Compliance raises very specific questions in dermatology related to the frequent use of local treatments: creams or ointments, including topical corticosteroids. The adherence in dermatology is a complex issue. It is difficult to quantify objectively because of the patient subjectivity, the constant adaptation to changes in the course of the disease, and due to the lack of adapted device. Moreover poor compliance may be related to topical corticosteroid phobia, defined as a fear vis-à-vis the topical corticosteroids, rational or not. The topical corticosteroid phobia is very common in the management of chronic inflammatory skin diseases especially in atopic dermatitis.
The most common side effect of topical corticosteroid use is skin atrophy. All topical steroids can induce atrophy, but higher potency steroids, occlusion, thinner skin, and older patient age increase the risk. The face, the backs of the hands, and intertriginous areas are particularly susceptible. Resolution often occurs after discontinuing use of these agents, but it may take months. Concurrent use of topical tretinoin (Retin-A) % may reduce the incidence of atrophy from chronic steroid applications. 30 Other side effects from topical steroids include permanent dermal atrophy, telangiectasia, and striae.
An Alternative Treatment
Decreased tear meniscus in dry eye.
As an alternative to steroids—or as an adjunctive therapy—topical cyclosporine can also be used to control inflammation in dry eye disease. While cyclosporine does not demonstrate the rapid anti-inflammatory effect of steroids, it carries fewer risks and is safe for long-term use.
Because of their complementary efficacy and safety profiles, many practitioners often begin dry eye treatment by prescribing both topical steroids and cyclosporine. Following the recommendation of the Asclepius Panel, the use of combination therapy is instituted with the topical corticosteroid, Lotemax (loteprednol etabonate ophthalmic suspension %, Bausch + Lomb) and Restasis (cyclosporine ophthalmic emulsion %, Allergan). 24 The Asclepius Panel recommends practitioners begin early treatment with an anti-inflammatory agent (such as Lotemax) four times a day to improve symptoms and to prevent disease progression. After two weeks, the frequency of the corticosteroid is reduced to twice daily and supplemented with Restasis twice a day. Treatment with loteprednol was stopped after day 60, while cyclosporine treatment is continued.