Madarosis: a marker of many maladies.

Madarosis is a terminology that refers to loss of eyebrows or eyelashes. This clinical sign occurs in various diseases ranging from local dermatological disorders to complex systemic diseases. Madarosis can be scarring or non-scarring depending upon the etiology. Appropriate diagnosis is essential for management. Follicular unit transplantation has been found to be a useful method of treating scarring madarosis and the procedure relevant to eyebrow and eyelash reconstruction has been discussed. A useful clinical approach to madarosis has also been included for bedside diagnosis. The literature search was conducted with Pubmed, Medline, and Google scholar using the keywords madarosis, eyebrow loss, and eyelash loss for articles from 1960 to September 2011. Relevant material was also searched in textbooks and used wherever appropriate.

INTRODUCTION

Madarosis is a term which was originally coined to denote loss of eyelashes due to destruction of hair follicles, but now encompasses the loss of cilia of both eyelashes and eyebrows.[1] The term takes its origin from the Greek word “madao” which means to fall off. Milphosis is a term that refers to the loss of eyelashes.[2]

Madarosis is an obvious clinical sign with a varied etiology. This seemingly innocuous sign may be an important manifestation of many local or systemic disorders. The causes, clinical features, and approach to madarosis are discussed in this review.

ANATOMY OF EYEBROWS AND EYELASHES

The eyebrows are two-arched eminences of skin situated above the orbital regions.[34] The hairs of the eyebrows are short, thick. and stiff and are set obliquely. The diameter of eyebrow hair is normally thinner than scalp hair in Asians, and the scalp hair in thinner in Caucasians.[5] The eyebrows can be roughly divided into three parts. The medial third is usually below the orbital margin with the hairs in this region oriented vertically. The middle third lies along the orbital margin with hairs oriented obliquely or horizontally. The lateral third usually lies above the orbital margin.[3] Eyebrow hair normally tends to be less dense laterally than medially; thus, hair loss from any cause is apt to be more obvious in the lateral portion.[6]

The fibers of the orbicularis oculi, corrugators, and frontal part of the occipitofrontalis are inserted into the dermis of the skin underlying the eyebrows. This helps in changing the contour of the eyebrows and consequently facial expression.

Eyelash hairs are usually present in two to three rows, and are short, thick, and curved in appearance. They are set obliquely, anterior to the palpebral muscle. The upper eyelashes are more numerous and curve upward, while the lower eyelashes curve down in order to avoid interlacing during eyelid closure. Eyelash cilia are unique in that they have no erector muscles. Eyelash hairs are oval in all races.[7]

The lid appendages and pilosebaceous unit are formed between the third and sixth months of intrauterine life. The development of the eyelashes is apparent initially as proliferation of the surface epithelial cells into the underlying mesenchyme while maintaining an intact basal lamina. Differentiation of the follicles occurs later.[4]

Eyelash hair grows at the rate of approximately 0.15 mm per day. They last for 5 to 6 months before falling out. After plucking, a new lash grows in about 8 to 10 weeks.[8]

FUNCTIONS OF EYEBROWS AND EYELASHES

Eyebrows protect the eyes from sweat that trickles down the forehead. They also protect the bony ridges above the eyes. In addition to the above, the eyebrows play a very important function in facial expression and body language. Eyelashes protect the eyeball from small foreign bodies and irritants and stimulate the closing reflex. Both eyebrows and eyelashes play a very important cosmetic function, and thus contribute greatly to the self esteem of an individual.[9]

CAUSES OF MADAROSIS

There are many causes of madarosis. A useful etiological classification is given in Table 1.

Table 1

Etiological classification of madarosis

OPHTHALMIC CONDITIONS ASSOCIATED WITH MADAROSIS

Blepharitis

Blepharitis is a chronic primary eyelid inflammation. It is fairly common in occurrence and being a condition with remissions and relapses, results in a decreased quality of life if adequate measures are not taken. Chronic blepharitis is the most common condition associated with madarosis.[10] Though there are various ways of classifying blepharitis, the most useful is the one proposed by Wilhelm,[24] wherein blepharitis can be classified based on whether there is a predominant involvement of the part of the eyelid anterior to the gray line (anterior blepharitis), or posterior to the gray line (posterior blepharitis). The gray line is an imaginary line dividing the eyelid into an anterior part consisting of the skin and muscle, and a posterior part consisting of the tarsus and conjunctiva.

