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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic prurigo &#40;CPG&#41; is a disease characterized by intense itching and lesions secondary to scratching&#46; Although CPG is a specific clinical entity&#44; it may also be secondary to numerous underlying conditions&#46; CPG has a significant impact on quality of life&#46; Both the intensity and frequency of itching and pain are greater in CPG than in either psoriasis or atopic dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">1</span></a> CPG patients&#8217; higher scores on the Dermatology Life Quality Index &#40;DLQI&#41; also reveal greater disease-related impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">2</span></a> Anxiety is experienced by 37&#37; of individuals with this diagnosis&#44; depression by 29&#37;&#44; and suicidal ideation by 19&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">3</span></a> The condition also has considerable economic impact&#44; requiring more medical visits than other skin diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Opinions still differ as to what constitutes a case of prurigo<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">5</span></a> and what the optimal treatment is&#44; given that few studies provide an evidence base for treatment&#46; The recent recognition of CPG as an independent condition is a first step toward more appropriate diagnosis and treatment of patients with this complaint&#46; Recent years have seen important advances relevant to CPG&#46; Discoveries related to immunology and the development of new drugs require our full attention and understanding if our patients are to benefit from them&#46; From this situation stems the interest of this review of recent publications on CPG&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Definitions</span><p id="par0015" class="elsevierStylePara elsevierViewall">Confusion as to how to define prurigo begins with terminology&#46; Two spellings&#44; and hence pronunciations&#44; of the Spanish term coexist&#58; <span class="elsevierStyleItalic">pr&#250;rigo</span> and <span class="elsevierStyleItalic">prurigo</span>&#46; Only the latter&#44; however&#44; is accepted by the Royal Academy&#39;s <span class="elsevierStyleItalic">Dictionary of the Spanish Language</span> &#40;DLE in its Spanish abbreviation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> Meanwhile&#44; the Spanish adjective form <span class="elsevierStyleItalic">pruriginoso</span> &#40;pruriginous&#41; is often used to qualify conditions that are pruritic &#8212; ie&#44; that cause itching&#44; or pruritus &#8212; even though the DLE reserves the qualifier <span class="elsevierStyleItalic">pruiginoso</span> to refer to anything related to the nature of the disease prurigo or that causes it&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> According to Pereira &#38; St&#228;nder&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">7</span></a> the English language literature offers 2 adjectives &#8212; <span class="elsevierStyleItalic">itchy</span> and <span class="elsevierStyleItalic">pruritic</span> &#8212; to refer to the main symptom &#40;as the Spanish adjective <span class="elsevierStyleItalic">prur&#237;tico</span> does&#41; as well as the adjective <span class="elsevierStyleItalic">pruriginous</span> to indicate a relation to prurigo&#46; This distinction may seem unimportant&#44; but it becomes relevant when we try to define the lesions of prurigo&#46; In this review&#44; the lesions typically associated with CPG will be termed pruriginous&#44; while pruritic will refer to itching caused by any condition&#44; including the lesions of prurigo&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Hippocrates recorded the first descriptions of CPG in the third century CE&#44; and the term prurigo seems to have first appeared in the United Kingdom at the end of the 18th century&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">8</span></a> Since then it has been used to refer to many unrelated conditions that cause itching&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">7</span></a> and because of the variety of clinical presentations involved&#44; multiple diagnostic terms have emerged&#46; One example is prurigo nodularis of Hyde&#46; Another is Besnier prurigo&#44; the presentation associated with atopic dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">9</span></a> Geographic variations have also emerged&#46; For example&#44; Japanese guidelines refer to 2 clinical subtypes &#8212; prurigo nodularis and prurigo chronica multiformis<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">10</span></a> &#8212; a distinction not made in the Western literature&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">With the goal of introducing clarity&#44; experts belonging to the European Prurigo Project published a consensus paper in 2018 to propose definitions&#44; classifications&#44; and terminology&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">11</span></a> The paper states that CPG is &#8220;a distinct disease defined by the presence of chronic pruritus and multiple localized or generalized pruriginous lesions&#46;&#8221; This entity&#44; the group notes&#44; &#8220;occurs due to a neuronal sensitization to itch and the development of an itch-scratch cycle &#91;and CPG&#93; can be of dermatological&#44; systemic&#44; neurologic&#44; and psychiatric&#47;psychosomatic&#44; multifactorial or undetermined origin&#8221; &#40;p&#46; 1064&#44; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> of the reference&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">11</span></a> Cases of CPG therefore have a common clinical appearance but their origin is potentially heterogeneous&#46; An underlying dermatologic condition is present in up to half of the cases&#46; The consensus group further described pruriginous lesions as &#8220;excoriated&#44; scaling and&#47;or crusted nodules and&#47;or plaques&#44; often with a whitish or pink centre and hyperpigmented border&#8221; &#40;p&#46; 1064&#44; footnote to <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Types of CPG have also been established&#44; as follows&#58; papular&#44; nodular&#44; plaque&#44; umbilicated &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> of the same reference&#41;&#44; and linear &#40;Pereira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">12</span></a>&#41;&#46; Pruriginous lesions of different morphologies may be present in the same patient simultaneously&#44; and the features of these lesions can change over the course of the disease&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Epidemiology</span><p id="par0030" class="elsevierStylePara elsevierViewall">Few published studies have dealt with the epidemiology of CPG&#44; a condition thought to be rare&#46; Its prevalence is estimated to be around 72 cases per 100<span class="elsevierStyleHsp" style=""></span>000 population&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">13</span></a> but in our experience&#44; this complaint is considerably more common&#44; especially in individuals aged between 50 and 60 years<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">14</span></a> and Black patients&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">15</span></a> No differences between the sexes have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pathophysiology</span><p id="par0035" class="elsevierStylePara elsevierViewall">Various diseases cause itching in complex ways involving numerous pathways that are often imperfectly understood&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">16</span></a> Moreover&#44; itching leads to scratching&#44; which disrupts the skin barrier&#44; prolonging inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">17</span></a> When itching becomes chronic&#44; diverse mechanisms eventually cause peripheral and central nervous system sensitization to the symptom&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">18</span></a> Only a minority of patients with chronic pruritus develop pruriginous lesions&#44; however&#46; A genetic predisposition and other factors that are still unknown probably favor the development of CPG in an individual with chronic itching&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogenesis of this chronic disease unfolds along 2 axes &#8212; nerve inflammation and nerve plasticity &#8212; as well as the interaction between them&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">19</span></a> Understanding the pathogenesis of CPG is the basis for finding an effective treatment&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Anatomically&#44; CPG is characterized by nerve ending hyperplasia in the papillary dermis and hypoplasia in the epidermis&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">20</span></a> Hypoplasia occurs in the epidermis in both healthy and damaged skin&#44;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">21</span></a> but its relevance is not entirely clear&#46; One hypothesis is that hypoplasia is due to subclinical small-fiber neuropathy&#44; but this anatomical abnormality does not necessarily manifest itself in functional changes&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">22</span></a> Furthermore&#44; hypoplasia is corrected when lesions recover&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">23</span></a> A finding of hypoplasia&#44; therefore&#44; is believed to be a consequence of scratching&#44; not its cause&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The proliferation of nerve endings in the dermis&#44; on the other hand&#44; seems to be related to increased local inflammatory activity&#44; which is in turn promoted by proinflammatory substances secreted by the same endings&#46; A positive feedback loop therefore emerges &#40;&#8593;local inflammation &#8594; &#8593;nerve inflammation &#8594; &#8593;proinflammatory substances &#8594; &#8593; local inflammation&#41;&#44; providing microscopic confirmation of the clinical itch-scratch cycle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Nerve growth factor &#40;NGF&#41;&#44; one of the principal proteins implicated in prurigo&#44; is secreted by mast cells and eosinophils and plays a role in the proliferation of nerve endings and keratinocytes&#44; leading to the anatomical changes seen in CPG&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">19</span></a> TH2 lymphocytes are important in the synthesis of NGF&#44; through the secretion of IL-4 and IL-13&#46;<a class="elsevierStyleCrossRefs" href="#bib0620"><span class="elsevierStyleSup">24&#44;25</span></a> The importance of the TH2 pathway could explain why atopic dermatitis is found in association with CPG in many patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Substance P&#44; one of the main mediators of neurogenic inflammation&#44; is secreted by nerve endings&#46; On binding to NK-1R &#40;neurokinin 1 receptor&#41; and M4GPRX2 &#40;mas-related G-protein coupled receptor member X2&#41; on cutaneous mast