Madarosis

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Article initiated by:

David Plemel, MD, Jordan Huang, Karim Punja

All contributors:

David Plemel, MD, Jill Wells, MD, Michael T Yen, MD, Joseph Giacometti, MD

Assigned editor:

Joseph Giacometti, MD

Review:

Assigned status Update Pending

 by Joseph Giacometti, MD on May 20, 2024.

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In ophthalmology, the term madarosis generally refers to the loss of eyelashes.

Disease

Figure 1. Anatomical structures of the upper eyelid margin. The anterior lamella is comprised of the skin and orbicularis oculi muscle. The posterior lamella is comprised of the tarsal plate and the conjunctiva.

Madarosis is a clinical sign that refers to eyelash or eyebrow loss from any cause. The word originates from the Greek word “madao” which means to fall off. Similarly, milphosis refers to eyelash loss or the falling out of eyelashes. The two terms are often used synonymously. Other terms related to eyelash loss include alopecia adnata (underdevelopment of the eyelashes), trichotillomania (hair/eyelash loss due to compulsive pulling/avulsion of hairs), and alopecia (broad term that describes the absence or loss of hair from any skin region where it is normally present).

Anatomy

Eyelash hairs are short, thick, and curved in appearance. The lower eyelashes curve downwards while the upper eyelashes curve upwards. Functionally, this prevents interlacing and protects the eyeball from foreign bodies and irritants. Eyelash hairs typically develop in rows of 2-3 hairs, growing approximately 0.15 mm per day. Eyelash hairs can take up to 8-10 weeks to grow, and last for 5-6 months before falling out.

Classification

Madarosis is classified based on two pathogenic pathways: scarring and non-scarring processes of the hair follicle. This classification system is based on the potential for eyelash regrowth and is dependent on the severity of the pre-existing condition.

Scarring madarosis: Refers to irreversible loss of eyelash hair due to destructive processes of the hair follicle. Common causes include discoid lupus erythematosus, lichen planopilaris, and malignant tumors (squamous cell carcinoma, basal cell carcinoma). Deep inflammatory processes such as folliculitis decalvans, tertiary syphilis, and lupus vulgaris can also cause scarring madarosis.

Non-scarring madarosis: Refers to reversible loss of eyelash hair due to non-destructive processes of the hair follicle. Common causes include superficial inflammatory processes such as psoriasis, atopic dermatitis, secondary syphilis, and seborrheic dermatitis, as well as entities that alter cell cycle kinetics such as thyroid hormonal disturbances.

Diagnosis

History

The majority of madarosis will be due to localized eyelid conditions like blepharitis, dermatologic disease or localized neoplasia.

When the diagnosis is not immediately clear on exam, it will be important to keep a broad differential. Obtain a complete medical history. Specifically ask about dermatologic, endocrine, neoplastic, autoimmune and infectious disease. Trauma, nutritional deficiency, medications and allergens can also be causative. A family history is important in congenital cases. In the right clinical context, a psychosocial history may be supportive of a diagnosis of trichotillomania.

Ask about hair loss in other body regions. Concurrent hair loss can suggest dermatological, endocrine, autoimmune, congenital, or drug-induced causes.

Physical examination

Madarosis is a clinical diagnosis.

On a local inspection, identify:

• The extent of lash loss (localized, or diffuse)
• The presence of eye lash or eyebrow hair regrowing at different rates, or having broken ends (suggestive of a diagnosis of trichotillomania)
• Blepharitis
• Lesions along the eyelash margin
• Localized skin rash
• Associated loss of eyebrow hairs

On a systemic exam, identify:

• Stigmata of skin disease
• Associated hair loss

Diagnostic procedures

Ophthalmic causes should be referred to an ophthalmologist. Non-ophthalmic causes should be referred to a dermatologist or family physician.

Differential diagnosis

Refer to figure 2 for approach to the differential diagnosis.

Management

Treatment of madarosis is dependent upon treatment of the predisposing disorder. Identification of the underlying disorder is critical for the management of madarosis.

General treatment

Non-scarring madarosis:

• Correction of underlying primary disorder often results in regrowth of eyelash/eyebrow hair
• Exception: Lepromatous leprosy, although a non-scarring process, generally does not result in hair regrowth after treatment of disorder

Scarring madarosis:

• Correction of underlying primary disorder does not result in regrowth of eyelash/eyebrow hair
• Hair transplant, eyelash/eyebrow reconstruction, and cosmesis are viable options for disorders causing hair follicle destruction such as inflammatory dermatoses, infection, trauma, malignancy, and congenital causes

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