Anterior blepharitis is usually either staphylococcal or seborrhoeic, and posterior blepharitis refers to any of the varieties of meibomian gland dysfunction.

The symptoms of anterior blepharitis include itching, burning, foreign body sensation, photophobia, and tearing. The signs include the presence of scurf, collarettes, and sleeves along the lashes.[25]

Scurf refers to the scales and greasy crusts that accumulate along the hair shaft and indicates the presence of seborrhea.[2627] Collarettes are composed of hard fibrinous scales[2528] surrounding each individual eyelash. They travel upward along with the growth of the lashes and are indicative of staphylococcal infection. Sleeves or cylindrical dandruff comprise scales that form a cuff around the lash root and are connected with it, in contrast to greasy scales which are not connected to the lash root.[29] Sleeves indicate infestation with Demodex folliculorum.

Staphylococcal blepharitis causes lid margin inflammation and folliculitis which destroys the hair follicle resulting in madarosis[30] which is usually non-scarring,[10] but occasionally may be scarring, especially if long standing.[15] Seborrhoeic blepharitis is very often associated with secondary bacterial infections and can result in madarosis either due to associated staphylococcal infection or due to rubbing caused by itching.

Posterior blepharitis is also known as meibomian gland dysfunction. MacKenzie and Jones[31] used the term “ophthalmia tarsi” to refer to blepharitis due to meibomian gland dysfunction.

Posterior blepharitis is characterized by either excessive foam in the tear film in the hypersecretory type, or plugging of the meibomian orifices in the obstructive type. Expression of the secretions reveals a turbid or toothpaste-like material.[32] If there is spillover inflammation of the anterior lid margin, there may be a loss of eyelashes.[33]

It may be frequently associated with rosacea, in which case there will be evidence of meibomian gland dysfunction and telangiectatic vessels at the eyelid margin.[34]

If a chronic blepharitis does not respond to conventional modes of therapy, then other diseases that may mimic it like discoid lupus erythematosus (DLE) should be considered.[35]

DERMATOLOGIC CONDITIONS ASSOCIATED WITH MADAROSIS

Atopic dermatitis

This manifests in childhood with chronic lower eyelid dermatitis and is often associated with other types of allergic disorders.[3637] The ocular features are eyelid dermatitis, Dennie-Morgan fold (an infraorbital fold or line due to lid edema in atopic dermatitis), keratitis, and a frequent association with keratoconus and cataracts. Loss of lateral third of eyebrows (Hertoghe sign)[38] is seen in atopic dermatitis due to constant scratching and rubbing.

Seborrhoeic dermatitis

Seborrhoeic dermatitis presents as erythema and scaling of eyebrows. The lids may also show erythematous yellowish fine scales. Edges of lids may show marginal blepharitis. All these features may be associated with madarosis.[39] Eyebrow loss is due to scratching as a result of pruritus which is common in seborrhoeic dermatitis.[36]

Lamellar ichthyosis

Some of the prominent findings[40] in lamellar ichthyosis are cicatricial lagophthalmos, ectropion of lids, and madarosis [Figure 1].

Figure 1

Madarosis in lamellar ichthyosis

Psoriasis

About 10% of patients with psoriasis can have eyelid involvement in the form of blepharitis, psoriatic plaques, and madarosis.[41]

Frontal fibrosing alopecia

Postmenopausal frontal fibrosing alopecia, a variant of lichen planopilaris, is a distinct form of scarring alopecia which is described in postmenopausal women. It consists of a receding hairline with scarring associated with a partial or complete loss of eyebrows in most affected individuals. The loss of eyebrows may be the presenting sign; however, the hairline reveals evidence of perifollicular erythema on closer observation. Histologic features are identical to that of lichen planopilaris.[42]

Ulerythema ophryogenes

Also known as keratosis pilaris atrophicans faciei, it is associated with pinhead follicular plugs with erythema in face along with involvement of and loss of eyebrows.[43]

Acne rosacea

The ocular findings in rosacea are quite frequent and non-specific. They include blepharitis, conjunctivitis, recurrent hordeola and chalazia, rosacea keratitis, and interstitial keratitis. The blepharitis can result in madarosis.[2534]

Telogen effluvium

The most common cause of hair loss is telogen effluvium. Telogen effluvium is an increased shedding of otherwise normal telogen hairs. It usually occurs in response to systemic disease or altered physiologic states such as severe emotional stress, etc. It can result in a diffuse loss of eyebrow hair.[44]

