Case and Research Letter
Superficial Granulomatous Pyoderma. Report of 2 Cases Treated With Topical Tacrolimus
Pioderma granulomatoso superficial. Presentación de 2 casos tratados con tacrolimus tópico
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Presentación de 2 casos tratados con tacrolimus tópico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "721" "paginaFinal" => "724" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Superficial Granulomatous Pyoderma. Report of 2 Cases Treated With Topical Tacrolimus" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1554 "Ancho" => 2500 "Tamanyo" => 587800 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">a) Erosiones y costras en el cuadrante superoexterno de la mama. b) Granuloma de 3 capas constituido por un área central con neutrófilos, rodeados de una inflamación granulomatosa, y todo ello envuelto en células plasmáticas y eosinófilos (hematoxilina-eosina, x40).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Ormaechea-Pérez, A. López-Pestaña, C. Lobo-Morán, A. 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Report of 2 Cases Treated With Topical Tacrolimus" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "721" "paginaFinal" => "724" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "N. Ormaechea-Pérez, A. López-Pestaña, C. Lobo-Morán, A. Tuneu-Valls" "autores" => array:4 [ 0 => array:4 [ "nombre" => "N." "apellidos" => "Ormaechea-Pérez" "email" => array:1 [ 0 => "nereaorma@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "López-Pestaña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Lobo-Morán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Tuneu-Valls" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Donostia, San Sebastián, Guipúzcoa, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Donostia, San Sebastián, Guipúzcoa, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pioderma granulomatoso superficial. Presentación de 2 casos tratados con tacrolimus tópico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1221 "Ancho" => 1584 "Tamanyo" => 176373 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Plaques with ulcers on the buttocks. B, Horseshoe-shaped ulcer measuring 7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm with an atrophic center and erythematous-violaceous borders on the upper back. C, Predominantly follicular inflammatory infiltrate with rupture of the follicular epithelium and granulomatous reaction with giant cells (hematoxylin-eosin, original magnification ×100). D, Residual scars on the buttocks. E, cribriform scars on the back.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">To the Editor:</span></p><p id="par0005" class="elsevierStylePara elsevierViewall">Superficial granulomatous pyoderma (SGP) or pyoderma vegetans is a rare inflammatory disease first described by Wilson-Jones and Winkelmann in 1988.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although considered a superficial, vegetative variant of pyoderma gangrenosum (PG), SGP has distinguishing features such as a chronic and slowly progressive course, lack of association with other diseases, shallower ulcers, the presence on histology of characteristic 3-layered granulomas,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and better response to treatment (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">We present 2 cases of SGP that were successfully treated with topical tacrolimus, with no recurrence after 5 years.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 77-year-old man with a history of hypertension and type 2 diabetes mellitus presented in July 2003 with erosive papular lesions, some of them with follicular dominance. The lesions coalesced to form plaques prone to ulceration and the formation of crusts on the buttocks and scalp (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). On the upper back he had a horseshoe-shaped ulcer measuring 7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm with an atrophic center and erythematous-violaceous borders (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The lesions had first appeared several months earlier and had been treated with topical antibiotics and oral cephalosporins. No improvement was observed. Cultures for bacteria, fungi, and mycobacteria were negative. Skin biopsy revealed an acute and chronic inflammatory infiltrate that was predominantly follicular, with rupture of the follicular epithelium and a granulomatous reaction with giant cells (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Results of laboratory tests were within the normal range. The patient received successive treatments with corticosteroids and topical antibiotics, oral tetracyclines, trimethoprim-sulfamethoxazole, colchicine, and isotretinoin, but little improvement was noted. Finally, after 6 months of treatment with topical tacrolimus 0.1% the lesions healed, leaving cribriform scars (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D and 1E).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 33-year-old woman with a history of schizophrenia came to our clinic with lesions on the right breast that had appeared a year earlier. She reported a history of right breast abscess that had required drainage by her gynecologist. Since then she had had erosive lesions with erythematous-violaceous borders on the upper outer quadrant of the breast that had not improved with topical antibiotics (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Cultures for bacteria, fungi, and mycobacteria were negative. A biopsy revealed a dense, mixed dermal infiltrate of plasma cells and suppurative granulomas (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). No microorganisms or foreign bodies were observed. Laboratory tests revealed only subclinical hypothyroidism. Following application of tacrolimus 0.1% ointment twice daily for 12 months, the lesions resolved.