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Juliana Wons,1,* Nadine Mihic,2,* Isabel B Pfister,1 Stefano Anastasi,1 Justus G Garweg,1,2 Markus Halberstadt3 1Swiss Eye Institute, Rotkreuz, and Berner Augenklinik am Lindenhofspital, Bern, Switzerland; 2Department of Ophthalmology, University of Bern, Bern, Switzerland; 3Private Practice for Ophthalmology, Flums, Switzerland*These authors contributed equally to this workCorrespondence: Markus HalberstadtAugenärzte Flums, Marktstrasse 21, Flums, 8890, SwitzerlandEmail augenaerzte-flums@hin.chPurpose: This study aimed to compare the effect of trabectome surgery in patients with and without intolerance to their medication and with preoperatively sufficiently controlled, insufficiently controlled, and uncontrolled intraocular pressure (IOP) on the surgical outcome.Patients and Methods: A total of 155 eyes (133 patients) with different forms of open angle glaucoma with or without intolerance to their glaucoma medication undergoing trabectome surgery alone (AIT) or combined with phacoemulsification (phaco-AIT) were included in this retrospective monocentric study. Patients were corresponding to IOP ≤ 18 mmHg (controlled but glaucoma progression or intolerance, group 1), 19– 26 mmHg (insufficiently controlled, group 2), and ≥ 26 mmHg (not controlled, group 3), respectively. Pre- and postoperative IOP and the number of IOP-lowering medications were registered over 12 months. Surgical success was defined as a postoperative IOP of ≤ 18mmHg and/or reduction of the topical treatment demand after 1 year.Results: Of the 155 included eyes, 79 received AIT and 76 received phaco-AIT. Sixty-nine eyes had a preoperatively sufficiently controlled IOP, 63 had an insufficiently controlled IOP, and 23 had an uncontrolled IOP. In all groups, the IOP significantly dropped by 6 and 12 months after surgery (p < 0.001). Surgical success war similar in all groups [47.8% (group 1), 38.1 (group 2) and 34.8% (group 3); p= 0.47]. The effect of AIT on IOP and glaucoma medication independent of intolerance to the anti-glaucoma medication and type of surgery (AIT/phaco-AIT).Conclusion: Independently of the preoperative IOP, a satisfying surgical success was achieved using AIT. In instances that do not qualify for filtrating surgery, trabectome surgery alone or in combination with phacoemulsification thus represents a safe and effective minimally invasive glaucoma surgery technique regardless of an intolerance to the topical medication.Keywords: glaucoma, ab interno trabeculectomy, trabectome, minimally-invasive glaucoma surgery, minimally-invasive glaucoma surgery, MIGS

There exist limited strategies to address the issue of topical medication without prescription (MWP) use.A survey with pre-coded questionnaires was conducted with 210 patients following up in the dermatology clinic of a tertiary care center. The knowledge and attitude scores were regressed against demographics and exploratory practice questions, and latent class analysis was carried out to check any particular set of characteristics associated with study subpopulations.Forty-seven (22%) participants were found using topical antimicrobial containing MWP. Participants with good knowledge score had 3.41 (95% C.I. = 1.68-7.33), 2.99 (1.37-6.73), and 2.49 (1.26-5.15) times association with opting of distance as the prime reason for availing topical MWP, habit of always reading the accompanying drug leaflet, and understanding that OTC topical medication may change the effect of the already prescribed drugs. Participants with good attitude score showed 2.76 (1.50-5.13) times association with limiting the use of steroid containing topical MWP. Latent class analysis identified one subset of participants having lesser knowledge and attitude scores and quoted financial reasons for the procurement of MWP; however, it was found to have greater income as compared to remaining participants.The strategy to identify the target patient audience so as to deliver patient education intervention programs, regarding safe and effective use of MWP was built.