Follicular mucinosis

There is pilosebaceous inflammation[45] with both scarring and non-scarring alopecia depending on the degree of inflammation. Most commonly, there is involvement of the head and neck, though widespread involvement is also seen. Eyebrow loss is a prominent finding and may be the presenting symptom when the eyebrow region is involved in the acute benign form of follicular mucinosis.[46]

Cutaneous sarcoidosis

Madarosis has been reported in a case of cutaneous sarcoidosis with nodules and plaques in the face.[47]

SYSTEMIC AND ENDOCRINE DISORDERS

Thyroid hormone receptors were detected in both dermal and epithelial compartments of the human pilosebaceous unit.[48] T4 and T3 decrease the apoptosis of hair follicles and T4 prolongs the duration of anagen in vitro.[49] Thyroidectomy delays initiation of anagen. Administration of thyroxine advances anagen, initiation of which is however delayed once toxic doses are given. Therefore, ratio of telogen to anagen hairs is increased in hypothyroidism as well as hyperthyroidism.[50] Thus, the hair follicles are affected in thyroid disorders, and madarosis is caused due to disturbances in hair cell kinetics. Hypothyroidism is associated with generalized hair loss probably due to coarse, dull, and brittle hair with reduced diameter.[51] The eyebrows and eyelashes may also be lost. Loss of lateral one-third of eyebrows known as Hertoghe sign[38] is a characteristic sign of hypothyroidism.[52] Some people also refer to it as Queen Anne's sign,[53] after Anne of Denmark whose portrait with shortened eyebrows has been interpreted by some as indicative of the presence of goiter, even though such a fact has not been proved by any known sources of information. Madarosis may even be the presenting sign in hyperthyroidism.[21] In hyperthyroidism, there is thinning with breaking off and shortening of hair.[54] Madarosis can also occur in hypopituitarism, hypoparathyroidism,[21] and hyperparathyroidism.[55]

Alopecia areata

Madarosis of non-scarring type is commonly seen in alopecia areata which is a hair-specific autoimmune disease associated with patchy loss of hair.[56] It presents as round or oval patches of non-scarring hair loss. Madarosis occurs as isolated involvement [Figure 2] or as a part of alopecia universalis.[57] When alopecia areata involves the eyelashes exclusively, there is rarely involvement of other parts of the body.[58] Alopecia areata can involve both the eyelids without scalp involvement also.[59] Short exclamation mark hairs are pathognomonic for alopecia areata.

Figure 2

Total eyebrow loss in a child with alopecia areata

Discoid lupus erythematosus

DLE is an autoimmune condition and is the most common form of chronic cutaneous lupus erythematosus.[35] Clinically, the lesions start as discoid erythematous patches which then develop into plaques with follicular plugging and scaling. Eyelid findings include blepharitis, lid scarring, entropion, and ectropion. Scaly plaques on the eyelids with loss of hair follicles results in madarosis[60] [Figure 3]. Numerous studies have reported the mimicking of a chronic blepharitis by DLE.[3561-63] A high index of suspicion is necessary in such cases, where the diagnosis is very often delayed by months to years.[35] Biopsy with histopathological examination should be done to confirm the diagnosis. Treatment with hydroxychloroquine results in a regrowth of the eyelashes.[61]

Figure 3

Loss of medial aspect of eyebrows in a patient with discoid lupus erythematosus

En coup de sabre

Eyebrow and eyelash loss has been reported in en coup de sabre, a form of localized scleroderma, wherein there is a linear band like scarring in the frontoparietal region.[6465] These are very often associated with neurological abnormalities.[66]

Graham-Little syndrome

This is a variant of lichen planopilaris which is associated with progressive cicatricial scalp alopecia along with non-scarring loss of pubic, and axillary hair, and lichenoid follicular eruption over the trunk and limbs.[67]

Parry-Romberg syndrome

Parry-Romberg syndrome is characterized by facial hemiatrophy and is associated with loss of eyebrows and eyelashes.[68]

Vogt Koyanagi Harada syndrome

It should be suspected when madarosis is associated with vitiligo and accompanies a granulomatous uveitis.[69]

NUTRITIONAL DISORDERS

Telogen hairs are shed in chronic marasmus[70] and malnutrition of any type.