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">SGP is a rare condition for which we found some 60 references in the literature. It usually presents on the trunk as a slow-growing, painless superficial ulcer with vegetative borders, although SGP lesions have been reported on the face, the limbs, and even the scrotum.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> When SGP is located on the face it is important to consider a diagnosis of Wegener disease.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although SGP has a more indolent course than PG and usually responds better to treatment, chronicity and recurrence are common.</p><p id="par0030" class="elsevierStylePara elsevierViewall">SGP rarely accompanies systemic diseases, although isolated cases have been associated with chronic lymphatic leukemia, polymyalgia rheumatica, IgA paraproteinemia, sarcoidosis, rheumatoid arthritis, and ulcerative colitis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Histology characteristically reveals a superficial dermal abscess or ulcer which tends to form granulomas in 3 layers: a central zone with neutrophils, cellular debris, and evidence of bleeding; a surrounding layer of histiocytes and giant cells; and an outer layer of plasma cells and eosinophils.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although not all cases have this characteristic histology, granulomatous inflammation is a consistent finding. The presence of eosinophils, plasma cells, and granulomas and the lack of involvement of the hypodermis help differentiate SGP from PG.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Moreover, sinus tracts and foreign bodies such as hair, suture material, and vegetable matter are usually observed in SGP but not in PG.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In both PG and SGP, definitive diagnosis is by exclusion. Differential diagnosis should include mycobacterial and fungal infections, ulcerative sarcoidosis, foreign body granuloma, and halogenoderma.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The pathogenesis is unknown. Characteristics supporting the hypothesis that SGP has a different etiology to PG are the presence of foreign bodies and the inflammatory infiltrate composed of giant cells, plasma cells, and eosinophils, in addition to neutrophils. SGP therefore seems to be a local response of the skin to an as yet unidentified element or to a normal tissue that the disordered immune response identifies as foreign.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The treatment of SGP is different to that of PG.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Spontaneous healing is not unusual, although recurrence is common. SGP located on the face is more refractory to treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> As in PG, surgical removal of SGP is not recommended because of the risk of pathergy. Since SGP has a more indolent clinical course than PG, aggressive treatments are not usually required in principle (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The response to topical corticosteroids is usually good, though slow.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Good responses to topical tacrolimus have also been reported.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10</span></a> Our positive experience with tacrolimus in 2 patients leads us to think it could be considered a first-line treatment.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, we have presented 2 cases of SGP, an uncommon diagnosis. We emphasize the favorable response to topical tacrolimus, although complete cure took several months to achieve.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ormaechea-Pérez N, et al. Pioderma granulomatoso superficial. Presentación de 2 casos tratados con tacrolimus tópico. Actas Dermosifiliogr. 2013;104:721–4.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1221 "Ancho" => 1584 "Tamanyo" => 176373 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Plaques with ulcers on the buttocks. B, Horseshoe-shaped ulcer measuring 7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm with an atrophic center and erythematous-violaceous borders on the upper back. C, Predominantly follicular inflammatory infiltrate with rupture of the follicular epithelium and granulomatous reaction with giant cells (hematoxylin-eosin, original magnification ×100). D, Residual scars on the buttocks. E, cribriform scars on the back.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1667 "Ancho" => 1252 "Tamanyo" => 259960 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Erosions and scabs on the upper outer quadrant of the breast. B, 3-layer granuloma composed of a central zone with neutrophils, a surrounding layer with granulomatous inflammation, and an outer layer of plasma cells and eosinophils (hematoxylin-eosin, original magnification ×40).