Objective The study compares low-level laser therapy with topical medications for treating aphthous ulcers. Methods A search of articles in this systematic review was completed in six databases. Treatment and comparative groups comprised of patients subjected to laser therapy and topical medications, respectively. Two different treatment outcomes were considered; pain and size of the lesion. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. Results From 109 articles, five randomized control trials fulfilled the selection criteria. The overall sample comprised of 98 males and 232 females, with a mean age of 32.4 years. The laser therapies in each included study had different active media and varying wavelengths. Topical medication used in the comparative group were triamcinolone acetonide, amlexanox, granofurin, and solcoseryl. Findings showed that patients who reported lower pain and decreased aphthous ulcer lesions were more in the laser therapy group than in the topical medication group. Conclusion Low-level laser therapy was better in treating aphthous ulcer lesions in comparison to topical medications, and all laser wavelengths in the included reports were seen to be effective. However, the results should be interpreted with caution, because no study demonstrated low-risk of bias in all the assessed domains.

Enzo Berardesca,1 Adriana Bonfigli,2 Bernard Cribier,3 Frederic Flament,4 Marco Vicic,4 Delphine Kerob,5 Jerry Tan6 1Phillip Frost Department of Dermatology, University of Miami, Miami, FL, USA; 2ISPE, Milano, Italy; 3Clinique Dermatologique, University Hospital, Strasbourg, France; 4L’Oréal Research and Innovation, Chevilly-Larue, France; 5Laboratoires Vichy International, Levallois-Perret, France; 6Western University, Department of Medicine and Windsor Clinical Research Inc, Windsor, ON, CanadaCorrespondence: Enzo BerardescaPhillip Frost Department of Dermatology, University of Miami, Miami, FL, USATel +1 393486962500Email berardesca@berardesca.itObjective: This study assessed the efficacy and tolerability of M89 in patients with rosacea associated with erythema and sensitive skin.Methods: Intra-individual study in a split-face design comparing after 30 days M89 twice daily and usual skin care in 20 adult subjects with rosacea and sensitive skin. M89 contains 89% Vichy volcanic mineralizing water (VVMW) and 0.4% hyaluronic acid. It is hypoallergenic and contains no perfume and this convenes in rosacea. Contained minerals reinforce the natural defences of the skin in restoring the natural skin barrier, stimulating antioxidant activity and reducing inflammation, commonly observed in subjects with rosacea. Clinical evaluations included assessment of erythema, desquamation, papules and pustules, skin tightness, dryness, burning sensation, itching, stinging and stinging test as well as local tolerability. Instrumental evaluations included skin hydration and TEWL. Subject satisfaction was assessed at Days 15 and 30. Demodex density was assessed at Day 30.Results: A significant superiority of M89 over the standard skin care was observed for erythema, skin tightness and dryness (all P≤ 0.05) as early as Day 15, the skin stinging test was significantly in favour of M89 (P< 0.05 at Day 15 and P< 0.01 at Day 30) and for skin hydration (P< 0.0001) at Day 15 and 30 with no difference in mean Demodex density between M89 and usual skin care after 30 days. Tolerance was excellent and subject satisfaction very high.Conclusion: Study results concerning M89 are encouraging for its use either alone or as an adjuvant daily skin care to topical medication in patients with persistent centrofacial erythema of rosacea with no more than 3 papules and pustules.Keywords: rosacea, sensitive skin, Vichy volcanic mineralizing water, M89, split face

Halobetasol propionate and tazarotene lotion 0.01%/0.045% (HP/TAZ) is a topical medication approved for the treatment of plaque psoriasis in adults. As a treatment modality, HP/TAZ has a combinatory therapeutic effect because it contains both a corticosteroid (HP) and a retinoid (TAZ) component. Here, we review the important clinical efficacy and safety data derived from pivotal clinical trials for HP/TAZ in the treatment of plaque psoriasis. We also discuss the mechanism of action, dosage guidelines, pharmacokinetics/pharmacodynamics, and clinical considerations for HP/TAZ, including why HP/TAZ should be avoided in pregnant patients.

