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Yes, it would be reasonable to use a more potent steroid and higher concentration of tacrolimus When treating ILVEN, it is generally preferred to use a low to moderate potency steroid, but in someone that has been resistant to treatment, it is reasonable to intensify treatment to a stronger steroid and tacrolimus. In fact, there are case reports of using the specific combination of fluocinonide and 0.1% tacrolimus in the treatment of ILVEN that has not responded to other treatment (see http://www.ncbi.nlm.nih.gov/pubmed/17241573).
There also has been some use of carbon dioxide laser in the treatment of ILVEN, but it would be reasonable to try the stronger steroid and tacrolimus first.
If I can provide any clarification, please let me know.
The fluocinonide is a 0.05% strength. The dosing frequency is 2-4 times per day, depending upon the severity of the condition and the clinical response. With the severity and persistence of your lesion, your doctor may choose to use the drug more often initially and then decrease the frequency with clinical improvement. The duration would also be dependent upon the clinical response. It is usually better to separate the application of two different topical drugs.
The CO2 laser would typically only be needed or used if it failed to respond to the fluocinonide and tacrolimus. Since the ILVEN is so rare, there are no studies that show the overall outcomes of CO2 laser, but there has been case reports of successful treatment. The CO2 laser is generally very well tolerated. Even the most common side effects of delayed healing and decreased pigmentation are not common. During the healing process, it is common for the area to be reddened, but this will typically resolve with healing. Serious side effects, such as scarring, are very rare.
The combination of fluocinonide and tacromlimus may lead to resolution of the appearance of the ILVEN, as in the article that I referenced above. If it does not adequately resolve, then the CO2 laser can be considered. The studies state that the treatment achieved excellent improvement and resolution of the ILVEN in one case study ( for example, see http://www.ncbi.nlm.nih.gov/pubmed/23692514).
When I cut and paste the URL into a new page, it worked for me. The article reference is J Cosmet Laser Ther 2013 Aug;15(4):242-5. doi: 10.3109/14764172.2013.807115. Epub 2013 Jun 21
In this situation the stronger strength, or 0.1% strength, would be preferred. The fluocinolone acetonide is not the same as fluocinonide and is not as potent, It can be used, just as the mometasone can be used, but only the fluocinonide is more potent than the mometasone.
Any potent steroid can have systemic side effects, although less side effect than taking oral steroids. If the fluocinonide is not available, it is not an option for you. I can only tell you what has been used in clinical studies. If that is not available in your country, then your doctor would need to decide what to use.
It can be used, but would be less potent than a steroid and tacrolimus.
There would likely not be any incremental benefit of adding salicylic acid, but it has not been specifically studied.
It is impossible to know until the clinical response is seen. If there is an excellent response, then either the steroid alone or both drugs can be stopped, as in the above study, but if there is a recurrence, there may need to be intermittent treatment.
ILVEN is rare. I only remember one case in my practice, and if I remember correctly, she only had a modest response to steroids, but also was not bothered by it, so was not interested in seeking more aggressive care. It is because it is so rare that the medical literature is primarily composed of case reports, rather than studies of multiple patients - even in research facilities, they do not accumulate any significant numbers of patients.
No, there is no evidence untreated lesions on the back would be an issue for any improvement that is achieved on the forearm.