Overview

Hair loss of the eyebrows and eyelashes is called madarosis and is capable of happening to any gender and in any age group. Madarosis can either affect one side of the face or both with total or partial hair loss. The hair loss may either be non-scarring, maintaining the structure of the hair follicle meaning madarosis may be reversed, or scarring, causing deep damage to the hair follicle which is not able to be reversed.¹ 

A virus is an infectious germ which replicates itself inside the human body and causes a person to become ill, often with flu-like symptoms (including headache, body ache, fever and fatigue). Viral infections, including herpes zoster ophthalmicus (HZO) and human immunodeficiency virus (HIV), are associated with madarosis, displaying a wide impact on health.^1,2 This article aims to describe the causes of madarosis, focussing on viral pathways, and methods to treat and prevent viral-mediated madarosis occurring.

Causes of madarosis

Non-infectious causes

The main non-infectious causes, causes not associated with contagious disease, include:² 

• Underlying health conditions: including alopecia areata, psoriasis, hypothyroidism, and hyperthyroidism
• Nutritional deficiencies: a lack of zinc, iron, and/or biotin can thin hair and encourage hair loss;
• Genetic conditions: including Ehlers-Danlos syndrome, ichthyosiform, ectodermal dysplasia, and cryptophthalmos
• Physical trauma: injuries or accidents, including burns and wounds, affecting the eyebrows and/or eyelashes may result in madarosis
• Medications and treatments: hair loss can be a side effect of several medications and treatments including botox, retinoids, androgens, chemotherapy, radiotherapy, laser treatment; and
• Mental health: Trichotillomania causes sufferers to deliberately pull out their hair

Infectious causes

There are three major classifications of germs which cause infection that can lead to madarosis:²

1. Bacterial
   • Staphylococcus aureus, causes chronic blepharitis causing inflammation and swelling of the eyelid which results in eyelash loss in extreme cases
   • Streptococcus pyogenes causes impetigo which may affect the face and result in eyebrow hair loss
   • Mycobacterium leprae, causes leprosy leading to complications of the skin, nerves, and immune system which influence hair loss
2. Fungal
   • Dermatophytes such as Trichophyton and Microsporum lead to an infection called Tinea Capitis, better known as ringworm, which usually causes hair loss in the scalp but can extend to the eyebrows in extreme cases
   • Candida species can cause an infection of the eyelids, named Candidiasis (commonly known as thrush), leading to eyelashes falling out
3. Viral
   • Varicella-zoster virus causes HZO, better known as shingles, affecting nerve supply to the eyes and causing hair loss
   • HIV compromises the immune system and results in many health complications, including madarosis

Pathophysiology of viral infections in madarosis

How viral infections lead to madarosis

Viral infections can lead to madarosis by directly damaging the skin and hair follicles through inflammation and viral replication. This damage impairs the follicles' ability to support hair growth, causing loss of eyelashes and eyebrows. Additionally, the immune response to the infection can further exacerbate inflammation and follicle damage, contributing to hair loss.

Chronic and recurrent infections

Chronic and recurrent viral infections can cause madarosis by constantly inflaming and damaging the hair follicles where eyelashes and eyebrows grow. The persistence of the infection may cause overstimulation of the immune system, causing further hair loss. Repeated, regular infections lead to repeating the cycle of damaging and healing, eventually scarring and destroying the hair follicles. Over long periods of time, the damage results in the permanent loss of eyelashes and eyebrows, otherwise known as scarring madarosis. 

Symptoms and diagnosis

Symptoms of madarosis due to viral infections

The major symptom of madarosis is eyelash or eyebrow loss. However, redness, swelling, pain and discharge from the eye are also associated with the condition.³

Diagnostic methods

A clinical examination by a GP, in combination with the patient’s medical history, is usually substantial evidence for a diagnosis of madarosis. However, tests extracting hairs, diagnosing the underlying virus responsible, skin biopsies, and blood tests can give a certain diagnosis of madarosis.¹

Management, treatment, and prevention

To manage viral-mediated madarosis, the underlying infection can be treated with antiviral medications, reducing inflammation and therefore minimizing hair loss, with corticosteroids. Keeping the immune system strong through practising a healthy lifestyle, including a balanced diet and regular exercise, helps prevent hair loss from coming back. Using topical creams applied directly to the affected area, such as minoxidil, can help to promote hair regrowth. Future infections can be prevented by practising good hygiene, keeping on top of vaccinations, and avoiding contact with infected individuals. Regular doctor visits can help manage chronic infections. Following the advice of a GP ensures the best and most efficient treatment.²

Summary

Madarosis, the loss of eyebrow and eyelash hairs, has many underlying causes, including viral infections which play a significant role in its pathogenesis. Viruses, including HZO and HIV, can directly damage hair follicles through immune responses and inflammatory processes, leading to worsened outcomes and a less treatable condition. Underlying infections can be treated with antiviral medications, corticosteroids, and topical creams applied directly to the areas of the skin affected. These measures stop the escalation of hair loss and keep madarosis a reversible condition. Viral infections can be prevented by maintaining good hygiene practices, staying up to date with vaccinations, and avoiding contact with viral-infected individuals.