Introduction

Madarosis is a medical term that refers to the loss or absence of eyelashes and/or eyebrows. Madarosis is not a disease in itself, but rather a sign of various underlying conditions, many of which are dermatological in nature. Eyelashes and eyebrows serve important functions beyond aesthetics; they protect the eyes from debris, sweat, and other potential irritants.¹ Their loss can therefore have functional as well as cosmetic implications. 

Dermatological disorders often lead to madarosis due to their direct impact on hair follicles, skin inflammation, or scarring in the affected areas. These skin conditions can disrupt the normal hair growth cycle, damage follicular structures, or create an environment unsuitable for healthy hair growth, ultimately resulting in the characteristic hair follicle loss associated with madarosis.²

This article explores the relationship between madarosis and several dermatological disorders, providing insights into its causes, associated conditions, diagnosis, and treatment options.

Causes of madarosis 

Madarosis can be caused by various factors, including dermatological disorders, ophthalmological conditions (e.g., blepharitis, trachoma), autoimmune disorders (e.g., alopecia areata, chronic cutaneous lupus erythematosus), nutritional deficiencies (e.g., zinc deficiencies), and infections (e.g., herpes, leprosy).³ 

Focusing on dermatological disorders, there are many conditions associated with madarosis:¹

Atopic dermatitis

Atopic dermatitis, also known as eczema, is a chronic inflammatory skin condition characterised by intense itching, redness, and dryness. When it affects the eyelids or eyebrow area, it can lead to madarosis. The condition often begins in childhood and is associated with a compromised skin barrier function and an overactive immune response. 

Seborrheic dermatitis

This common skin disorder affects areas rich in sebaceous glands, including the scalp, face, and often the eyebrows. It involves red, inflamed skin covered with flaky, white or yellowish scales. The exact cause is unknown, but factors like yeast overgrowth, excess oil production, and individual susceptibility play a role. Eyebrow loss may be a result of scratching from pruritus, a symptom common in seborrheic dermatitis. 

Lamellar ichthyosis 

Lamellar ichthyosis is a rare genetic disorder affecting skin cell production and shedding. It's characterised by the formation of large, dark, plate-like scales over most of the body, including the face and scalp. The condition is present from birth and persists throughout life. When it affects the eyebrow and eyelid areas, abnormal skin development and thick scaling can impair hair growth, resulting in sparse or absent eyebrows and eyelashes.

Psoriasis 

Psoriasis is a chronic autoimmune condition that causes rapid skin cell turnover, resulting in thick, scaly patches on the skin. While it commonly affects areas like elbows and knees, it can occur anywhere on the body, including the face and eyebrows. In facial psoriasis, the eyebrow area may become inflamed and develop silvery scales. 

Acne rosacea

Rosacea is a chronic inflammatory skin condition primarily affecting the central face. It's characterized by flushing, persistent redness, visible blood vessels, and sometimes papules and pustules. There's also a subtype known as ocular rosacea that affects the eyes and eyelids. Ocular rosacea, in particular, can lead to irritation and inflammation of the eyelids. Blepharitis, an ocular finding in rosacea, can result in madarosis.

Overview of pathophysiology 

The general pathophysiology of madarosis can help explain how various dermatological disorders lead to this condition. 

Several key mechanisms include:⁴

• Disruption of the hair growth cycle: The normal hair growth cycle consists of anagen (growth), catagen (transition), and telogen (resting) phases. Dermatological disorders can interfere with this cycle, often pushing more follicles into the telogen phase or preventing the initiation of a new anagen phase
• Inflammation of hair follicles: Many skin conditions cause localised inflammation. This inflammation can damage the hair follicle structure and disrupt normal function
• Autoimmune reactions: Some disorders involve the immune system attacking hair follicles. This can lead to follicle destruction and prevent hair regrowth
• Alterations in sebum production: Sebaceous glands play a role in maintaining healthy hair follicles. Overproduction or underproduction of sebum can affect follicle health and hair growth
• Oxidative stress: Some dermatological conditions increase oxidative stress in the skin. This can damage hair follicles and impair their function