Purpose Treatment non-adherence leads to negative therapeutic outcomes and financial burdens on the healthcare system. This study aims to compare the mean adherence scores among patients with five dermatological diseases and four treatment types and to identify the associated patient-related factors. Patients and methods This is a cross-sectional study conducted from January 2019 to August 2019. The questionnaire was distributed among patients attending the outpatient dermatology clinic at King Khalid University Hospital, Riyadh, Saudi Arabia. It included 2330 patients who were over 16 years old and diagnosed with any of the five dermatological diseases (psoriasis, chronic dermatitis, acne vulgaris, hair growth disorders, and vitiligo). The 12-item Medication Adherence Scale was used to quantify the mean adherence score. Results Patients with psoriasis or chronic dermatitis were less adherent to treatments than patients with acne vulgaris, hair growth disorder, or vitiligo. Oral treatment and phototherapy had higher mean adherence scores than injection or topical treatment. High adherence was found in female, single patients; those who did not feel stigmatized from using treatment; those who did not have bad experience with the treatment; those who did not suffer from forgetfulness; those who connected receiving treatment with a habit; those who did not lack treatment responsiveness; those who had an excellent relationship with a dermatologist; and patients with a lesion in an exposed area. Stepwise multiple linear regression was also used to identify the independent variables related to adherence score. Conclusion Psoriasis and chronic dermatitis patients had the lowest mean adherence scores. Patient who were on oral medication had the highest adherence score, while those on topical medication had the lowest score. The thoughtful consideration of factors associated with high adherence is important for optimal therapeutic outcomes.

Purpose Long-term treatment adherence for a chronic asymptomatic condition is a demanding task for many patients. Treating progressive glaucoma can also be confounding for physicians, particularly when management relies on assumption of adherence. This study investigated associations between self-reported adherence and frequency of medication changes due to glaucoma progression. Methods A total of 128 participants with primary open angle glaucoma were recruited from glaucoma clinics in Flinders Eye Center, South Australia, and completed confidential questionnaires. Information was obtained regarding beliefs about glaucoma and their treatment. Adherence was assessed using the four-item Morisky, Green and Levine Medication Adherence Questionnaire (MGL). Medical records were analyzed for the number of medication changes, due to glaucoma progression. Results Adherence to topical glaucoma medication was categorized as 'high' in 41.4% (Morisky, Green and Levine (MGL). Data were analyzed for behaviors affecting adherence, history of adherence, and reasons for changed adherence. Chi-squared test demonstrated that there was no significant association noted between adherence and changes in medication regime (χ2 (2,128)=0.968, P=0.915); however, a significantly lower adherence was detected if participants had difficulties with their drop regime (χ2 (2,128)=7.24, P=0.027) or had help with drop insertion (χ2 (1,128)=9.77, P=0.008). Conclusion This study revealed a higher rate of non-adherence than has previously been demonstrated in other studies. This may be attributed to the unique design of the confidential questionnaire and the independent and sympathetic questioning techniques used. Further work to develop a specific glaucoma medication adherence questionnaire would be valuable to enhance glaucoma management.

Introduction: Fractional lasers and microneedling devices are increasingly used with topical drugs to treat various conditions, including alopecia, as they grant access to dermal structures such as hair follicles and cutaneous vasculature. Objective: To perform a comprehensive review on transcutaneous drug delivery for the management of alopecia. Methods: PubMed, Embase, and Ovid Medline databases were searched using terms including: alopecia, microneedling, lasers, androgenetic alopecia (AGA), alopecia areata (AA), drug delivery. Articles were examined for inclusion criteria: diagnosis of alopecia regardless of type, use of fractional laser or microneedling devices, and subsequent administration of topical medication. Results: 8 studies, 6 prospective clinical trials and 2 case series, examining either AA or AGA were identified. For AA, five studies examined microneedling together with topical triamcinolone in three of these, while two studies used photodynamic therapy. Regarding AGA, two studies used topical minoxidil plus microneedling, and one examined topical finasteride with fractional erbium glass laser. Improvement was seen in 6 of the 8 studies. Discussion: Transcutaneous drug delivery via fractional laser and microneedling is a promising modality with preliminary evidence for increased hair regrowth over topical therapy alone. Further studies are needed to elucidate treatment parameters and appropriate device selection for drug delivery.

