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Ask Dr. D. Love Your Own Question
Dr. D. Love
Dr. D. Love, Doctor
Category: Dermatology
Satisfied Customers: 17529
Experience:  Family Physician for 10 years; Hospital Medical Director for 10 years.
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I've got ilven since birth on the dorsilateral aspect of my

Customer Question

hello Doc, i've got ilven since birth on the dorsilateral aspect of my left fore arm and over the left scapula region and mid-back. Back in my college, our head of the derma prescribed mometasone and tacrolimus 0.03%. We also tried calcipotriol but i developed severe allergy to that and discontinued its use. These days the nevus is becoming more pruritic and i'm thinking to go with more potent steroid like fluocinonide and tacrolimus 0.1%. May i know what'd your suggestion be on this? Thank you dr
Submitted: 1 year ago.
Category: Dermatology
Expert:  Dr. D. Love replied 1 year ago.

Hello from JustAnswer.

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.

Customer: replied 1 year ago.
Okay, what concentration of fluocinonide would be best to use? Also can they be applied simultaneously or they need to be applied with few hours apart? Also how many times a day can they be applied and how long can i use fluocinonide for? Thank you.
Customer: replied 1 year ago.
Here's the picture of my ilven, doctor
Expert:  Dr. D. Love replied 1 year ago.

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.

Customer: replied 1 year ago.
Okay, when the inlammation subsides can CO2 laser be used on it. Kindly brief me about the laser procedure, it's outcome and any possible adverse effects. Thank you.
Expert:  Dr. D. Love replied 1 year ago.

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.

Customer: replied 1 year ago.
Okay doctor. What do you exactly mean by 'if it fails to respond to topical steroids' because the lesion never completely goes off. It responded to steroids when its inflammed, but once the inflammation subsides, the main lesion is still there on my hand. I want to get rid off it doctor. Please elaborate.
Customer: replied 1 year ago.
Also what do you mean when you said that there had been reports of successful treatment with laser? Did the skin become completely normal in those cases, as clean as unaffected area?
Expert:  Dr. D. Love replied 1 year ago.

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).

Customer: replied 1 year ago.
Doctor, the link says the page doesn't exist.
Expert:  Dr. D. Love replied 1 year ago.

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

Customer: replied 1 year ago.
Doctor, in India fluocinonide is available as 0.025%/1gm and 0.025%/1gm and 0.1%/15gm. What'd be the best strength? Also is the drug fluocinolone acetate same as fluocinonide? I know it's a derivative of fluocinolone but can it be applied?
Expert:  Dr. D. Love replied 1 year ago.

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.

Customer: replied 1 year ago.
Doctor, wouldn't there be systemic side effects of fluocionide?
Customer: replied 1 year ago.
only fluocinolone acetonide is available in India.
Expert:  Dr. D. Love replied 1 year ago.

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.

Customer: replied 1 year ago.
Okay, can the combination of salicylic acid be used along with a steroid?
Expert:  Dr. D. Love replied 1 year ago.

It can be used, but would be less potent than a steroid and tacrolimus.

Customer: replied 1 year ago.
No doctor, i was asking if it could be used with steroid and tacrolimus. Would there be any additional benefit with salicylic acid?
Expert:  Dr. D. Love replied 1 year ago.

There would likely not be any incremental benefit of adding salicylic acid, but it has not been specifically studied.

Customer: replied 1 year ago.
Okay doctor, if there's an adequate response, can the steroid be withdrawn and continue using tacrolimus? I don't understand one thing about ilven that whether people with ilven have to apply topical agents everyday until their death or just when they've severe pruritus. Please clarify if i have to use tacrolimus for the rest of my life.
Expert:  Dr. D. Love replied 1 year ago.

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.

Customer: replied 1 year ago.
Okay doctor, How many ilven cases have you seen in your practice and how many of them resolved by more than 50% of lesion?
Expert:  Dr. D. Love replied 1 year ago.

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.

Customer: replied 1 year ago.
Okay doctor, can unresolved lesions at other site cause a recurrence at a resolved site? I mean that i've got these lesions on fore hand, scapular and mid back regions, but i only treat the one on my forearm and not at all bothered about the one's on my back as they're covered up all the time. So, if the forearm lesion resolves and lesions on the back are left untreated, would that be a problem to my healed forearm?
Expert:  Dr. D. Love replied 1 year ago.

No, there is no evidence untreated lesions on the back would be an issue for any improvement that is achieved on the forearm.