Hypoproteinemia[71] causes loss of hair due to premature onset of telogen. Loss of eyebrow hair has been reported due to chronic zinc deficiency in a patient receiving only parenteral nutrition for 2 months.[26] Acrodermatitis enteropathica is an inherited disorder of zinc deficiency which shows loss of eyebrows and lashes in addition to cutaneous manifestations.[7273] Biotin deficiency can result in encephalopathy, neurological disorders, skin desquamation, and loss of eyebrows and eyelashes.[74] Iron deficiency may be a possible cause for diffuse telogen hair loss; its exact role however is subject to speculation.[75]

INFECTIONS

Leprosy

Madarosis is the hallmark of lepromatous leprosy. It was reported in 76% of patients with multibacillary leprosy.[76] Bilateral symmetric cicatricial madarosis occurs in lepromatous leprosy due to histiocytic infiltration of hair follicles[7778] [Figure 4]. It occurs in multibacillary leprosy after at least 5 to 10 years of untreated disease.[79] Loss or atrophy of the eyelashes may follow. Madarosis adds to the cosmetic disfigurement caused by leprosy. Absence of madarosis is a good prognostic sign in long-standing cases.[80] Unilateral madarosis may occur in tuberculoid leprosy due to the facial patch in the eyebrow region. In tuberculoid leprosy, madarosis occurs due to granulomatous infiltration of hair follicles leading to their destruction.

Figure 4

Bilateral eyebrow loss in a patient with lepromatous leprosy

Secondary syphilis

Non-scarring eyebrow loss has been reported in secondary syphilis. It is incomplete and has been described as having a moth-eaten appearance. Antisyphilitic treatment has been found to reverse the hair loss.[81] Tertiary syphilis can be associated with cicatricial loss of eyebrows.[82]

Viral infections

Herpes zoster ophthalmicus causes scarring of the eyelid along with cicatricial ectropion, entropion, trichiasis, madarosis, and poliosis.[83] Madarosis has also been described in AIDS.[84]

Fungal infections

Paracoccidioidomycosis which is seen in Latin America can cause erythematous lesions with madarosis, which can ultimately lead to cicatricial changes and eyelid malpositions.[85]

Basak et al. reported 10 cases of periocular tinea which had been misdiagnosed for a long time before the correct diagnosis was made. Only two cases had the central clearing typical of tinea corporis, but all of them were associated with madarosis. There was an improvement in the lesions as well as the madarosis following treatment with topical and systemic antifungals.[86]

Eyelash loss can occur with infection with trichophyton and microsporum species.[87]

PARASITE INFESTATION

Demodicosis

Infestation with the mite D. folliculorum which inhabits the eyelashes is well known. Two species are known to inhabit human beings—D. folliculorum and Demodex brevis.[29] It might either be asymptomatic or may cause symptoms of blepharitis. Kemal et al. report an overall prevalence of 27.4% in their study group.[88] Gao et al. have reported a 100% prevalence of the mite when there is cylindrical dandruff.[29] Patients with demodicosis can develop madarosis.[29]

PHTHIRIASIS PALPEBRARUM

Madarosis has also been described in phthiriasis of the eyelid. Phthiriasis palpebrarum is the term used to denote infestation of the eyelashes by the pubic louse or Phthirus pubis, also known as crab louse. The parasite is usually transmitted by sexual contact or through fomites. Heavy infestation may result in involvement of axillae, eyebrows, and scalp. When eyebrows and lashes are involved, blue-gray macules or maculae caeruleae may be found on the shoulders, arms, and trunk.[89] The louse can be identified under the microscope as having a wide body and strong second and third pair of legs.[90]

TRAUMA

Trichotillomania

It is an impulse-controlled disorder characterized by compulsive plucking or breakage of hair.[91] The most frequent site of hair pulling is the scalp, but the eyebrows, eyelashes, and pubic hair may also be involved. Trichotillomania manifests in eyelashes and eyebrows as irregular patches of alopecia containing hairs of varying lengths. Inflammation, scarring, and atrophy are conspicuous by their absence. Patients often attempt to conceal their alopecia by cosmetological camouflage. In case of a diagnostic dilemma, histological features such as increased numbers of catagen hairs, pigment casts, and traumatized hair bulbs provide a clue.

