When oral acne treatments lead to ocular surface disease, the solution lies in office-based therapies.
Acne takes several common forms that can affect individuals of virtually any age. Approximately 9. 4% associated with the global population has acne. 1 In teenagers and pregnant women, hormone changes are the underlying cause. Rosacea, which affects approximately 5% of the worldwide population, 2 causes redness plus papule breakouts, most commonly in patients 30 years and older.
And since the start of the COVID-19 pandemic, individuals of all ages have developed mask acne—or “maskne”—as protective face masks change the skin’s microbiome, triggering outbreaks and exacerbating underlying pimples or rosacea. 3
As someone who had acne as a teenager, I’m happy there are now many therapies available to help patients achieve clearer skin. However, as a medical optometrist, I see the effects of pimples treatments on the meibomian glands and the ocular surface area. After all, acne medications need to reduce oil plus dry up blemishes—2 goals at odds with the production of healthy, functioning tear film.
Here, I’ll share the complications seen from prescription treatments and over-the-counter (OTC) products, and how today’s in-office procedures are helping my patients have clear pores and skin and comfortable eyes.
Isotretinoin medications— such as Accutane (Roche), Absorica (Sun Pharmaceutical Industries Ltd), Claravis (Barr Laboratories), Myorisan (Akorn), Zenatane (Dr. Reddy’s Laboratories)— are usually oral retinoids prescribed on-label for severe nodular acne and off-
label for a plethora of skin problems, including rosacea. 4
It works by shrinking the particular sebaceous glands, which significantly lowers manufacturing of oils in the skin and reduces pimples. Unfortunately, because the meibomian glands are sebaceous, oil-producing glands, this systemic medication shrinks them as well.
My patients who are taking isotretinoin or have used it in the particular past present with typical signs plus symptoms associated with meibomian gland dysfunction (MGD): intolerable evaporative dry eye, keratitis, low tear breakup time (TBUT), fluctuating vision, grittiness, foreign body sensation, styes, and contact lens discomfort. Meibography shows that the glands of these individuals have been clogged or even atrophied. Whenever I express their intrigue, the meibum is often thick, toothpaste-like and opaque. In my experience, the particular longer the patient offers used isotretinoin, the more likely it is that some glands are usually lost.
Figure 1 shows meibography images of a 27-year-old female patient along with dry vision
disease (DED) before and after receiving in-office dry attention treatments.
A thorough history asking about medications is important, as our practice frequently sees sufferers several that were prescribed isotretinoin (due to various skin problems). Some patients took isotretinoin years ago as teenagers, plus it left a lasting impact on the meibomian glands. Even our older dry eyesight patients report increased frequency and severity of ocular symptoms after being recommended isotretinoin for maskne or for post-pregnancy acne.
Likewise, patients are more likely to develop dry eyes as they age, so isotretinoin raises the already high risk associated with MGD within older individuals.
Topical medicines and epidermis care items
Although topical acne medications are applied directly to the skin, these people must be used with care to avoid contributing to DED ( Figure 2 ).
Patients should not use this kind of topical medications near the particular eyes or even when handling contact lenses.
Unfortunately, I also observe patients with dry, irritated eyes that have already been less careful with medicines or other skin care products.
Tretinoin (Retin-A Cream, Janssen Pharmaceuticals) is a common prescription acne medication that tightens your skin. However, if it comes inside contact along with the eyelids and is absorbed, it can damage epithelial cells in the meibomian glands 5 and cause significant dry eye symptoms. Common ingredients in OTC pimples products—such as benzoyl peroxide and salicylic acid—can possess similar effects. 6
While we can’t cure dry eye or MGD, we can decrease flare-ups plus major episodes as well as provide patients a lot more comfort simply by reducing the impact from the condition on our patients’ quality of lives and daily activities.
We accomplish this by addressing the key contributing factors as well as the root cause of dry vision with office-based therapies—rather than relying solely on pharmaceuticals—because the goal is in order to remove or even minimize patients’ treatment burden.
For sufferers who have used isotretinoin, I have the particular added goal of preserving the anatomical structure of the meibomian glands, as okay as regenerating damaged intrigue, if possible. Three in-office therapies assist in meeting these goals: eyelid exfoliation, thermal expression, and light-based therapy.
These work synergistically as the combined 3-step plan, or they may also be utilized independently, depending on a patient’s specific needs or presentation.
Step 1 : Eyelid the peeling off
The BlephEx (Alcon) device and Zocular Eyelid System Treatment (ZEST) system are two ways to deep clean and remove eyelid scurf, plaque, bacterial biofilm, plus demodex mites from the base of the eyelashes and at the opening of the meibomian glands.
For those patients with significant signs or symptoms of blepharitis, consider repeating 1 of these therapies 2 to 4 times a year.
Step 2: Advanced thermal expression
Immediately after eyelid exfoliation, I perform advanced heat expression with LipiFlow (Johnson & Johnson Vision), Systane iLux (Alcon), or TearCare (Sight Sciences). This step warms and melts the meibum so it can be easily expressed from the clogged glands.