cells&#44;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">26</span></a> substance P evokes degranulation and the release of such mediators of pruritus as histamine and leukotrienes&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">27</span></a> NK-1Rs are also present in keratinocytes&#44; which release other pruritogenic substances &#40;partially explaining the inability of antihistamines to achieve complete control over itching&#41; as well as other inflammatory mediators such as IL-1<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">28</span></a> and NGF itself&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">19</span></a> Neurogenic inflammation stimulates increased release of neuropeptides by type-C afferent nerve fibers&#44; increasing their sensitization and spontaneous activity&#44; and perpetuating chronic pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">29</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">IL-31 is another significant mediator in the neuroimmune system&#46; This cytokine&#44; which is important in various conditions&#44; is upregulated 50-fold in nodular-type prurigo<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">30</span></a> and is able to evoke intense pruritus in animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">30</span></a> Produced mainly by TH2 lymphocytes&#44; IL-31 binds to a receptor present in a subpopulation of sensory neurons in the spinal ganglia that are positive for TRPV1 and TRPA1 &#8212; the transient receptor potential cation channel &#40;subfamilies V and A&#41; member 1&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnosis</span><p id="par0070" class="elsevierStylePara elsevierViewall">CPG is a clinical diagnosis based on a thorough physical examination and a detailed medical history&#46; A patient usually presents complaining of intense itching and has signs of scratching &#40;excoriated lesions&#41; that are generalized in most cases but spare the face&#44; palms and soles &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; There is usually no excoriation in the interscapular area and center of the back&#44; where patients cannot reach&#44; such that the lesions create the so-called butterfly sign &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Diagnosis is not always quite so simple&#44; however&#44; and dermatologists vary considerably in how they make decisions&#46; Diagnostic criteria were proposed by the European Prurigo Project<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">11</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; We should emphasize that the necessary initial symptom is itching&#44; given that the other criteria listed may also appear in various other skin diseases&#44; which must be ruled out&#46; The patient&#39;s cooperation is important for establishing whether the itching began prior to the appearance of the pruriginous lesions or afterwards&#46; The project&#39;s criteria are useful for distinguishing CPG from neurotic excoriations&#44; in which the patient does not report itching but admits to scratching&#44; and dermatitis artefacta&#44; in which the patient denies a hand in causing the lesions&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In short&#44; the associated criteria are not requisites&#46; However&#44; they facilitate diagnosis&#44; and strict adhesion to them will allow the clinician to rule out other diseases when evaluating a diagnosis of CPG&#46; Diseases to rule out are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">CPG lesions have characteristic histologic features&#46; The epidermis typically presents orthohyperkeratosis and acanthosis nigricans that can occasionally progress to pseudoepitheliomatous hyperplasia&#46; The so-called hairy palms sign can be recognized as hyperkeratosis similar to acral peeling skin&#44; but with hair follicles&#46; Fibrosis in the papillary and reticular dermis is marked by a proliferation of fibroblasts and a predominantly perivascular and interstitial inflammatory infiltrate with lymphocytes and macrophages&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">32</span></a> Many of these features are similar to those of lichen simplex chronicus&#44; another condition caused by scratching&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">32</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Dermoscopy can help differentiate between CPG and other diseases&#44; especially hypertrophic lichen planus&#46; In nodular-type CPG there are pearly white areas&#44; red globules&#44; glomerular vessels&#44; and reddish-brown crusts&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">33&#8211;35</span></a> Also typical are peripheral white striations forming a starburst pattern&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">33&#8211;35</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">We will next focus on 2 entities that can be confusing and are the subject of debate&#46; They should be included in the differential diagnosis of CPG&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Nodular bullous pemphigoid is considered a rare clinical variant of pemphigoid that causes intense pruritus&#46; Bullous and pruriginous lesions are both present in this diagnosis&#44;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">36</span></a> and some authors consider it to be an independent disease&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">37</span></a> However&#44; the morphology of lesions and the clinical course would also seem to be compatible with a diagnosis of CPG secondary to the itching caused by bullous pemphigoid&#46; It is therefore important to examine the patient with chronic pruritus to discover whether there is a prior history of blisters and if necessary proceed to obtain biopsy specimens of perilesional skin for direct immunofluorescence&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Based on clinical and histological similarities&#44; some authors consider acquired reactive perforating dermatoses to be forms of umbilicated CPG that are a response to long-term stimulus in conditions like diabetes mellitus and renal insufficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">38</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Some authors describe a prurigo nodularis-like phenotype in atopic dermatitis&#44;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">39&#44;40</span></a> which can be truly difficult to distinguish from nodular-type CPG secondary to atopic dermatitis&#46; The pruritic lesions we find in reactive perforating dermatoses and those reported in the aforementioned prurigo nodularis-like condition should be considered true cases of CPG&#46; Reactive perforating dermatoses would be CPG secondary to some systemic disease&#46; The &#8220;nodular-like&#8221; condition would be CPG secondary to atopic dermatitis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Management</span><p id="par0110" class="elsevierStylePara elsevierViewall">After a confirmed diagnosis of CPG&#44; potential underlying causes should be investigated and ruled out to find the origin of pruritus&#46; The causes of CPG are multiple in 90&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">14</span></a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> lists the most frequent ones&#46; In up to half of patients the origin is a dermatologic condition&#44;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">14&#44;41</span></a> most often atopic dermatitis&#44; which is also the most common single cause&#46; The onset of CPG tends to come at an earlier age when atopic dermatitis is present&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">41&#44;42</span></a> Consequently&#44; a complete dermatologic medical history and an exhaustive physical examination are necessary&#46; If a patient reports that CPG lesions appeared over inflamed skin&#44; biopsy is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">43</span></a> Biopsy is also recommended if the clinician suspects skin diseases other than prurigo that can begin without specific lesions&#46; Examples of such diseases are bullous pemphigoid and dermatitis herpetiformis&#46; CPG cases associated with dermatitis due to contact allergy have also been described&#44; so the clinician should evaluate whether or not to order patch tests&#46; However&#44; the evidence is still scarce regarding the usefulness of patch testing&#46;<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">44&#44;45</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Additional tests may be needed to rule out the causes of the patient&#39;s symptoms and to complete the differential diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">20&#44;43</span></a><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> proposes a diagnostic algorithm for CPG&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Severity scales and quality of life questionnaires may be useful for objectively evaluating the efficacy of treatments&#46; The DLQI and visual analog scales are available for patient reporting of symptoms&#44; and there is also a version of the Investigator Global Assessment &#40;IGA&#41; of severity that is specific to nodular-type CPG&#46; The IGA&#39;s severity classification relies on physician estimation of the approximate number of lesions present at a given moment&#46; Five levels are defined&#58; clear &#40;0 nodules&#41;&#44; almost clear &#40;1&#8211;5 nodules&#41;&#44; mild &#40;6&#8211;19 nodules&#41;&#44; moderate &#40;20&#8211;100 nodules&#41;&#44; and severe &#40;more than 100 nodules&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">43</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><p id="par0125" class="elsevierStylePara elsevierViewall">The treatment of CPG is highly complex because there are no specific therapeutic targets&#46; A large number of medications are prescribed&#44;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">5</span></a> but their efficacy is generally low&#46; The aim of therapy should be 2-fold&#58; to attenuate itching and reduce the number of lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">43</span></a> It is essential to first treat the underlying pruritic disease that is the basis for the clinical picture&#46; However&#44; since the lesions of CPG are self-perpetuating&#44; they may persist&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">7</span></a> Most patients also require specific treatment for pruriginous lesions&#46; Additional difficulties are that most treatments have not been evaluated in randomized controlled trials&#44;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">46</span></a> that the trials done have highly heterogeneous endpoints&#44; and that nodular-type CPG is the clinical setting in all the trials published so far&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> proposes a therapeutic algorithm&#46; Most cases require several simultaneous treatments&#46; Therapy should be multimodal and always attempt to target the primary cause along with lesions&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Topical