Trichoteiromania (hair loss due to repeated rubbing) and trichotemnomania (obsessive shaving of hair) can also result in loss of hair.[92]

COCAINE ABUSE

Tames and Goldenring described a case of bilateral loss of eyebrows and eyelashes in a patient with AIDS-related complex who had smoked crack cocaine. This has been attributed to hot vapors during the process of smoking, and which therefore caused singeing of the brows and lashes. There was a complete reversal once the patient abstained from cocaine.[93]

RADIOTHERAPY FOR OCULAR TUMORS

Toxic alopecia occurs when there is a disruption of hair growth in the anagen phase. This usually occurs following chemotherapy and radiotherapy.[94] Radiotherapy for various types of ocular tumors, eyelid and choroidal tumors have been reported to produce madarosis.[95-97] Hair loss due to radiation is usually reversible, but may be permanent when the dose of radiation is in the range of 50 to 60 Gy.[94]

DRUGS

Retinoids, heparin, anticonvulsants, angiotensin-converting enzyme inhibitors, and androgens can all precipitate telogen hair shedding and madarosis.[98]

Other drugs commonly attributed to causing madarosis are miotics, anticoagulants, anti-cholesterol drugs, antithyroid drugs, propranolol, valproic acid, boric acid, and bromocriptine.[2199] Anticoagulants in high doses have been found to produce loss of scalp, pubic, axillary, and facial hair with loss of eyebrows after a latent period of a few weeks of treatment with dextran and heparin.[100] Propranolol can cause diffuse alopecia along with loss of eyebrows due to telogen effluvium,[101] usually after three months of therapy.[44] Loss of medial aspect of eyebrows can be seen in fetuses exposed to valproic acid.[102] Diffuse alopecia including that of eyebrows has been described due to chronic ingestion of mouthwashes containing boric acid. There was complete reversal following stopping the practice.[103] Levodopa has been noted to cause severe diffuse alopecia within three months of daily use.[104] Hair loss can occur soon after starting topical minoxidil therapy (due to detachment of club hairs following resting hairs reentering anagen), and after cessation of therapy (due to telogen effluvium).[98]

Reversible loss of eyebrows and lashes along with other ocular side effects, possibly due to use of niacin to treat hyperlipidemia, has been reported.[105]

CHEMOTHERAPEUTIC DRUGS

Madarosis has been reported as a frequent complication of chemotherapy with docetaxel.[106-108] Garibaldi and Adler described a case that developed madarosis following addition of cetuximab,[109] and which resolved following discontinuation of the treatment.

Eight of 69 eyes receiving intra-arterial chemotherapy with melphalan for retinoblastoma were found to develop a cutaneous periocular erythema with partial loss of eyelashes.[110] Gobin et al. also reported a 12.6% incidence of madarosis following intra-arterial chemotherapy for retinoblastoma.[111] Moti and Fausel described a case of cyclical alopecia areata including the eyebrows and eyelashes after treatment with paclitaxel and carboplatin.[112] Other drugs which have been implicated in hair loss due to anagen effluvium are adriamycin, cyclophosphamide, daunorubicin, epirubicin, etoposide, ifosfamide, irinotecan, topotecan, vindesine, and vinorelbine.[98113]

Razeghinejad et al. described a case of acute madarosis associated with fever, two days following Measles, Mumps and Rubella (MMR) vaccination.[114] There was associated D. folliculorum in one of the eyelids, and though a causal role is speculated, they attribute the triggering factor to be the MMR vaccination.

Kowing described a patient who developed unilateral madarosis and alopecia following Botulinum A toxin injections in the left masseter and left temporalis muscles for the treatment of left oromandibular dystonia.[115] Kass et al.[17] described madarosis following chronic epinephrine therapy.

TOXICITY

Hypervitaminosis A

Hair loss can occur either in acute or chronic hypervitaminosis A. Loss of eyebrows and eyelashes can occur in chronic hypervitaminosis A which can occur in a number of conditions, either due to enthusiastic overdosing or due to intentional prescription of high doses for diseases such as acne, retinal disorders with night blindness, and others.[116] The cutaneous manifestations include dry, rough, and scaly skin. Chronic hypervitaminosis A is also becoming increasingly common with use of retinoids for various skin disorders. Acitretin has been noted to cause a high incidence of diffuse hair loss.[117] Premature teloptosis may be a prime factor in hair loss induced by retinoids.[98]

Thallium

Thallium poisoning should be suspected in any patient manifesting nervous system and gastrointestinal symptoms along with alopecia. The hair loss affects the scalp, periocular hair, limbs, and sometimes the axillae. Examination of the hair roots under a microscope using polarized light shows distorted anagen roots and several black zones in continued poisoning.[118]

