Introduction

The term "madarosis," which means "bald" in Greek, comes from the word "madaros" conveying "hair loss of the eyebrows" or "ciliary madarosis," referring to the loss of eyelashes.¹ Originally, “madarosis” was used to describe the loss of eyelashes as a result of hair follicle damage, but it is now used to discuss the loss of cilia (hair-like structures found on other parts of the body) in both the eyebrows and the eyelashes. This seemingly benign (not harmful) symptom could significantly indicate several systemic or localised illnesses.² The loss of eyebrow or eyelash hair may be a result of this disorder, either completely or partially.  Madarosis may also leave scars when there is greater damage to the basic hair structures, leading to permanent loss of hair in the brows and lashes. Loss of hair may be reversed if there is no scarring, as the basic hair structures are preserved. The use of medication to destroy cancer cells is known as chemotherapy. In cases where cancer has advanced or is likely to do so, chemotherapy may be employed. It is often used in an attempt to eradicate cancer (curative chemotherapy), increase the efficacy of other treatments (chemoradiation), decrease the chance that cancer will return after radiation treatment or surgery (adjuvant chemotherapy), and relieve symptoms if therapy is not feasible (palliative chemotherapy).³ Chemotherapy destroys rapidly proliferating cancer cells and also stops or inhibits the growth of rapidly dividing healthy cells. The cells that allow your hair to grow and the ones that border your mouth and bowels are two examples. Adverse reactions, including mouth sores, nausea, and hair loss, might result from damage to healthy cells. Most side effects improve or disappear once treatment is completed.  Weariness and fatigue are the most frequent adverse effects.⁴

Causes and diagnosis of madarosis

Any procedure that harms the hair shaft or bulb causes madarosis, which can result in either permanent or temporary hair loss. Staphylococcal infection, herpes simplex, rosacea, alopecia areata, hypothyroidism (which usually affects the outer third of both eyebrows bilaterally), hyperthyroidism, atopic dermatitis, psoriasis, trauma, and other conditions are common causes of madarosis. Moreover, madarosis can be treatment-induced, including injections of botulinum toxin (botox), radiation, chemotherapy, and laser treatment.⁵ Clinical diagnosis of madarosis is possible with sufficient history and investigation. Tests that can be useful include fungal scraping for microscopy and culture, skin biopsy, trichoscopy (dermoscopy of the hair and scalp), skin samples for bacterial culture as well as laboratory tests detecting viral infections, especially polymerase chain reaction (PCR) assays.⁵

Mechanism of chemotherapy-induced madarosis

For patients who use systemic cytotoxic medicines (drugs that kill cancer cells), chemotherapy-induced alopecia (CIA) happens to be one of the more noticeable and feared side effects. When hair follicle keratinocytes (cells making up the outermost layer of skin) enter the development phase known as anagen, cytotoxic medicines destroy rapidly growing cells, including cancer cells and non-cancer cells. Apoptosis (destruction of cells) and hair shaft breakage/shedding are caused by cytotoxic medications primarily targeting extremely regenerative keratinocytes within the hair matrix.⁶ Depending on the medicine, dosage, duration, frequency, and mode of administration, there are significant differences in the probability of CIA and the extent of hair loss. The severity of hair abnormalities affecting facial hair, eyebrows, and eyelashes may differ depending on the prescribed medications and treatment plans. When there is either no hair regrowth or just partial hair regrowth six months following the end of chemotherapy, permanent chemotherapy-induced alopecia (pCIA) is identified. The occurrence of pCIA is contingent upon dosage and scheduling and has been linked to chemotherapy drugs including docetaxel administered at concentrations of 75 mg/m² or greater each cycle, and less frequently, paclitaxel.⁶