Treatments</span><p id="par0135" class="elsevierStylePara elsevierViewall">Topical preparations are generally the first line of therapy in mild cases of CPG&#46; They are also used to complement systemic therapy&#46; Topical corticosteroids act by regulating the immune response through T lymphocytes and cytokines&#46; In 1 clinical trial&#44; both pruritus and the number of lesions decreased significantly with application of a 0&#46;1&#37; betamethasone cream under occlusion versus application of a comparator&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">47</span></a> Our own experience suggests that application of a very high-potency corticosteroid cream such as 0&#46;05&#37; clobetasol propionate can be more useful given the difficulty medications have in penetrating the typical hyperkeratosis of pruriginous lesions&#46; Studies providing a lower grade of evidence have reported improvement with intralesional application of corticosteroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0740"><span class="elsevierStyleSup">48&#44;49</span></a> This technique can be especially useful for treating small numbers of refractory lesions&#46; Topical calcineurin inhibitors are a safe alternative for achieving results similar to corticosteroid treatment in longterm therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">50</span></a> Calcipotriol was also effective in a single small study&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">51</span></a> Capsaicin seems to produce an antipruritic effect upon binding to TRPV1&#44; desensitizing nerve endings&#46; A transient side effect of capsaicin application is a burning sensation that limits its use in CPG to local treatments in cases of neuropathic pruritus&#46;<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">52&#44;53</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Systemic Treatments</span><p id="par0140" class="elsevierStylePara elsevierViewall">Phototherapy can be useful mainly in patients with generalized CPG who are not candidates for systemic immunosuppressants because of advanced age or comorbidity&#46; Psoralen plus UV-A therapy &#40;PUVA&#41; and other modalities using UV-A&#44; UV-B&#44; and narrowband UV-B light have been found efficacious&#46;<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">54&#8211;59</span></a> A combination of a UV-B 308<span class="elsevierStyleHsp" style=""></span>nm excimer light and a PUVA bath proved superior to PUVA alone in a small randomized trial&#44;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">60</span></a> but no other trials have compared phototherapeutic modalities&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Antihistamines are often used to control itching even though they do not usually provide sufficient relief by themselves&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">61</span></a> A small case series found that combining antihistamines with leukotriene inhibitor therapy was efficacious&#46;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">62</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Gabapentinoids seem to act by inhibiting synaptic secretion of glutamate&#44; which is an excitatory neurotransmitter&#46; These drugs are particularly useful when the central nervous system plays a role&#44; as they can stabilize mood and reduce the urge to scratch&#46;<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">63</span></a> Although good results in CPG have been reported based on open trials and case series&#44;<a class="elsevierStyleCrossRefs" href="#bib0820"><span class="elsevierStyleSup">64&#8211;66</span></a> caution is advisable&#46; Doses should be increased gradually given that gapentinoids have adverse effects such as nausea&#44; sleepiness&#44; and dizziness&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">67</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Antidepressants such as amitriptyline&#44;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">68</span></a> paroxetine&#44; and fluvoxamine<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">69</span></a> have been efficacious in the treatment of both pruritus and pruriginous lesions&#46; Because these drugs can induce drowsiness they are especially useful in patients who report insomnia due to pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">43</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Good results have been reported in CPG of diverse origins for the use of &#956;-opioid receptor antagonists like naltrexone&#46;<a class="elsevierStyleCrossRefs" href="#bib0850"><span class="elsevierStyleSup">70&#44;71</span></a> A limitation is that they often cause adverse effects such as nausea and vomiting&#46;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">72</span></a> One phase 2 clinical trial underway includes the study of the effect on pruritus of nalbuphine&#44; a &#954;-receptor agonist and &#956;-receptor antagonist&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">73</span></a> This drug has appeared to reduce pruritus mediated by IL-31 in animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">74</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Another effective alternative is thalidomide&#46;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">75&#44;76</span></a> This drug has serious adverse effects&#44; including peripheral neuropathy &#40;in 20&#37; of patients&#41; in addition to its teratogenic potential&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">77</span></a> A low-dose regimen &#40;under 100<span class="elsevierStyleHsp" style=""></span>mg&#41; may avoid such adverse effects yet maintain thalidomide&#39;s antipruritic efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0890"><span class="elsevierStyleSup">78&#44;79</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The main systemic immunosuppressants used in CPG are methotrexate and ciclosporin&#46; Case series have demonstrated their efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">80&#8211;82</span></a> A decision to opt for one over the other should be made based on their different side effects&#46; Ciclosporin is generally reserved for younger patients without kidney disease or for scenarios that require a faster onset of action&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Therapies Under Development</span><p id="par0175" class="elsevierStylePara elsevierViewall">Advances in our understanding of the pathophysiology of CPG and the role of certain interleukins have led to the development of new drugs that may prove effective&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Dupilumab is a monoclonal antibody that binds to the &#945; receptor of IL-4&#44; inhibiting both IL-4 and IL-13 signaling&#46;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">83</span></a> Several uncontrolled studies and case series &#40;with 70 patients in total&#41; support its efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">39&#44;40&#44;84&#8211;91</span></a> Treatment leads to improvement and is well tolerated in most cases&#46; Conjunctivitis is the only adverse effect&#46; Since dupilumab is authorized to treat atopic dermatitis&#44; patients who are not atopic might be expected to improve less&#46; However&#44; 2 studies that compared patients with and without atopy did not see significant differences in clinical improvement between them&#46;<a class="elsevierStyleCrossRefs" href="#bib0960"><span class="elsevierStyleSup">92&#44;93</span></a> One of the studies did find a more rapid response to treatment in the patients with atopic dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">93</span></a> Current evidence therefore suggests that dupilumab may be effective&#46; Confirmation may come on publication of the results of a phase 3 trial that is still running&#46;<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">94</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">A phase 2 trial of nemolizumab in moderate to severe nodular CPG &#40;defined by the presence of more than 20 lesions&#41; and severe pruritus &#40;score of more than 7 on a numerical scale of 0 to 10&#41; was recently published&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">95</span></a> Nemolizumab is a monoclonal antibody that blocs receptor A of IL-31&#46; The authors reported a significant effect on pruritus&#44; the primary endpoint&#46; Itching decreased by 53&#37; in patients on nemolizumab by week 4&#44; versus 20&#37; in patients on placebo &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Improvement was unrelated to a patient&#39;s history of atopy&#46; Treatment with nemolizumab was associated with abdominal pain&#44; diarrhea&#44; and musculoskeletal symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">95</span></a> A phase 3 trial is currently underway&#46;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">96</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">A phase 2 placebo-controlled trial of oral aprepitant revealed no advantage of the active treatment for improving pruritus in CPG&#46;<a class="elsevierStyleCrossRef" href="#bib0985"><span class="elsevierStyleSup">97</span></a> Aprepitant is a selective NK-1R antagonist&#46; However&#44; serlopitant&#44; another drug in development that has the same mechanism of action&#44; did improve pruritus in a phase 2 trial&#46;<a class="elsevierStyleCrossRef" href="#bib0990"><span class="elsevierStyleSup">98</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Vixarelimab&#44; an oncostatin M-receptor inhibitor&#44; showed promising results in controlling pruritus in a phase 2 trial&#46;<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">99</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">A small clinical study &#40;10 patients&#41; found that apremilast led to no improvement&#46;<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">100</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0205" class="elsevierStylePara elsevierViewall">CPG is an independent clinical entity associated with neuronal sensitization that causes a secondary itch-scratch cycle&#46; The management of CPG is complex because of highly varied underlying causes and clinical presentations&#46; However&#44; the ability to correctly identify and classify CPG will facilitate better management&#46; Promising medical therapies that are under development may improve the management of this difficult-to-treat disease&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Diagnosis"
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        10 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Management"
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          "identificador" => "sec0035"
          "titulo" => "Treatment"
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          "identificador" => "sec0040"
          "titulo" => "Topical Treatments"
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          "titulo" => "Systemic Treatments"
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            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Therapies Under Development"