While topical medications remain the cornerstone of the psoriasis treatment paradigm, they also come with the risk of multiple side effects. An alternative topical treatment option, calcipotriene or calcipotriol, is a vitamin D derivative that is thought to work by inhibiting keratinocyte proliferation and enhancing keratinocyte differentiation. Multiple studies have demonstrated its efficacy and safety in improving psoriasis when used in combination with topical corticosteroids. Given the effectiveness and side effect profile seen with this combination of topical steroid and calcipotriene, the US Food and Drug Administration approved a calcipotriene/betamethasone dipropionate product for use in psoriasis patients over the age of 12 in 2006. Our paper seeks to review clinical trial evidence of this combination medication and its use in the treatment of psoriasis vulgaris. While assessment of available evidence indicates that the topical medication is both safe and effective for the treatment of psoriasis vulgaris, addressing limitations of what is known, such as tolerability, adherence, and patient preference, of this combination drug in future high-impact studies is needed.

Rosacea is a chronic skin condition characterized by transient and persistent erythema of the central face. The symptom of persistent erythema can be particularly frustrating for both patients and physicians as it is difficult to treat. Areas covered: Current treatment options for the treatment of rosacea include metronidazole, azelaic acid, sodium sulfacetamide-sulfur, and brimonidine. Until recently, brimonidine gel was the only option approved specifically for the treatment of facial erythema. However, oxymetazoline hydrochloride 1% cream is a newly FDA approved topical medication for adult rosacea patients. A primarily alpha-1a agonist, oxymetazoline hydrochloride (HCl) is thought to diminish erythema through vasoconstriction. Our paper seeks to evaluate evidence for topical oxymetazoline HCl with respect to its efficacy and safety for its approved indication of treating the persistent erythema associated with rosacea. Expert commentary: While assessment of available clinical trial data indicates that the medication is as effective as other available treatment for controlling rosacea-associated erythema with minimal risk of adverse effects, studies of long-term duration and direct comparison will be necessary to establish its place in treatment guidelines and clinical practice. As further evidence becomes available, the real-world clinical potential of topical oxymetazoline cream will become clearer.

The incidence of adult acne is increasing worldwide. Despite clinical overlap with conventional acne, it has distinct features. Areas covered: A literature search of English-language review articles, randomized control studies and retrospective studies conducted over the past 30 years was performed using PubMed and Google Scholar. Search terms included acne, adult, topical medication, oral medication and skin of color. We highlight important clinical features and treatment modalities pertinent to the evaluation and management of adult acne. Given the relative dearth of literature detailing treatment options specific to adult acne, we offer expert opinion regarding management of the condition especially in special populations such as skin of color and pregnancy. Expert Opinion: It is unclear whether adult acne represents a distinct entity or a continuum of adolescent disease. Providers may opt to use topical medication as first-line, but should have a low threshold for switching to systemic therapy given the magnitude of psychosocial and emotional burden associated with the condition.

Introduction: Glaucoma is principally a disease that affects the elderly population. Although the same treatments are available for the elderly as the young, there are special considerations that have to be made for older patients.Areas covered: This review will discuss the current management options for glaucoma highlighting the factors that particularly apply to the elderly population. The published literature on treatments for glaucoma with the terms ‘age’, ‘aging’, ‘older’ and ‘elderly’ were searched using PubMed.Expert commentary: Topical medication may not be appropriate for all elderly patients due to particular side-effects and other intraocular pressure lowering treatments, including cataract surgery should be considered for these patients. Low target intraocular pressures are not always required in this age group and over-treatment of elderly patients should be avoided.