Impact on patients

Considering that facial and scalp hair are believed to be essential components of youth, attractiveness, and good health in social interactions, CIA significantly impairs patients' sexuality, body image, self-esteem, and general quality of life. In a survey of 179 patients, both male and female, who acquired CIA, 101 (56.4%) said that alopecia was the most detrimental adverse consequence of chemotherapy, 129 (72%) reported that their social life was being negatively impacted by their hair loss, and 37 (20.6%) claimed they were hiding their hair loss with hair accessories. For fear of developing  CIA, cancer patients would even consider refusing life-saving chemotherapy.⁶ Due to the high incidence of hair loss following chemotherapy and the fact that it is frequently interpreted as an indication of poor health or cancer treatment, patients experience significant psychological stress from the anxiety and anticipation of chemotherapy.⁶ Up to 14% of patients decide to reject chemotherapy completely, and 8% of patients consider doing so. Qualitative research has also revealed that many breast cancer patients believe that having CIA is more upsetting than removing a breast. It is crucial to investigate additional care and management using interdisciplinary methods. Therefore, it is recommended that patients who are experiencing negative psychological issues seek out psychological support via counselling, patient associations, or support groups.⁶

Management and mitigation strategies

There are few preventative and therapeutic strategies available for the CIA, despite the serious harm that it causes to a great number of patients. The US Food and Drug Administration (FDA) approved scalp cooling as the sole method of CIA prevention in 2015. To encourage hair growth following CIA, researchers have recently looked into topical and oral minoxidil, platelet-rich plasma (PRP) injections, photobiomodulation therapy (PBMT), and additional oral and topical treatments that have been effective in boosting hair growth in other alopecia conditions.⁶ Numerous topical and systemic medications, such as cyclosporine, an immunosuppressive calcineurin inhibitor that promotes active hair growth have been investigated for their potential to prevent or treat CIA. Tacrolimus and pimecrolimus are examples of topical calcineurin inhibitors that have demonstrated some efficacy in treating frontal fibrosing alopecia and alopecia areata.⁶ Additionally, research in animals demonstrated that topical tacrolimus produces anagen and shields against CIA; however, patient efficacy has not yet been determined.  Since antioxidants can get rid of reactive oxygen species and free radicals, they may be useful in preventing toxicity brought on by chemotherapy. Complementary and alternative medicine (CAM) is being increasingly used by alopecia patients as a safe and all-natural treatment. A variety of natural products have been proposed to boost hair density, including saw palmetto, vitamin B6, vitamin B7 (biotin), zinc, amino acids, caffeine, capsaicin, garlic gel, marine proteins, melatonin, onion juice, curcumin, procyanidin flavonoids, pumpkin seed oil, rosemary oil, and oral glucosides of peonies.⁶ Hypnosis, aromatherapy using essential oils, acupuncture, massage, electromagnetic stimulation, mindfulness psychotherapy, and homoeopathy are some more treatment options. A botanical lotion called CG428 was found to increase hair density and thickness in pCIA-survivors of breast cancer in a randomised, double-blind controlled experiment. 

Conclusion

Madarosis is the loss of hair on the brow and eyelashes, which can be caused by a number of conditions, including infections, systemic illnesses, and chemotherapy-related treatments.  The term was originally used to describe the loss of eyelashes as a result of injury to the hair follicles, but it now includes the loss of eyebrows as well as cilia. Chemotherapy causes chemotherapy-induced alopecia (CIA) by affecting fast-growing cells such as hair follicles and killing rapidly dividing cancer cells.  When using certain chemotherapy drugs and dosages, this hair loss may be either transient or permanent in certain situations. Patients' lives are profoundly affected by CIA, which affects their overall quality of life, body image, and self-esteem. Some patients may even refuse chemotherapy out of sheer psychological distress at the possibility of hair loss.  Therapeutic approaches like minoxidil and PRP injections are being investigated for their ability to encourage hair regeneration, and preventive strategies like scalp freezing have demonstrated some benefits. Additionally, natural vitamins and complementary and alternative medicine (CAM) techniques like aromatherapy and acupuncture provide extra assistance for hair healing.

Despite these treatments, there is still a pressing need for more dependable and efficient CIA management therapies. Healthcare professionals need to provide patients with all the assistance they need to deal with the upsetting consequences of hair loss, including psychological counselling and patient education. Research is essential for the creation of novel therapies and to enhance the quality of life for chemotherapy patients. By tackling the mental and physical aspects of CIA, we can improve patient outcomes and provide assistance to individuals enduring the arduous process of cancer therapy.