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        14 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conclusions"
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        15 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Conflicts of Interest"
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        16 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-01-16"
    "fechaAceptado" => "2021-11-01"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1532025"
          "palabras" => array:4 [
            0 => "Chronic prurigo"
            1 => "Prurigo nodularis"
            2 => "Pruritus"
            3 => "Atopic dermatitis"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1532026"
          "palabras" => array:4 [
            0 => "Prurigo cr&#243;nico"
            1 => "Prurigo nodularis"
            2 => "Pruritus"
            3 => "Dermatitis at&#243;pica"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chronic prurigo is itself a common condition&#44; but it can also occur secondary to a large number of diseases&#46; Management is challenging as historically chronic prurigo has been poorly defined and very few treatments are available&#46; Clinically&#44; it presents as excoriated&#44; hyperkeratotic lesions&#46; When chronic prurigo is suspected&#44; a comprehensive differential diagnosis is essential&#46; New diagnostic criteria have appeared in recent years and new drugs have been developed&#46; Although no truly effective treatment is yet available&#44; patients will benefit from a greater understanding of this condition&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El prurigo cr&#243;nico es una entidad con una apariencia cl&#237;nica com&#250;n pero que puede ser secundaria a un gran n&#250;mero de patolog&#237;as&#46; Hist&#243;ricamente ha sido una enfermedad no bien definida y con escasas terapias disponibles&#44; por lo que su manejo es muy complejo&#46; Cl&#237;nicamente se caracteriza por lesiones escoriadas e hiperquerat&#243;sicas en el contexto de un paciente con prurito cr&#243;nico&#46; Ante la sospecha de un prurigo cr&#243;nico&#44; es fundamental realizar un buen diagn&#243;stico diferencial e identificar todas sus posibles causas&#46; En los &#250;ltimos a&#241;os se han producido importantes avances con la aparici&#243;n de nuevos criterios diagn&#243;sticos y con el desarrollo de nuevos f&#225;rmacos&#46; Un mayor conocimiento de esta patolog&#237;a redundar&#225; en el beneficio de unos pacientes que hasta el momento carecen de un tratamiento claramente efectivo&#46;</p></span>"
      ]
    ]
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1878
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Schematic illustration of the local nerve inflammation cycle&#46; NGF indicates nerve growth factor&#59; NK-1R&#44; neurokinin-1 receptor&#59; SP&#44; substance P&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Symmetrically distributed excoriated nodules on the legs of a 42-year-old woman with a history of atopic dermatitis&#46; A&#44; Anterior surface&#46; B&#44; Posterior surface&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A&#44; Pruritus with nodular and linear type lesions and linear excoriations that spare the central portion of the back&#46; B&#44; Pruritus with nodular lesions forming the butterfly sign on the back&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Proposed diagnostic algorithm for CPG&#46; It is important to emphasize that most cases of CPG are multifactorial in origin&#44; such that confirming a cause does not mean that additional possible causes should not be investigated&#46; CPG refers to chronic prurigo&#59; HE&#44; hematoxylin&#8211;eosin&#59; DIF&#44; direct immunofluorescence&#44; HbA1C&#44; glycated hemoglobin&#59; ESR&#44; erythrocyte sedimentation rate&#59; HBV&#44; hepatitis B virus&#59; HCV&#44; hepatitis C virus&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Proposed therapeutic algorithm for CPG&#46; The primary cause of pruritus should be targeted along with the treatment of pruritus&#46; Most patients require combination therapies&#46; PUVA refers to psoralen plus UV-A&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; CPG&#44; chronic prurigo&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Main criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Chronic itching &#40;&#62;6 wk&#41;&#46; Itching must be the first symptom&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- History and&#47;or signs of scratching &#40;e&#46;g&#46;&#44; excoriations&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Multiple localized or generalized pruriginous lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Associated criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Signs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Symmetrical distribution of lesions into areas where the skin can be reached and scratched&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal or lichenified skin between lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Possibility of other lesions caused by scratching&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Face and palms rarely involved&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pruriginous lesions are persistent&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Itching precedes skin lesions&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Possibility of burning&#44; stinging&#44; or other pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Signs of chronicity&#58; very intense&#44; continuous itching&#59; alloknesis&#44; hyperknesis&#44; and the propagation of pruriginous lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Functional aspects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Quality of life deterioration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Loss of sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lost work days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obsessive&#8211;compulsive behavior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Emotional aspects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anger&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disgust&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Embarrassment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Impotence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Pathophysiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic pruritus may induce neuronal sensitization&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Itch&#8211;scratch cycle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Various conditions may cause chronic pruritus&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria for CPG&#58; the 3 main Criteria Must be Present to Support the Diagnosis&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Stings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cutaneous lymphomas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Dermatitis herpetiformis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertrophic lichen planus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurotic excoriations and dermatitis artefacta&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sporotrichoid infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mycobacterial infections&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple keratoacanthomas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Multiple dermatofibromas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bullous pemphigoid&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Dermatologic conditions</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">- Atopic dermatitis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Hematologic cancers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- HIV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Cirrhosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Neuropathic causes</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Brachioradial pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Postherpetic neuralgia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Unknown</span>&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Exploring the EQ-5D dimension of pain&#47;discomfort in dermatology outpatients from a multicentre study in 13 European countries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2340/00015555-3477"
                      "Revista" => array:3 [
                        "tituloSerie" => "Acta Derm Venereol"
                        "fecha" => "2020"
                        "itemHostRev" => array:3 [
                          "pii" => "S095980491831387X"
                          "estado" => "S300"
                          "issn" => "09598049"
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              "identificador" => "bib0510"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Humanistic burden of chronic pruritus in patients with inflammatory dermatoses&#58; results of the European Academy of Dermatology and Venereology Network on Assessment of Severity and Burden of Pruritus &#40;PruNet&#41; cross-sectional trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2018.04.044"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2018"
                        "volumen" => "79"
                        "paginaInicial" => "457"
                        "paginaFinal" => "463&#46;e5"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0515"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The self-assessed psychological comorbidities of prurigo in European patients&#58; a multicentre study in 13 countries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.15145"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol"
                        "fecha" => "2019"
                        "volumen" => "33"
                        "paginaInicial" => "157"
                        "paginaFinal" => "162"
                      ]
                    ]
                  ]
                ]
              ]
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            3 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Healthcare resource utilization and payer cost analysis of patients with prurigo nodularis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.18925"
                      "Revista" => array:2 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2020"
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            ]
            4 => array:3 [
              "identificador" => "bib0525"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Prurigo nodularis&#58; a physician survey to evaluate current perceptions of its classification&#44; clinical experience and unmet need"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.15107"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatology Venereol"
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Review
Update on Chronic Prurigo
Prurigo crónico: actualización
A. Docampo-Simón
Corresponding author
docamposimon@gmail.com

Corresponding author.