To present the management of bilateral congenital superior fornicial prolapse and provide its up-to-date review of literature.We present the management of congenital bilateral superior fornicial prolapse treated conservatively with topical antibiotics, lubricants and hypertonic saline. One-week, 2-weeks and 1-month follow-up is presented. Results were assessed in terms of reduction of chemosis and eyelid opening. Updated current English peer-reviewed literature was researched.The superior fornicial prolapse resolved with conservative management within 10 days, resulting in normal eyelid motility at the end of 1 month. At present 61 cases have been reported in English peer-reviewed journals. The proposed etiology is varied. Conservative management with topical medication provides relief.Congenital fornicial prolapse is a rare condition. Topical medication provides complete resolution of prolapse. Authors emphasise the need for awareness of condition among ophthalmologists and neonatologists, because of its gruesome appearance.

The combination of excimer laser and topical treatment has not been studied in clinical trials. This within-patient comparison study evaluates the response rates of plaque-type psoriasis after treatment with topical only (dithranol or calcipotriol), laser only, and combination therapy with topical medication and laser.A total of 61 patients with psoriatic plaques located at symmetric body areas (PASI ≥ 6) were screened, 59 were enrolled, 54 completed treatment and 45 completed the 6 months follow-up. Treatments with the excimer laser were performed twice weekly until resolution or a maximum of 15 treatments. Each ointment was applied on one of the test lesions, which had to be at least 10 cm apart from each other. Efficacy was rated with a modified PASI score.At the end of the treatment phase only one patient in both topical therapy regimens met the criteria of partial clearance (modified PASI ≤ 2). The combined therapies resulted in 23 cases of partial clearance in both treatment arms. Four areas treated with calcipotriol, respectively six areas treated with dithranol resulted in total clearance at the end of the treatment phase. The average reduction of modified PASI scores was higher in combination than in topical treatment alone (49.8% calcipotriol + excimer versus 22.9% calcipotriol, 49.7% dithranol + excimer versus 26.8% dithranol). After six months there was a total clearance of 30.5% dithranol + excimer.Treatment of plaque-type psoriasis with laser in combination with topical treatment is a safe and effective therapy. The best long-term results can be obtained by the application of dithranol and excimer laser.

Patients may be subject to a variety of different topical medications when undergoing treatment for ocular disease. Preservatives are added to multidose medication bottles to inhibit microbial contamination. An assortment of different preservative formulations has been used in ophthalmic medicines and many of these preservatives have been linked to unwanted ocular surface side effects. Benzalkonium chloride in particular has been linked to a number of different adverse effects, such as disruption of the tear film as well as damage to ocular surface epithelial cells. As a result, the manufacturers of ocular medications have developed innovative new preservative systems in an attempt to limit these toxic side effects. This article reviews the different ophthalmic preservative formulations, their benefits, detriments, mechanisms of action and historical aspects. Future prospects and clinical objectives with regard to ophthalmic preservatives are also discussed.

Objectives: Our aim was to assess basic drug information given by physicians when prescribing new topical medication and to compare this with outpatients’ subsequent knowledge. Methods: Basic drug information was noted during consultations. Subsequently, patients answered a questionnaire regarding diagnosis, treatment, and satisfaction with the consultation. Neither physicians nor patients were informed about the specific study objective. Results: A total of 17 patients were included. Information provided during the consultations versus patients’ knowledge after 2 weeks was: diagnosis (65% vs 41%), dosage by number (100% vs 71%), dosage by quantity (18% vs 12%), and treatment duration (65% vs 35%). None was informed about adverse effects and 47% were fully satisfied with the consultation. Conclusions: Basic drug information provided by physicians was deficient and patients’ knowledge was even lower.

OBJECTIVE To determine the relative cost effectiveness of long term rotational antibiotics and isotretinoin for moderate/severe acne over a 5-year period.DESIGN Retrospective study of pairs of patients matched for age, sex, acne severity and duration of acne.SETTING Teaching hospital dermatology out-patient department.SUBJECTS A group of 100 patients under long-term assessment for relapse rate following isotretinoin treatment were matched against a group of 100 similar patients who were given long-term antibiotics.MAIN OUTCOME MEASURE Prescribing costs and costs of out-patient visits. Costings were derived for dispensing from hospital (isotretinoin and antibiotics) or the community (antibiotics).RESULTS The mean duration of courses of isotretinoin was 19 weeks compared with 64.4 months for courses of rotational antibiotics and topical medication. Isotretinoin produced more than 60% improvement in 88% of patients, while only one patient in the antibiotic group improved by more than 50% of the initial acne ...

