Bilateral madarosis as the solitary presenting feature of multibacillary leprosy.

Madarosis is window of diagnosis to various diseases and disorders. Though the patient presents to the dermatologist or the ophthalmologist for the treatment of this disease, a consultation with various other departments is necessary for the accurate diagnosis and treatment of this condition. Madarosis occurs in leprosy frequently but its occurrence as a presenting manifestation of leprosy has seldom been reported. Here, we are presenting a case of lepromatous leprosy who presented with bilateral madarosis only with no obvious skin lesions of leprosy.

INTRODUCTION

The clinical presentation of leprosy can be varied especially in an endemic area like Indian subcontinent. Leprosy is one of the important cause for loss of eyebrows or madarosis. This is particularly seen in advanced cases of lepromatous leprosy or if the patient gets tuberculoid lesions over the eyebrows. But madarosis as an isolated presenting feature of leprosy is seldom reported. We report a case of a woman presenting with madarosis as a presenting feature of leprosy.

A 28-year-old housewife from central India presented with total loss of bilateral eye brows for the past 2 months. The onset was insidious and finally resulted in the total loss of both eyebrows. She also noticed increase in thickness of the skin of the eyebrows during this period. There was no history of fever, mucosal lesions or general symptoms. There was no history of any loss of hair from anywhere else on the body. She did not have any other skin lesions on the body. Other than the loss of eyebrows the patient was totally asymptomatic and she consulted mainly for cosmetic reasons. No other skin lesions elsewhere on the body. Her past medical history was uneventful. There was also no significant family history for any medical disorders. On physical examination her vitals were stable, there was no pallor, icterus, clubbing, or lymphadenopathy. Respiratory and cardiovascular system examination revealed no abnormalities. On the face there was an ill-defined plaque of size 2×4 cm over both eyebrows region with total absence of hair [Figure 1]. Cranial nerve examination revealed no significant findings. Peripheral nerve examination showed thickened right ulnar nerve, which was not tender. There were no other significant mucosal or cutaneous findings. Ophthalmologic examination revealed no other abnormalities. A slit skin smear examination was ordered due to thickened ulnar nerve and infiltrated plaque on the face. The results came positive with a bacillary index of 6 and morphological index of 90%. Patient was started on multi-drug therapy multibacillary (MDT-MB) for a year. For the madarosis, patient was advised camouflage therapy with eyeliners as she did not want any surgical intervention.

Figure 1

Bilateral loss of eyebrows in a leprosy patient

DISCUSSION

The term madarosis is derived from the Greek word “madaros” meaning “pulpy or bald”. The term madarosis is lately used to define loss of eyebrows (superciliary madarosis) and also loss of the eyelashes (ciliary madarosis).[1] Madarosis may be a presenting feature of various diseases and a search for the underlying cause warrants in every case of madarosis.[2] It can occur due to infections such as staphylococcus infection, leprosy etc, trauma, endocrine disorders like hypothyroisdism or hyperthyroidism, autoimmune diseases, tumors, drugs, toxins, congenital disorders, and some psychiatric conditions like trichotillomania. The loss of eyebrows can be broadly being classified into scarring and non-scarring. In scarring cases, the regrowth of the eyebrows will not occur after the primary cuase has been taken care of and surgical intervention needs to be done. But in non-scarring variety, hair growth occurs once the primary cause is been treated.

Loss of eyebrows or madarosis is a common finding in advanced cases of leprosy or tuberculoid leprosy. The incidence of madarosis due to leprosy varies in various studies and it has been reported to be present in upto 45-76% of the multibacillary leprosy cases in some studies.[34] But bilateral madarosis as a presenting feature of lepromatous leprosy has never been reported before. In multibacillary leprosy, the madarosis occurs if the patient is left without treatment for many years. It occurs as a result of histiocytic infiltration of the hair follicles in cases of multibacillary leprosy and presents bilaterally. While in cases of paucibacillary leprosy like the tuberculoid leprosy the madarosis is generally unilateral at the site of the leprosy patch and occurs as a result of the destruction of the hair follicles due to granulomatous inflammation. Absence of madarosis in long standing cases of leprosy indicates good prognostic sign.[5]

Management of the madarosis requires identification and treatment of the underlying condition. Though lepromatous leprosy leads to a non-scarring form of madarosis, usually hair growth does not occur after treatment and hair transplant or cosmetic camouflage needs to be done for covering up the defect.