, M.J. Sánchez-Pujol, J.F. Silvestre-Salvador
Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic prurigo &#40;CPG&#41; is a disease characterized by intense itching and lesions secondary to scratching&#46; Although CPG is a specific clinical entity&#44; it may also be secondary to numerous underlying conditions&#46; CPG has a significant impact on quality of life&#46; Both the intensity and frequency of itching and pain are greater in CPG than in either psoriasis or atopic dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">1</span></a> CPG patients&#8217; higher scores on the Dermatology Life Quality Index &#40;DLQI&#41; also reveal greater disease-related impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">2</span></a> Anxiety is experienced by 37&#37; of individuals with this diagnosis&#44; depression by 29&#37;&#44; and suicidal ideation by 19&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">3</span></a> The condition also has considerable economic impact&#44; requiring more medical visits than other skin diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Opinions still differ as to what constitutes a case of prurigo<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">5</span></a> and what the optimal treatment is&#44; given that few studies provide an evidence base for treatment&#46; The recent recognition of CPG as an independent condition is a first step toward more appropriate diagnosis and treatment of patients with this complaint&#46; Recent years have seen important advances relevant to CPG&#46; Discoveries related to immunology and the development of new drugs require our full attention and understanding if our patients are to benefit from them&#46; From this situation stems the interest of this review of recent publications on CPG&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Definitions</span><p id="par0015" class="elsevierStylePara elsevierViewall">Confusion as to how to define prurigo begins with terminology&#46; Two spellings&#44; and hence pronunciations&#44; of the Spanish term coexist&#58; <span class="elsevierStyleItalic">pr&#250;rigo</span> and <span class="elsevierStyleItalic">prurigo</span>&#46; Only the latter&#44; however&#44; is accepted by the Royal Academy&#39;s <span class="elsevierStyleItalic">Dictionary of the Spanish Language</span> &#40;DLE in its Spanish abbreviation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> Meanwhile&#44; the Spanish adjective form <span class="elsevierStyleItalic">pruriginoso</span> &#40;pruriginous&#41; is often used to qualify conditions that are pruritic &#8212; ie&#44; that cause itching&#44; or pruritus &#8212; even though the DLE reserves the qualifier <span class="elsevierStyleItalic">pruiginoso</span> to refer to anything related to the nature of the disease prurigo or that causes it&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">6</span></a> According to Pereira &#38; St&#228;nder&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">7</span></a> the English language literature offers 2 adjectives &#8212; <span class="elsevierStyleItalic">itchy</span> and <span class="elsevierStyleItalic">pruritic</span> &#8212; to refer to the main symptom &#40;as the Spanish adjective <span class="elsevierStyleItalic">prur&#237;tico</span> does&#41; as well as the adjective <span class="elsevierStyleItalic">pruriginous</span> to indicate a relation to prurigo&#46; This distinction may seem unimportant&#44; but it becomes relevant when we try to define the lesions of prurigo&#46; In this review&#44; the lesions typically associated with CPG will be termed pruriginous&#44; while pruritic will refer to itching caused by any condition&#44; including the lesions of prurigo&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Hippocrates recorded the first descriptions of CPG in the third century CE&#44; and the term prurigo seems to have first appeared in the United Kingdom at the end of the 18th century&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">8</span></a> Since then it has been used to refer to many unrelated conditions that cause itching&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">7</span></a> and because of the variety of clinical presentations involved&#44; multiple diagnostic terms have emerged&#46; One example is prurigo nodularis of Hyde&#46; Another is Besnier prurigo&#44; the presentation associated with atopic dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">9</span></a> Geographic variations have also emerged&#46; For example&#44; Japanese guidelines refer to 2 clinical subtypes &#8212; prurigo nodularis and prurigo chronica multiformis<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">10</span></a> &#8212; a distinction not made in the Western literature&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">With the goal of introducing clarity&#44; experts belonging to the European Prurigo Project published a consensus paper in 2018 to propose definitions&#44; classifications&#44; and terminology&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">11</span></a> The paper states that CPG is &#8220;a distinct disease defined by the presence of chronic pruritus and multiple localized or generalized pruriginous lesions&#46;&#8221; This entity&#44; the group notes&#44; &#8220;occurs due to a neuronal sensitization to itch and the development of an itch-scratch cycle &#91;and CPG&#93; can be of dermatological&#44; systemic&#44; neurologic&#44; and psychiatric&#47;psychosomatic&#44; multifactorial or undetermined origin&#8221; &#40;p&#46; 1064&#44; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> of the reference&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">11</span></a> Cases of CPG therefore have a common clinical appearance but their origin is potentially heterogeneous&#46; An underlying dermatologic condition is present in up to half of the cases&#46; The consensus group further described pruriginous lesions as &#8220;excoriated&#44; scaling and&#47;or crusted nodules and&#47;or plaques&#44; often with a whitish or pink centre and hyperpigmented border&#8221; &#40;p&#46; 1064&#44; footnote to <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Types of CPG have also been established&#44; as follows&#58; papular&#44; nodular&#44; plaque&#44; umbilicated &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> of the same reference&#41;&#44; and linear &#40;Pereira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">12</span></a>&#41;&#46; Pruriginous lesions of different morphologies may be present in the same patient simultaneously&#44; and the features of these lesions can change over the course of the disease&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Epidemiology</span><p id="par0030" class="elsevierStylePara elsevierViewall">Few published studies have dealt with the epidemiology of CPG&#44; a condition thought to be rare&#46; Its prevalence is estimated to be around 72 cases per 100<span class="elsevierStyleHsp" style=""></span>000 population&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">13</span></a> but in our experience&#44; this complaint is considerably more common&#44; especially in individuals aged between 50 and 60 years<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">14</span></a> and Black patients&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">15</span></a> No differences between the sexes have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pathophysiology</span><p id="par0035" class="elsevierStylePara elsevierViewall">Various diseases cause itching in complex ways involving numerous pathways that are often imperfectly understood&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">16</span></a> Moreover&#44; itching leads to scratching&#44; which disrupts the skin barrier&#44; prolonging inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">17</span></a> When itching becomes chronic&#44; diverse mechanisms eventually cause peripheral and central nervous system sensitization to the symptom&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">18</span></a> Only a minority of patients with chronic pruritus develop pruriginous lesions&#44; however&#46; A genetic predisposition and other factors that are still unknown probably favor the development of CPG in an individual with chronic itching&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogenesis of this chronic disease unfolds along 2 axes &#8212; nerve inflammation and nerve plasticity &#8212; as well as the interaction between them&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">19</span></a> Understanding the pathogenesis of CPG is the basis for finding an effective treatment&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Anatomically&#44; CPG is characterized by nerve ending hyperplasia in the papillary dermis and hypoplasia in the epidermis&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">20</span></a> Hypoplasia occurs in the epidermis in both healthy and damaged skin&#44;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">21</span></a> but its relevance is not entirely clear&#46; One hypothesis is that hypoplasia is due to subclinical small-fiber neuropathy&#44; but this anatomical abnormality does not necessarily manifest itself in functional changes&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">22</span></a> Furthermore&#44; hypoplasia is corrected when lesions recover&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">23</span></a> A finding of hypoplasia&#44; therefore&#44; is believed to be a consequence of scratching&#44; not its cause&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The proliferation of nerve endings in the dermis&#44; on the other hand&#44; seems to be related to increased local inflammatory activity&#44; which is in turn promoted by proinflammatory substances secreted