Removing the blocked unhealthy oils helps restore healthy tear quality, consistency, and stability. This can be repeated every 6 to 12 months, or individuals can have it done sooner if their glands are prone to clogging.
Step 3: Light-based therapy
I carry out OptiLight (Lumenis) light-based therapy during the particular same visit as thermal expression, plus then continue every two to 4 weeks for a total associated with 4 sessions. OptiLight is the first and only light-based treatment that is FDA approved for dry eye management. It restores the function of the meibomian glands, improves TBUT, and breaks the particular cycle associated with inflammation that characterizes DED.
Figure 3 depicts noninvasive TBUT progress of the patient along with DED over different visits (post-treatment), where significant improvement can be seen.
In patients who have impaired gland function from isotretinoin use, I have seen modest regeneration starting approximately 6 months after treatment, which is remarkable. It’s a relief to have this therapy with regard to isotretinoin patients—without it, the meibomian gland damage will be much more difficult to overcome, and sufferers would be less likely to see improvement.
After the initial four sessions, patients often ask to carry on OptiLight maintenance
classes because they appreciate the effects. My individuals with milder cases do well with 3- to 6-month OptiLight servicing, whereas sufferers with moderate to severe DED often need a lot more frequent treatments.
After these types of treatments, I customize a home routine regarding patients to follow, which frequently complements plus prolongs the particular benefits of the in-office treatments.
A typical dry eye kit may include a reesterified triglyceride omega-3 supplement; a warm compress; a high-quality preservative-free, lipid-based artificial tear; and a lid hygiene product (Avenova, NovaBay Pharmaceuticals).
(As an optional approach, there are even some at-home devices now available intended for patients to use safely and effectively, including NuLids plus iTear neuro-stimulation. )
In addition to evolving both our in-office and at-home protocols, I also share tips regarding cleaner cosmetics, proper contact lens wear, optimal visual ergonomics, healthier diet, moderate exercise, and other lifestyle habits.
Switching skin treatments
It’s important to note that I never tell patients to stop using prescription medications such as isotretinoin. But I do educate them about how the medication is usually affecting their meibomian intrigue and may be contributing to their own dry vision symptoms. We offer to connect with their particular dermatologist and discuss alternatives.
For example , I actually recently had a case where the patient had stopped driving because associated with fluctuating, blurry vision from MGD related to isotretinoin use. I discussed the problem with her prescribing physician, and the particular patient was happy to change skin remedies.
Alternatively, some patients enjoy how their skin looks when they take isotretinoin. Even though they experience discomfort in the eyes, these patients prioritize the aesthetic benefits. If they choose to continue with isotretinoin, We still offer to manage their dry eye symptoms. (Thankfully, isotretinoin is not the lifetime medication; patients are usually prescribed a 6-month course of the drug. )
To cut down on pharmaceuticals that will contribute to dry out eye, dermatologists may offer in-office procedures for acne and rosacea, including chemical peels or even microdermabrasion. Moreover, photobiomodulation may help—in fact, OptiLight has an intense pulsed light handpiece that allows physicians to target the telangiectasia and reduce rosacea inflammation.
DED is definitely such the multifactorial disease that even when optometrists identify major contributors such as acne medicine, we have to check for other factors as well.
I’ve experienced patients along with isotretinoin-driven MGD who spend long hours working on computers, wear face masks, overwear their contact lenses, and take common drying pharmaceuticals like birth control pills, antihistamines, or antidepressants. I educate patients about all these factors and recommend behavioral plus lifestyle changes when possible.
Yet for individuals with pimples, it’s important to let all of them know that they can get clear skin and still have comfortable eyes.
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2 . Gether L, Overgaard LK, Egeberg The, Thyssen JP. Incidence and prevalence associated with rosacea: a systematic review and meta-analysis. Br J Dermatol. 2018; 179(2): 282-289. doi: 10. 1111/bjd. 16481
3. Damiani G, Gironi LC, Grada A, et al. COVID-19 related masks increase severity of each acne (maskne) and rosacea (mask rosacea): multi-center, real-life, telemedical, plus observational prospective study. Dermatol Ther . 2021; 34(2): e14848. doi: 10. 1111/dth. 14848
4. Nickle SB, Nathan Peterson N, Peterson M. Updated physician’s guide to the off-label uses of oral isotretinoin. J Clin Aesthet Dermatol. 2014; 7(4): 22-34.
5. Periman LM, O’Dell LE. When beauty doesn’t blink. Ophthalmology Management. August one, 2016. Accessed July 20, 2022. https://www.ophthalmologymanagement.com/issues/2016/august-2016/when-beauty-doesn-8217;t-blink
6. O’Dell THE, Sullivan AG, Periman LM. If I actually could turn back time. Advanced Ocular Care. November/December 2016. Utilized July twenty, 2022. https://www.dryeyediva.com/_files/ugd/0f73d1_d63272a18a3e4921948cfe31a901c866.pdf