Barbara Cvenkel,1 Špela Štunf,1 Irena Srebotnik Kirbiš,2 Margareta Strojan Fležar2 1Department of Ophthalmology, University Medical Center Ljubljana, Ljubljana, Slovenia; 2Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Purpose: The aim of this study was to assess signs and symptoms of ocular surface disease (OSD) and the cytomorphological changes of ocular surface in glaucoma patients using preserved antiglaucoma drops.Methods: In this cross-sectional study, 109 participants (79 patients with topical medication and 30 untreated controls) completed the Ocular Surface Diseases Index (OSDI) questionnaire and underwent an ophthalmic examination, including Schirmer test, tear film breakup time (TBUT), and fluorescein staining. Conjunctival specimens were collected by impression cytology and analyzed by light microscopy using Nelson’s grading scheme (grades 0–3). This classification is based on the nucleus-to-cytoplasm ratios of epithelial cells and the numbers of goblet cells, with grade 2 considered abnormal.Results: The medication group had significantly shorter TBUT (median [interquartile range]: 6.0seconds [5.0–8.0 seconds] vs 9.5seconds [6.0–12.3 seconds]; P

Glaucoma is a chronic, progressive disease in which retinal ganglion cells disappear and subsequent, gradual reductions in the visual field ensues. Glaucoma eye drops have hypotensive effects and like all other medications are associated with adverse effects. Adverse reactions may either result from the main agent or from preservatives used in the drug vehicle. The preservative benzalkonium chloride, is one such compound that causes frequent adverse reactions such as superficial punctate keratitis, corneal erosion, conjunctival allergy, and conjunctival injection. Adverse reactions related to main hypotensive agents have been divided into those affecting the eye and those affecting the entire body. In particular, β-blockers frequently cause systematic adverse reactions, including bradycardia, decrease in blood pressure, irregular pulse and asthma attacks. Prostaglandin analogs have distinctive local adverse reactions, including eyelash bristling/lengthening, eyelid pigmentation, iris pigmentation, and upper eyelid deepening. No systemic adverse reactions have been linked to prostaglandin analog eye drop usage. These adverse reactions may be minimized when they are detected early and prevented by reducing the number of different eye drops used (via fixed combination eye drops), reducing the number of times eye drops are administered, using benzalkonium chloride-free eye drops, using lower concentration eye drops, and providing proper drop instillation training. Additionally, a one-time topical medication can be given to patients to allow observation of any adverse reactions, thereafter the preparation of a topical medication with the fewest known adverse reactions can be prescribed. This does require precise patient monitoring and inquiries about patient symptoms following medication use.

The formulation of topical medication bases must inevitably respond to restrictions imposed by a number or physical properties of the medication itself (solubility, pH stability, ionic activity, etc.) as well as to various auxiliary effects desired, such as skin pemeability or non-permeability, resistance to wash-off or ease of wash-off, speed of release of the drug, etc. All such factors determine the “formulation environment” to be provided for the active ingredient, in which it must then be tested for shelf-life stability, pharmacologic activity and safety.Once the basic requirements have been determined for the formulation, it becomes relatively simple to set a “formulation profile” for the product whether it shall be an anhydrous ointment or W/O or O/Wemulsion; whether encapsulation or other techniques are required to provide “timed release” of the active ingredient(s); the type of preservative required; to what degree side-effects of the drug can be altered by various formulation techniques;...

Only a complete approach can be expected to yield successful results in the treatment of dermatologic disorders. Requisites are definitive diagnosis if possible, adaptation of the mode of therapy to the patient's way of life, careful selection of remedies, and thorough instruction of the patient regarding their application and removal as well as what he can and cannot do during the treatment period. An essential and often overlooked component of therapy is the choice of an appropriate vehicle for topical medication.