by the same endings&#46; A positive feedback loop therefore emerges &#40;&#8593;local inflammation &#8594; &#8593;nerve inflammation &#8594; &#8593;proinflammatory substances &#8594; &#8593; local inflammation&#41;&#44; providing microscopic confirmation of the clinical itch-scratch cycle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Nerve growth factor &#40;NGF&#41;&#44; one of the principal proteins implicated in prurigo&#44; is secreted by mast cells and eosinophils and plays a role in the proliferation of nerve endings and keratinocytes&#44; leading to the anatomical changes seen in CPG&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">19</span></a> TH2 lymphocytes are important in the synthesis of NGF&#44; through the secretion of IL-4 and IL-13&#46;<a class="elsevierStyleCrossRefs" href="#bib0620"><span class="elsevierStyleSup">24&#44;25</span></a> The importance of the TH2 pathway could explain why atopic dermatitis is found in association with CPG in many patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Substance P&#44; one of the main mediators of neurogenic inflammation&#44; is secreted by nerve endings&#46; On binding to NK-1R &#40;neurokinin 1 receptor&#41; and M4GPRX2 &#40;mas-related G-protein coupled receptor member X2&#41; on cutaneous mast cells&#44;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">26</span></a> substance P evokes degranulation and the release of such mediators of pruritus as histamine and leukotrienes&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">27</span></a> NK-1Rs are also present in keratinocytes&#44; which release other pruritogenic substances &#40;partially explaining the inability of antihistamines to achieve complete control over itching&#41; as well as other inflammatory mediators such as IL-1<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">28</span></a> and NGF itself&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">19</span></a> Neurogenic inflammation stimulates increased release of neuropeptides by type-C afferent nerve fibers&#44; increasing their sensitization and spontaneous activity&#44; and perpetuating chronic pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">29</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">IL-31 is another significant mediator in the neuroimmune system&#46; This cytokine&#44; which is important in various conditions&#44; is upregulated 50-fold in nodular-type prurigo<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">30</span></a> and is able to evoke intense pruritus in animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">30</span></a> Produced mainly by TH2 lymphocytes&#44; IL-31 binds to a receptor present in a subpopulation of sensory neurons in the spinal ganglia that are positive for TRPV1 and TRPA1 &#8212; the transient receptor potential cation channel &#40;subfamilies V and A&#41; member 1&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnosis</span><p id="par0070" class="elsevierStylePara elsevierViewall">CPG is a clinical diagnosis based on a thorough physical examination and a detailed medical history&#46; A patient usually presents complaining of intense itching and has signs of scratching &#40;excoriated lesions&#41; that are generalized in most cases but spare the face&#44; palms and soles &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; There is usually no excoriation in the interscapular area and center of the back&#44; where patients cannot reach&#44; such that the lesions create the so-called butterfly sign &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Diagnosis is not always quite so simple&#44; however&#44; and dermatologists vary considerably in how they make decisions&#46; Diagnostic criteria were proposed by the European Prurigo Project<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">11</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; We should emphasize that the necessary initial symptom is itching&#44; given that the other criteria listed may also appear in various other skin diseases&#44; which must be ruled out&#46; The patient&#39;s cooperation is important for establishing whether the itching began prior to the appearance of the pruriginous lesions or afterwards&#46; The project&#39;s criteria are useful for distinguishing CPG from neurotic excoriations&#44; in which the patient does not report itching but admits to scratching&#44; and dermatitis artefacta&#44; in which the patient denies a hand in causing the lesions&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In short&#44; the associated criteria are not requisites&#46; However&#44; they facilitate diagnosis&#44; and strict adhesion to them will allow the clinician to rule out other diseases when evaluating a diagnosis of CPG&#46; Diseases to rule out are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">CPG lesions have characteristic histologic features&#46; The epidermis typically presents orthohyperkeratosis and acanthosis nigricans that can occasionally progress to pseudoepitheliomatous hyperplasia&#46; The so-called hairy palms sign can be recognized as hyperkeratosis similar to acral peeling skin&#44; but with hair follicles&#46; Fibrosis in the papillary and reticular dermis is marked by a proliferation of fibroblasts and a predominantly perivascular and interstitial inflammatory infiltrate with lymphocytes and macrophages&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">32</span></a> Many of these features are similar to those of lichen simplex chronicus&#44; another condition caused by scratching&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">32</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Dermoscopy can help differentiate between CPG and other diseases&#44; especially hypertrophic lichen planus&#46; In nodular-type CPG there are pearly white areas&#44; red globules&#44; glomerular vessels&#44; and reddish-brown crusts&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">33&#8211;35</span></a> Also typical are peripheral white striations forming a starburst pattern&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">33&#8211;35</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">We will next focus on 2 entities that can be confusing and are the subject of debate&#46; They should be included in the differential diagnosis of CPG&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Nodular bullous pemphigoid is considered a rare clinical variant of pemphigoid that causes intense pruritus&#46; Bullous and pruriginous lesions are both present in this diagnosis&#44;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">36</span></a> and some authors consider it to be an independent disease&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">37</span></a> However&#44; the morphology of lesions and the clinical course would also seem to be compatible with a diagnosis of CPG secondary to the itching caused by bullous pemphigoid&#46; It is therefore important to examine the patient with chronic pruritus to discover whether there is a prior history of blisters and if necessary proceed to obtain biopsy specimens of perilesional skin for direct immunofluorescence&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Based on clinical and histological similarities&#44; some authors consider acquired reactive perforating dermatoses to be forms of umbilicated CPG that are a response to long-term stimulus in conditions like diabetes mellitus and renal insufficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">38</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Some authors describe a prurigo nodularis-like phenotype in atopic dermatitis&#44;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">39&#44;40</span></a> which can be truly difficult to distinguish from nodular-type CPG secondary to atopic dermatitis&#46; The pruritic lesions we find in reactive perforating dermatoses and those reported in the aforementioned prurigo nodularis-like condition should be considered true cases of CPG&#46; Reactive perforating dermatoses would be CPG secondary to some systemic disease&#46; The &#8220;nodular-like&#8221; condition would be CPG secondary to atopic dermatitis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Management</span><p id="par0110" class="elsevierStylePara elsevierViewall">After a confirmed diagnosis of CPG&#44; potential underlying causes should be investigated and ruled out to find the origin of pruritus&#46; The causes of CPG are multiple in 90&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">14</span></a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> lists the most frequent ones&#46; In up to half of patients the origin is a dermatologic condition&#44;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">14&#44;41</span></a> most often atopic dermatitis&#44; which is also the most common single cause&#46; The onset of CPG tends to come at an earlier age when atopic dermatitis is present&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">41&#44;42</span></a> Consequently&#44; a complete dermatologic medical history and an exhaustive physical examination are necessary&#46; If a patient reports that CPG lesions appeared over inflamed skin&#44; biopsy is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">43</span></a> Biopsy is also recommended if the clinician suspects skin diseases other than prurigo that can begin without specific lesions&#46; Examples of such diseases are bullous pemphigoid and dermatitis herpetiformis&#46; CPG cases associated with dermatitis due to contact allergy have also been described&#44; so the clinician should evaluate whether or not to order patch tests&#46; However&#44; the evidence is still scarce regarding the usefulness of patch testing&#46;<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">44&#44;45</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Additional