Diagnosis 

Diagnosing madarosis usually involves:⁵

• Clinical examination: Close inspection of the skin surface for signs of scarring or preservation of follicular openings
• Trichoscopy: Provides microscopic visualisation of the hair follicles and surrounding skin, helping differentiate between scarring and non-scarring types
• Skin biopsy: Often the gold standard for definitively classifying madarosis as scarring or non-scarring:
  • Histopathology in scarring madarosis shows replacement of hair follicles with fibrous tissue and loss of sebaceous glands
  • Non-scarring madarosis shows preserved hair follicle architecture and possible inflammation around hair follicles
• Additional tests: Based on suspected underlying causes (e.g., blood tests for endocrine disorders)

Establishing the diagnosis of madarosis requires its classification into two major types: scarring and non-scarring madarosis.⁵ In scarring madarosis, the hair follicles are permanently damaged or destroyed. Clinical signs include smooth shiny skin in the affected area, absence of visible follicular openings, and possible skin atrophy or depigmentation. There is also a potential alteration in skin texture, often appearing taut or waxy. The use of trichoscopy may reveal loss of follicular openings, white areas indicating fibrosis, and irregular blood vessels. Additional diagnostic features such as histopathology show replacement of hair follicles with fibrous tissue and loss of sebaceous glands. Dermoscopy may reveal an absence of hair shafts and follicular ostia. 

In non-scarring madarosis, hair follicles remain intact, allowing potential regrowth. Clinical signs include preservation of follicular openings, normal skin texture in the affected area, and the possible presence of short, fine hairs (vellus hairs).⁵ Trichoscopy may show visible follicular openings, possible presence of exclamation mark hairs (in alopecia areata), and normal skin vasculature. Thus, classification is essential as treatment approaches may differ between the two; scarring madarosis may require more aggressive treatment to halt the progression and prevent further permanent hair loss, while non-scarring types focus on reversing the condition and stimulating regrowth. 

In some cases, distinguishing between scarring and non-scarring madarosis can be challenging, particularly in early stages or mixed presentations. In such instances, a combination of clinical examination, trichoscopy, and sometimes histopathological analysis may be necessary for accurate classification.

Treatment options

There are a number of possible treatments although this depends on the individual’s pre-existing condition. For instance, for alopecia areata, treatment typically involves topical or intralesional corticosteroids to reduce inflammation and promote hair regrowth. For seborrheic dermatitis, antifungal agents such as ketoconazole in shampoo or cream form may be used as treatment.¹ 

Hence, treatment primarily focuses on addressing the underlying dermatological condition. General treatment approaches may include:³

• Topical treatments: Corticosteroids, immunomodulators, or growth factors
• Systemic treatments: Immunosuppressants or nutritional supplements
• Cosmetic procedures: Tattoos, microblading, hair transplantation, or artificial eyelashes/eyebrows

Prevention and management measures

A number of preventative and management measures can be implemented for madarosis.⁵ Proper eyelid and eyebrow hygiene is essential, including gentle daily cleansing with mild, hypoallergenic products to remove debris and excess oils without irritating the delicate skin around the eyes. Nutritional support plays a vital role, with a balanced diet rich in proteins, vitamins, and minerals supporting overall hair health. Avoiding trauma to the eyebrows and eyelashes is equally important; this includes refraining from excessive plucking or waxing and being gentle when applying or removing eye makeup and contact lenses.

Summary 

Madarosis, characterised by the loss of eyelashes and/or eyebrows, is frequently associated with various dermatological disorders. Each of these conditions presents unique challenges in managing madarosis, requiring tailored interventions based on the underlying pathology. Understanding the complex relationship between madarosis and dermatological disorders is essential for healthcare providers to effectively diagnose, treat, and manage this condition. By continuing to advance knowledge in this field, there may be opportunities to develop more effective, personalised approaches to treating and managing madarosis, ultimately improving the quality of life for affected individuals.