Mercury poisoning can occur following use of some cosmetics like bleaching creams, and which result in systemic effects which include diffuse hair loss.[71]

Tumors

Both benign and malignant tumors such as seborrhoeic keratosis, molluscum contagiosum, basal cell carcinoma, squamous-cell carcinoma, sebaceous cell carcinoma, and sclerosing sweat duct carcinoma have been shown to be associated with loss of eyelashes.[1111-113119120] A sebaceous cell carcinoma very often presents as a recurrent chalazion. An associated madarosis (due to lid infiltration and follicle destruction) would help to differentiate the two.[121122] Tsuji et al. reported a rare case of primary epithelioid hemangioendothelioma of the eyelid associated with madarosis.[123] Primary leiomyoma of the eyelid has been reported with madarosis.[124] Kuan[125] described a case of lacrimal gland tumor masquerading as blepharitis with madarosis.

Systemic mastocytosis

Eyebrow loss with leonine facies has been described in a case of systemic mastocytosis.[126]

Cutaneous T-cell lymphoma

The most frequent ocular findings[127] are blepharoconjunctivitis, cicatricial ectropion, meibomianitis, chalazia, and madarosis.

MISCELLANEOUS

Trichodysplasia spinulosa

A new entity variously called as trichodysplasia spinulosa,[128] trichodysplasia of immunosuppression,[129] and cyclosporine-induced folliculodystrophy[130] has been described in immunocompromised patients, usually organ transplant recipients on immunosuppression. It involves the development of alopecia predominantly of the face with indurated spinous papules. There is a profound loss of eyebrows[131] and sometimes eyelashes. The histopathologic picture is that of abnormal follicles with hyperkeratotic infundibula and absence of normal hair shafts. The inner root sheath epithelium showed proliferation in the cells and dystrophic trichohyaline granules. Electron microscopy of skin showed presence of intracellular viral particles.[132] This entity has lately been reported in immunosuppressive states in patients without organ transplantation such as leukemias and lymphoma.[133-136] van der Meijden et al. described the discovery of a new polyoma virus in a patient with trichodysplasia spinulosa.[131] Histopathological examination can reveal the diagnosis. A recent simple pull-test wherein the spicules can be plucked and examined under the microscope for inner root sheath keratinization has been described.[136] Some successful treatments described are cessation of cyclosporine therapy[130] and oral valganciclovir[137138] and topical cidofovir.[131]

Nezafati et al. described a case of madarosis occurring in a patient who had undergone root canal therapy followed by intrasinus foreign body consisting of root canal filling material. There was a complete regrowth of lashes 6 weeks following surgery for the removal of the foreign body.[139]

Diffuse alopecia including loss of eyebrows has been described in Cronkhite-Canada syndrome which consists of adult onset gastrointestinal polyps, hyperpigmentation of skin, nail dystrophy, onychomadesis, diarrhea, and weight loss.[140]

Various inherited syndromes may be associated with madarosis. The individual clinical features and type of madarosis are described in Table 2.

Table 2

Inherited disorders with madarosis

MANAGEMENT OF MADAROSIS

Management of madarosis primarily depends upon treatment of the predisposing disorder. Inherited disorders can be identified by the associated clinical features. Establishing the diagnosis is an important prerequisite for the management of madarosis. For this, madarosis can be broadly classified as scarring and non-scarring. In non-scarring madarosis, generally regrowth of hair occurs after treatment of the primary disorder. In disorders such as lepromatous leprosy, though the madarosis is non-scarring, hair regrowth does not occur. In such cases, and in cases of scarring madarosis, hair transplant is essential for cosmetic purposes.

The treatment of the individual disorders responsible for madarosis is beyond the purview of this article. A useful approach to a patient with madarosis is presented in Figure 5.

Figure 5

Approach to a patient with madarosis

Aesthetic camouflage for eyelashes can be achieved with the help of mascara or artificial eyelashes[9] and by tattooing and dermatography for eyebrows.[181]

Minoxidil[182183] may be used in the topical treatment of eyebrow loss due to alopecia areata in the form of a 5% solution applied twice daily. Hair growth usually starts by 12 weeks, and it reaches its peak by about 12 months.