tests may be needed to rule out the causes of the patient&#39;s symptoms and to complete the differential diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">20&#44;43</span></a><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> proposes a diagnostic algorithm for CPG&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Severity scales and quality of life questionnaires may be useful for objectively evaluating the efficacy of treatments&#46; The DLQI and visual analog scales are available for patient reporting of symptoms&#44; and there is also a version of the Investigator Global Assessment &#40;IGA&#41; of severity that is specific to nodular-type CPG&#46; The IGA&#39;s severity classification relies on physician estimation of the approximate number of lesions present at a given moment&#46; Five levels are defined&#58; clear &#40;0 nodules&#41;&#44; almost clear &#40;1&#8211;5 nodules&#41;&#44; mild &#40;6&#8211;19 nodules&#41;&#44; moderate &#40;20&#8211;100 nodules&#41;&#44; and severe &#40;more than 100 nodules&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">43</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><p id="par0125" class="elsevierStylePara elsevierViewall">The treatment of CPG is highly complex because there are no specific therapeutic targets&#46; A large number of medications are prescribed&#44;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">5</span></a> but their efficacy is generally low&#46; The aim of therapy should be 2-fold&#58; to attenuate itching and reduce the number of lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">43</span></a> It is essential to first treat the underlying pruritic disease that is the basis for the clinical picture&#46; However&#44; since the lesions of CPG are self-perpetuating&#44; they may persist&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">7</span></a> Most patients also require specific treatment for pruriginous lesions&#46; Additional difficulties are that most treatments have not been evaluated in randomized controlled trials&#44;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">46</span></a> that the trials done have highly heterogeneous endpoints&#44; and that nodular-type CPG is the clinical setting in all the trials published so far&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> proposes a therapeutic algorithm&#46; Most cases require several simultaneous treatments&#46; Therapy should be multimodal and always attempt to target the primary cause along with lesions&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Topical Treatments</span><p id="par0135" class="elsevierStylePara elsevierViewall">Topical preparations are generally the first line of therapy in mild cases of CPG&#46; They are also used to complement systemic therapy&#46; Topical corticosteroids act by regulating the immune response through T lymphocytes and cytokines&#46; In 1 clinical trial&#44; both pruritus and the number of lesions decreased significantly with application of a 0&#46;1&#37; betamethasone cream under occlusion versus application of a comparator&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">47</span></a> Our own experience suggests that application of a very high-potency corticosteroid cream such as 0&#46;05&#37; clobetasol propionate can be more useful given the difficulty medications have in penetrating the typical hyperkeratosis of pruriginous lesions&#46; Studies providing a lower grade of evidence have reported improvement with intralesional application of corticosteroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0740"><span class="elsevierStyleSup">48&#44;49</span></a> This technique can be especially useful for treating small numbers of refractory lesions&#46; Topical calcineurin inhibitors are a safe alternative for achieving results similar to corticosteroid treatment in longterm therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">50</span></a> Calcipotriol was also effective in a single small study&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">51</span></a> Capsaicin seems to produce an antipruritic effect upon binding to TRPV1&#44; desensitizing nerve endings&#46; A transient side effect of capsaicin application is a burning sensation that limits its use in CPG to local treatments in cases of neuropathic pruritus&#46;<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">52&#44;53</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Systemic Treatments</span><p id="par0140" class="elsevierStylePara elsevierViewall">Phototherapy can be useful mainly in patients with generalized CPG who are not candidates for systemic immunosuppressants because of advanced age or comorbidity&#46; Psoralen plus UV-A therapy &#40;PUVA&#41; and other modalities using UV-A&#44; UV-B&#44; and narrowband UV-B light have been found efficacious&#46;<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">54&#8211;59</span></a> A combination of a UV-B 308<span class="elsevierStyleHsp" style=""></span>nm excimer light and a PUVA bath proved superior to PUVA alone in a small randomized trial&#44;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">60</span></a> but no other trials have compared phototherapeutic modalities&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Antihistamines are often used to control itching even though they do not usually provide sufficient relief by themselves&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">61</span></a> A small case series found that combining antihistamines with leukotriene inhibitor therapy was efficacious&#46;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">62</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Gabapentinoids seem to act by inhibiting synaptic secretion of glutamate&#44; which is an excitatory neurotransmitter&#46; These drugs are particularly useful when the central nervous system plays a role&#44; as they can stabilize mood and reduce the urge to scratch&#46;<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">63</span></a> Although good results in CPG have been reported based on open trials and case series&#44;<a class="elsevierStyleCrossRefs" href="#bib0820"><span class="elsevierStyleSup">64&#8211;66</span></a> caution is advisable&#46; Doses should be increased gradually given that gapentinoids have adverse effects such as nausea&#44; sleepiness&#44; and dizziness&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">67</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Antidepressants such as amitriptyline&#44;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">68</span></a> paroxetine&#44; and fluvoxamine<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">69</span></a> have been efficacious in the treatment of both pruritus and pruriginous lesions&#46; Because these drugs can induce drowsiness they are especially useful in patients who report insomnia due to pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">43</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Good results have been reported in CPG of diverse origins for the use of &#956;-opioid receptor antagonists like naltrexone&#46;<a class="elsevierStyleCrossRefs" href="#bib0850"><span class="elsevierStyleSup">70&#44;71</span></a> A limitation is that they often cause adverse effects such as nausea and vomiting&#46;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">72</span></a> One phase 2 clinical trial underway includes the study of the effect on pruritus of nalbuphine&#44; a &#954;-receptor agonist and &#956;-receptor antagonist&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">73</span></a> This drug has appeared to reduce pruritus mediated by IL-31 in animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">74</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Another effective alternative is thalidomide&#46;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">75&#44;76</span></a> This drug has serious adverse effects&#44; including peripheral neuropathy &#40;in 20&#37; of patients&#41; in addition to its teratogenic potential&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">77</span></a> A low-dose regimen &#40;under 100<span class="elsevierStyleHsp" style=""></span>mg&#41; may avoid such adverse effects yet maintain thalidomide&#39;s antipruritic efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0890"><span class="elsevierStyleSup">78&#44;79</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The main systemic immunosuppressants used in CPG are methotrexate and ciclosporin&#46; Case series have demonstrated their efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">80&#8211;82</span></a> A decision to opt for one over the other should be made based on their different side effects&#46; Ciclosporin is generally reserved for younger patients without kidney disease or for scenarios that require a faster onset of action&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Therapies Under Development</span><p id="par0175" class="elsevierStylePara elsevierViewall">Advances in our understanding of the pathophysiology of CPG and the role of certain interleukins have led to the development of new drugs that may prove effective&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Dupilumab is a monoclonal antibody that binds to the &#945; receptor of IL-4&#44; inhibiting both IL-4 and IL-13 signaling&#46;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">83</span></a> Several uncontrolled studies and case series &#40;with 70 patients in total&#41; support its efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">39&#44;40&#44;84&#8211;91</span></a> Treatment leads to improvement and is well tolerated in most cases&#46; Conjunctivitis is the only adverse effect&#46; Since dupilumab is authorized to treat atopic dermatitis&#44; patients who are not atopic might be expected