more susceptible to irritation, damage, and secondary infections. This compromised barrier allows allergens and microbes to penetrate more easily, particularly around the eyes, leading to further inflammation and eventual hair loss in these regions.³ 

Management and treatment 

Management and treatment of the comorbidity involves treating both, the underlying atopic dermatitis, as well as promoting hair regrowth in regions where hair was lost.⁴

Managing atopic dermatitis 

Unfortunately, there is currently no direct cure for atopic dermatitis, however, there are several treatments that focus on easing symptoms through topical applications: 

• Topical Corticosteroids: These help reduce inflammation and itching, preventing further damage to hair follicles
• Topical Calcineurin Inhibitors: Non-steroidal alternatives are used to treat mild to moderate eczema without the typical side effects of steroids
• Barrier Repair Creams: Improve skin barrier function, reducing susceptibility to irritants and infections
• Intensive Moisturizers and Emollients: Keep the skin hydrated, preventing dryness and irritation 

Topical antibiotics and antifungal creams, such as miconazole, can also be applied to treat secondary infections that may exacerbate inflammation and contribute to hair loss. 

In addition to topical treatments, oral antihistamines and systemic immunosuppressants can be used to control itching and inflammation associated with atopic dermatitis. Antihistamines help reduce itching by lessening the urge to scratch, thereby minimizing mechanical damage. Systemic immunosuppressants, such as cyclosporine can manage the effects of the overactive immune system and alleviate overall symptoms.^1,2 

In conjunction with the treatments mentioned above, lifestyle changes are recommended. These include dietary adjustments, such as reducing cow’s milk consumption, which is a known trigger of atopic dermatitis in some individuals. Other potential food triggers vary from person to person and should be monitored closely. Gentle skin care practices are also advised, including the use of mild, fragrance-free soaps, and shampoos to minimise irritation.^1,2 

Managing madarosis

While much of the management and treatment of madarosis focuses on addressing underlying atopic dermatitis, there are additional non-specific measures that can be beneficial: 

• Cosmetic Options: Using eyebrow pencils or makeup to enhance the appearance of eyebrows and eyelashes, as well as exploring non-permanent cosmetic options for eyelash enhancement
• Consultation with Specialists: Seeking advice from dermatologists or ophthalmologists to monitor and manage the condition effectively  
• Psychological Support: Engaging in counselling or joining support groups to address the emotional impact and self-esteem concerns associated with hair loss 

These measures complement the medical treatment of atopic dermatitis-related madarosis, providing additional support and enhancing overall well-being.

Summary 

Madarosis, characterised by the loss of eyebrows or eyelashes, is often a secondary condition resulting from various primary pathologies, including atopic dermatitis. Atopic dermatitis, a prevalent skin condition, features dry, itchy, and inflamed skin, and is influenced by genetic factors, environmental triggers, and immune system dysregulation. The chronic inflammation, intense itching, and compromised skin barrier associated with atopic dermatitis can lead to this secondary condition. 

Diagnosis of this comorbidity involves thorough clinical evaluation and laboratory testing. While there is no cure for either condition, treatment options include topical therapies and oral medications to manage symptoms. Additionally, lifestyle changes, such as dietary adjustments and gentle skincare practices, can help alleviate symptoms and improve the overall quality of life for individuals affected by both conditions.