Topic prostaglandin analogues are used for the treatment of glaucoma. Uniocular increase in length, thickness, and pigmentation of the lashes were described by Johnstone in 1997 by patients using latanoprost in one eye.[184] There are reports of a response of alopecia of eyelashes to cutaneously administered latanoprost,[185186] though others report limited success.[187] Eyelash growth has also been reported following bimatoprost 0.03% topically to the base of the eyelashes in healthy individuals[188-190] and in individuals with alopecia areata.[191] Bimatoprost ophthalmic solution 0.03% is the only Food and drug administration (FDA)-approved product to safely and effectively enhance the growth of a patient's own eyelashes.[192193]

Surgical management of madarosis

Surgical reconstruction of eyebrows and eyelashes has its origins in the earlier part of the 20th century. Because of the involvement of the eyebrows in demonstrating various emotions, the restoration of eyebrows is more important cosmetically than scalp hair when there is a loss of both.[194]

Various techniques have been described over the years. Nylon implants were used by some people. Now, they are banned in many countries because of sequelae-like scarring and infection. Follicular unit transplantation has been found to give very good results[195] and is now the procedure of choice for most types of hair transplantation. The details of the procedure with respect to eyebrow and eyelash reconstruction will be discussed here.

Follicular unit transplantation for eyebrows

Indications for eyebrow transplant are scarring eyebrow loss, leprosy, and therapy-resistant alopecia areata.[57196]

Procedure

The occipital area is usually used for harvesting the donor strip. Softer texture hair for periocular transplantation may be taken from below the nuchal ridge or the lower part of the parietal scalp.[197] A 1×4-cm elliptical area of skin is removed. It is then dissected under the stereomicroscope[198] into individual follicular units.

Single hair units are preferred as eyebrows consist of only one hair follicular units.[199] Alternatively, follicular unit extraction may be done to reduce donor area scarring.[200] Single hair unit harvesting using an 18-gauge needle has also been described.[201]

The recipient sites in the eyebrow can be conveniently made with 20 to 22-gauge needles parallel to the skin, so that hair grows flat on the skin and does not stick out from the face. About 150 hairs are required for a full eyebrow graft. Poddar et al. described good results with a technique of creating recipient tracks with the erbium yttrium aluminium garnet laser.[202]

Accurate placement of the grafts is necessary to ensure a good cosmetic result. In the medial third, the needles should be inserted parallel to the brow axis.[203] The follicles should point toward the tip of the nose and the hairs should converge toward each other in the other two segments, that is, the bulbs in the upper part point toward the forehead and in the lower part toward the other eyebrow.[204]

Eyelash grafting

For eyelash grafting, the hair from the follicle is threaded into a French eye needle, which is then inserted into the eyelids and pulled out through the lid margin in the region of the normal position of eyelashes. The follicle will then remain in position in the track created by the needle. The hair may then be trimmed as necessary.[5]

Eyelash transplantation may also be done using a strip composite graft from the eyebrow. This method has been advocated because of the similarity between eyebrow and lash hairs.[205]

The other techniques available for eyelash reconstruction are follicular unit and reverse follicular unit grafting, double follicular unit grafting, single hair grafting using the sewing technique, or the Choi/KNU implanter.[206]

Eyebrow grafts show almost near total success. Eyebrow hair usually starts to grow after three to four months and is fully grown by about six months.[194]

Eyelash grafts are less successful due to greater degree of handling. This may be compensated by transplanting a larger number of lashes. However, six one hair grafts per eyelid may often be enough, though there are others who transplant up to 40 hairs per eyelid.[206]

Thus, many of the surgical procedures described for eyebrow and eyelash loss have proved to be an effective method of management for scarring madarosis.

CONCLUSION

Madarosis is a clinical sign that has become pathognomonic of leprosy in countries like India. However, this apparently benign clinical sign has wider ramifications in many systemic and dermatological disorders. Hence, establishing a proper diagnosis and appropriate management is mandatory. Though management of the primary disease results in regrowth of eyebrows and eyelashes, many require surgical management. Thus, the management of a patient with madarosis requires a coordinated effort from the dermatologist, ophthalmologist, internist, and reconstructive surgeon.

LITERATURE SEARCH

The literature search was conducted with Pubmed, Medline, and Google scholar using the keywords madarosis, eyebrow loss, and eyelash loss for articles from 1960 to September 2011. Only English articles were used as references. Relevant material was also searched in textbooks and used wherever appropriate.