to improve less&#46; However&#44; 2 studies that compared patients with and without atopy did not see significant differences in clinical improvement between them&#46;<a class="elsevierStyleCrossRefs" href="#bib0960"><span class="elsevierStyleSup">92&#44;93</span></a> One of the studies did find a more rapid response to treatment in the patients with atopic dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">93</span></a> Current evidence therefore suggests that dupilumab may be effective&#46; Confirmation may come on publication of the results of a phase 3 trial that is still running&#46;<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">94</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">A phase 2 trial of nemolizumab in moderate to severe nodular CPG &#40;defined by the presence of more than 20 lesions&#41; and severe pruritus &#40;score of more than 7 on a numerical scale of 0 to 10&#41; was recently published&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">95</span></a> Nemolizumab is a monoclonal antibody that blocs receptor A of IL-31&#46; The authors reported a significant effect on pruritus&#44; the primary endpoint&#46; Itching decreased by 53&#37; in patients on nemolizumab by week 4&#44; versus 20&#37; in patients on placebo &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Improvement was unrelated to a patient&#39;s history of atopy&#46; Treatment with nemolizumab was associated with abdominal pain&#44; diarrhea&#44; and musculoskeletal symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">95</span></a> A phase 3 trial is currently underway&#46;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">96</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">A phase 2 placebo-controlled trial of oral aprepitant revealed no advantage of the active treatment for improving pruritus in CPG&#46;<a class="elsevierStyleCrossRef" href="#bib0985"><span class="elsevierStyleSup">97</span></a> Aprepitant is a selective NK-1R antagonist&#46; However&#44; serlopitant&#44; another drug in development that has the same mechanism of action&#44; did improve pruritus in a phase 2 trial&#46;<a class="elsevierStyleCrossRef" href="#bib0990"><span class="elsevierStyleSup">98</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Vixarelimab&#44; an oncostatin M-receptor inhibitor&#44; showed promising results in controlling pruritus in a phase 2 trial&#46;<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">99</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">A small clinical study &#40;10 patients&#41; found that apremilast led to no improvement&#46;<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">100</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0205" class="elsevierStylePara elsevierViewall">CPG is an independent clinical entity associated with neuronal sensitization that causes a secondary itch-scratch cycle&#46; The management of CPG is complex because of highly varied underlying causes and clinical presentations&#46; However&#44; the ability to correctly identify and classify CPG will facilitate better management&#46; Promising medical therapies that are under development may improve the management of this difficult-to-treat disease&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chronic prurigo is itself a common condition&#44; but it can also occur secondary to a large number of diseases&#46; Management is challenging as historically chronic prurigo has been poorly defined and very few treatments are available&#46; Clinically&#44; it presents as excoriated&#44; hyperkeratotic lesions&#46; When chronic prurigo is suspected&#44; a comprehensive differential diagnosis is essential&#46; New diagnostic criteria have appeared in recent years and new drugs have been developed&#46; Although no truly effective treatment is yet available&#44; patients will benefit from a greater understanding of this condition&#46;</p></span>"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El prurigo cr&#243;nico es una entidad con una apariencia cl&#237;nica com&#250;n pero que puede ser secundaria a un gran n&#250;mero de patolog&#237;as&#46; Hist&#243;ricamente ha sido una enfermedad no bien definida y con escasas terapias disponibles&#44; por lo que su manejo es muy complejo&#46; Cl&#237;nicamente se caracteriza por lesiones escoriadas e hiperquerat&#243;sicas en el contexto de un paciente con prurito cr&#243;nico&#46; Ante la sospecha de un prurigo cr&#243;nico&#44; es fundamental realizar un buen diagn&#243;stico diferencial e identificar todas sus posibles causas&#46; En los &#250;ltimos a&#241;os se han producido importantes avances con la aparici&#243;n de nuevos criterios diagn&#243;sticos y con el desarrollo de nuevos f&#225;rmacos&#46; Un mayor conocimiento de esta patolog&#237;a redundar&#225; en el beneficio de unos pacientes que hasta el momento carecen de un tratamiento claramente efectivo&#46;</p></span>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; CPG&#44; chronic prurigo&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Main criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Chronic itching &#40;&#62;6 wk&#41;&#46; Itching must be the first symptom&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- History and&#47;or signs of scratching &#40;e&#46;g&#46;&#44; excoriations&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Multiple localized or generalized pruriginous lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Associated criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Signs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Symmetrical distribution of lesions into areas where the skin can be reached and scratched&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal or lichenified skin between lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Possibility of other lesions caused by scratching&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Face and palms rarely involved&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pruriginous lesions are persistent&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Itching precedes skin lesions&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Possibility of burning&#44; stinging&#44; or other pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Signs of chronicity&#58; very intense&#44; continuous itching&#59; alloknesis&#44; hyperknesis&#44; and the propagation of pruriginous lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Functional aspects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Quality of life deterioration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Loss of sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lost work days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obsessive&#8211;compulsive behavior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Emotional aspects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anger&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disgust&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Embarrassment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Impotence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Pathophysiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic pruritus may induce neuronal sensitization&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Itch&#8211;scratch cycle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Various conditions may cause chronic pruritus&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria for CPG&#58; the 3 main Criteria Must be Present to Support the Diagnosis&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cutaneous lymphomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dermatitis herpetiformis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertrophic lichen planus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scabies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurotic excoriations and dermatitis artefacta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sporotrichoid infections&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Exploring the EQ-5D dimension of pain&#47;discomfort in dermatology outpatients from a multicentre study in 13 European countries"
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                    0 => array:2 [
                      "titulo" => "Humanistic burden of chronic pruritus in patients with inflammatory dermatoses&#58; results of the European Academy of Dermatology and Venereology Network on Assessment of Severity and Burden of Pruritus &#40;PruNet&#41; cross-sectional trial"
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                        "tituloSerie" => "J Eur Acad Dermatol Venereol"
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                      "titulo" => "How to define chronic prurigo&#63;"
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                      "titulo" => "&#91;Nihil certum&#58; Historical development of the term prurigo&#93;"
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                      "titulo" => "European Academy of Dermatology and Venereology European prurigo project&#58; Expert consensus on the definition&#44; classification and terminology of chronic prurigo"
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                        0 => array:2 [
                          "etal" => true
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                      "titulo" => "Position statement&#58; Linear prurigo is a subtype of chronic prurigo"
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                      "titulo" => "Prurigo as a symptom of atopic and non-atopic diseases&#58; Aetiological survey in a consecutive cohort of 108 patients"
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ISSN: 00017310
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