Breaking Down MGD Treatments Through the Lens of Sebaceous Gland Dysfunction

Treatments for meibomian gland dysfunction (MGD) are similar to those for sebaceous gland disorders and aim to modify sebum production, enhance sebum flow in cases of obstruction, alter the skin microbiome, and reduce inflammation. Analyzing MGD treatments through the lens of sebaceous gland disorders can provide valuable insights. Part one of this two-part series focused on the anatomy and physiology of sebaceous and meibomian glands and their role in MGD. This second and final part discusses treatments for disorders of sebaceous and meibomian glands.

PHARMACOLOGIC MANAGEMENT

Some sebaceous gland disorders involve significant inflammation, altered sebum production, and impaired skin-barrier function. Common treatments include topical and oral antiinflammatory agents such as corticosteroids and tetracyclines, which help reduce inflammation and manage symptoms. Medications aimed at regulating sebum production and addressing sebaceous gland inflammation, such as retinoids and antibiotics, are central to managing disorders such as acne and rosacea.

Similar to its role in ocular surface disease, inflammation is a contributing factor in meibomitis and blepharitis, both of which can lead to MGD.¹ Topical antiinflammatory treatments such as cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) cyclosporine ophthalmic solution 0.9% (Cequa, Sun Pharma), cyclosporine ophthalmic solution 0.1% (Vevye, Harrow) and lifitegrast ophthalmic solution 5% (Xiidra, Bausch + Lomb), along with antibiotics such as topical azithromycin and oral doxycycline or azithromycin, can help reduce inflammation in patients with MGD and blepharitis.^2,3 Topical corticosteroids may also be beneficial for managing dry eye flares associated with meibomitis. Additionally, products such as perfluorohexyloctane ophthalmic solution (Miebo, Bausch + Lomb) can help stabilize the tear film and provide symptomatic relief for patients with evaporative dry eye.

MECHANICAL THERAPIES

Mechanical treatments, such as microdermabrasion, chemical peels, light or laser therapy, microneedling, and comedo extraction, are used to physically clear obstructions in sebaceous glands, facilitating better sebum flow and reducing symptoms. Other mechanical therapies, such as warm compresses, eyelid massages, and gland expression help clear blockages and stimulate meibomian gland function. Meibomian gland probing can also penetrate through scar tissue and keratinize the orifice or ductule. Devices such as the LipiFlow Thermal Pulsation System (Johnson & Johnson Vision) and the TearCare System (Sight Sciences), which combine heat and pressure to clear obstructed meibum, exemplify how mechanical therapies can enhance meibomian gland function by improving flow and removing obstruction. The Eye Lipid Mobilizer (Eyedetec Medical) is a device undergoing FDA approval that uses heat and vibration for the treatment of MGD to improve on the traditional warm compress.

LIGHT AND LASER THERAPIES

Intense pulsed light (IPL) therapy is beneficial for MGD, as it has been shown to effectively reduce inflammation and control sebaceous gland activity in conditions such as acne and rosacea.^4,5 Similarly, red and blue light therapy may be used in cases of acne to alter sebum secretion, reduce bacterial overload, and alleviate inflammation.6 Low-level light therapy, or photobiomodulation, can also be applied to stimulate cellular, mitochondrial, and meibomian gland function, offering another avenue for improving meibomian gland health.^7,8

KERATINIZATION

Some sebaceous gland disorders involve excessive keratinization, which leads to the formation of plugs that impair gland function and affect skin appearance. This buildup can block sebaceous glands, resulting in inflammation and exacerbating symptoms. For instance, in acne, keratin plaques in the sebum create an environment conducive to bacterial growth. In seborrheic dermatitis, keratinization leads to flaky patches and irritation. In hyperkeratotic skin disorders, dermatologists often use keratolytic agents to reduce epithelial desquamation, break crosslinked disulfide bonds in sebum, and soften sebum secretions.

Reducing keratinization in the meibomian glands can be beneficial for MGD. Emerging treatments, such as selenium sulfide ointment (AZR-MD-001, Azura Ophthalmics), aim to reduce keratinization, break disulfide bonds, and increase meibum secretion volume, showing promise in improving meibomian gland function and meibum quality.^9,10 This treatment has also demonstrated effectiveness in seborrheic blepharitis.^11-13 By removing obstructions and lowering the melting point of meibum, it can reduce viscosity and allow body heat to effectively melt waxy secretions. Furthermore, this therapy may enhance the efficacy of warm compresses, or even eliminate the need for them entirely, in cases of advanced hyperkeratinization, where disulfide bonds within the meibum significantly elevate its melting point. Such a treatment could restore gland function, improve tear film stability, reduce dryness, enhance fluctuating vision, and improve contact lens tolerance.

Case Example

A patient presented with no meibomian glands yielding a liquid secretion due to hyperkeratinization of the meibomian gland orifices and thickened meibum secretions, likely from disulfide bond formation between keratin proteins within the meibum and keratin aggregate formation. Meibography (Figure 1) revealed periductal fibrosis and gland narrowing due to chronic inflammation, fibroblast activation, gland remodeling, and mechanical compression. The patient also exhibited a 100% incomplete blink rate and reduced lipid layer thickness (Figure 2). After meibomian gland probing (Figure 3), the glands began to express, but only with significant pressure applied to the eyelids. This patient would likely benefit tremendously from selenium sulfide ophthalmic ointment, once available.

ADJUNCTIVE AND SUPPORTIVE THERAPIES

In addition to primary treatments, supportive measures, such as proper skin care and lifestyle changes, are important in managing sebaceous gland disorders.

Incorporating therapies such as omega-3 supplementation and lid hygiene products may enhance overall gland health and alleviate symptoms in MGD.^14,15 Omega-3 fatty acids have been shown to improve meibum quality and tear film stability. Additionally, blepharoexfoliation procedures, eyelid cleansing products, and hypochlorous acid sprays help reduce microbial load, potentially mitigating inflammation and obstruction and improving meibum quality.^2,16 Newly available non–omega-3 supplement Blink NutriTears (Bausch + Lomb) demonstrates improvements in various dry eye metrics related to MGD, including tear breakup time, tear osmolarity, ocular surface staining, and MMP-9 level.¹⁷ This supplement contains lutein, zeaxanthin, curcumin, and vitamin D3 and likely exerts its effects through antiinflammatory and antioxidant properties.

OFF-LABEL TREATMENTS

Off-label and emerging treatments, including novel antiparasitic agents and systemic therapies, are under investigation for managing sebaceous gland disorders.

Similarly, exploring off-label uses for medications such as lotilaner (Xdemvy, Tarsus Pharmaceuticals) to treat MGD associated with Demodex blepharitis by targeting presumed Demodex brevis obstruction in the meibomian glands and associated inflammation, as well as intranasal varenicline (Tyrvaya, Viatris) given the innervation of the meibomian glands by the trigeminal nerve, could provide new avenues for enhancing meibomian gland function and improving meibum production. In challenging cases, investigating additional therapeutic options with plausible mechanisms may also be beneficial.

OPTIMIZING THE OVERLAP

MGD and sebaceous gland dysfunction share similar underlying pathophysiology and significant overlap in therapeutic approaches. Examining treatment strategies for sebaceous gland disorders offers valuable insights for managing MGD. Integrating these insights into clinical practice can enhance management strategies and improve patient outcomes.