Periocular pigmentation associated with use of travoprost for the treatment of alopecia areata of the eyelashes

Prostaglandin analogues are intraocular pressure (IOP)- lowering drugs for use in patients with glaucoma and ocular hypertension. Travoprost (AL-6221) (TravatanTM, Alcon, Ft Worth, TX, USA), a PGF2a analogue, is an isopropyl ester of the more active enantiomer(+) of fluprostenol, a selective FP prostanoid receptor agonist.1 It is structurally similar to other prostaglandin F2a analogues such as latanoprost. Since the introduction of prostaglandin analogues in 1996, several adverse effects have been reported, includ- ing increased eyelash growth, darkening of the iris and periocular skin colour change.2 Travoprost induces growth of lashes and ancillary hairs around the eyelids. Manifestations include greater thick- ness and length of lashes, additional lash rows, and con- version of vellus to terminal hairs in canthal areas as well as in regions adjacent to lash rows. In conjunction with increased growth, increased pigmentation occurs. Vellus hairs of the lower eyelids also undergo increased growth and pigmentation. Eyelash hypertrichosis has recently been reported in 75% of patients in clinical trials evaluating efficacy of the PGF2a analogue travoprost in the treatment of ocularhypertension.3 Prostaglandin receptors are present in the dermal papilla and in the outer root sheath of the hair follicle and appear to be involved in the development and regrowth of the hair follicle in mice. Prostaglandin ana- logues are believed to prolong the anagen phase of eyelashes.4 Experimental studies indicate that hair growth stimulation by minoxidil might also be mediated by prostaglandin production.5 Travoprost has therefore been proposed as a possible treatment for alopecia areata involving the eyelashes. We report three cases of periocu- lar skin pigmentation, which developed during treatment with topical travoprost for alopecia areata involving the eyelashes.