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type of Feature \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Superficial Granulomatous Pyoderma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Pyoderma Gangrenosum \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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 and symptoms \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">Superficial ulcer, clean base \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">Deep ulcer, necrotic center \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"> \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">Painless \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">Painful \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"> \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">Located on trunk \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">Located on lower limbs \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"> \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">Single lesion \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 lesions \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"> \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">Less often associated with systemic disease \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">Associated with inflammatory bowel disease, rheumatoid arthritis, lymphoid tumors, etc. \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"> \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">Slow growth \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Histology \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 granulomatous inflammatory infiltrate (eosinophils, plasma cells) \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">Acute diffuse inflammatory infiltrate (neutrophils) \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"> \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">Formation of fistulous tracts \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">No fistulous tracts \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"> \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">Foreign bodies such as hair and suture material may be found. \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">No foreign bodies \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment \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">Topical: corticosteroids, tacrolimus \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">Topical: corticosteroids, tacrolimus \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"> \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">Oral: corticosteroids, tetracyclines, dapsone, ciclosporin, infliximab, intravenous immunoglobulins \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">Oral: corticosteroids, ciclosporin, dapsone, clofazimine, minocycline, oral tacrolimus, mycophenolate mofetil, TNF, intravenous immunoglobulins \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prognosis \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">Good prognosis \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">Frequent relapses \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"> \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">Frequent recurrence \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">Often requires maintenance treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] 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| Year/Month | Html | Total | |
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| 2023 October | 61 | 38 | 99 |
| 2023 September | 70 | 56 | 126 |
| 2023 August | 53 | 47 | 100 |
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| 2022 February | 111 | 43 | 154 |
| 2022 January | 125 | 62 | 187 |
| 2021 December | 104 | 80 | 184 |
| 2021 November | 113 | 52 | 165 |
| 2021 October | 58 | 60 | 118 |
| 2021 September | 56 | 49 | 105 |
| 2021 August | 51 | 34 | 85 |
| 2021 July | 58 | 34 | 92 |
| 2021 June | 72 | 39 | 111 |
| 2021 May | 70 | 43 | 113 |
| 2021 April | 154 | 73 | 227 |
| 2021 March | 102 | 25 | 127 |
| 2021 February | 96 | 35 | 131 |
| 2021 January | 46 | 21 | 67 |
| 2020 December | 39 | 22 | 61 |
| 2020 November | 46 | 31 | 77 |
| 2020 October | 59 | 12 | 71 |
| 2020 September | 42 | 10 | 52 |
| 2020 August | 33 | 23 | 56 |
| 2020 July | 42 | 21 | 63 |
| 2020 June | 49 | 33 | 82 |
| 2020 May | 31 | 24 | 55 |
| 2020 April | 45 | 28 | 73 |
| 2020 March | 38 | 28 | 66 |
| 2020 February | 5 | 7 | 12 |
| 2020 January | 4 | 8 | 12 |
| 2019 December | 8 | 9 | 17 |
| 2019 November | 4 | 8 | 12 |
| 2019 October | 0 | 4 | 4 |
| 2019 September | 8 | 3 | 11 |
| 2019 August | 6 | 4 | 10 |
| 2019 July | 3 | 7 | 10 |
| 2019 June | 6 | 6 | 12 |
| 2019 May | 4 | 37 | 41 |
| 2019 April | 9 | 6 | 15 |
| 2019 March | 4 | 5 | 9 |
| 2019 February | 0 | 1 | 1 |
| 2019 January | 6 | 0 | 6 |
| 2018 December | 6 | 0 | 6 |
| 2018 November | 7 | 0 | 7 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 3 | 1 | 4 |
| 2018 August | 0 | 7 | 7 |
| 2018 July | 0 | 2 | 2 |
| 2018 June | 0 | 2 | 2 |
| 2018 May | 0 | 5 | 5 |
| 2018 April | 0 | 10 | 10 |
| 2018 March | 5 | 2 | 7 |
| 2018 February | 63 | 10 | 73 |
| 2018 January | 86 | 7 | 93 |
| 2017 December | 95 | 7 | 102 |
| 2017 November | 67 | 8 | 75 |
| 2017 October | 63 | 6 | 69 |
| 2017 September | 66 | 14 | 80 |
| 2017 August | 80 | 19 | 99 |
| 2017 July | 64 | 11 | 75 |
| 2017 June | 62 | 27 | 89 |
| 2017 May | 64 | 15 | 79 |
| 2017 April | 49 | 7 | 56 |
| 2017 March | 49 | 25 | 74 |
| 2017 February | 83 | 13 | 96 |
| 2017 January | 43 | 21 | 64 |
| 2016 December | 63 | 25 | 88 |
| 2016 November | 87 | 16 | 103 |
| 2016 October | 121 | 11 | 132 |
| 2016 September | 210 | 15 | 225 |
| 2016 August | 184 | 14 | 198 |
| 2016 July | 81 | 5 | 86 |
| 2016 June | 8 | 13 | 21 |
| 2016 May | 6 | 12 | 18 |
| 2016 April | 5 | 1 | 6 |
| 2016 March | 6 | 1 | 7 |
| 2016 February | 5 | 18 | 23 |
| 2016 January | 5 | 4 | 9 |
| 2015 December | 15 | 4 | 19 |
| 2015 November | 23 | 1 | 24 |
| 2015 October | 22 | 6 | 28 |
| 2015 September | 7 | 8 | 15 |
| 2015 August | 4 | 2 | 6 |
| 2015 July | 97 | 9 | 106 |
| 2015 June | 69 | 8 | 77 |
| 2015 May | 72 | 12 | 84 |
| 2015 April | 57 | 6 | 63 |
| 2015 March | 39 | 4 | 43 |
| 2015 February | 43 | 6 | 49 |
| 2015 January | 35 | 11 | 46 |
| 2014 December | 40 | 2 | 42 |
| 2014 November | 30 | 9 | 39 |
| 2014 October | 36 | 9 | 45 |
| 2014 September | 40 | 5 | 45 |
| 2014 August | 39 | 11 | 50 |
| 2014 July | 41 | 14 | 55 |
| 2014 June | 53 | 7 | 60 |
| 2014 May | 38 | 7 | 45 |
| 2014 April | 37 | 6 | 43 |
| 2014 March | 36 | 5 | 41 |
| 2014 February | 29 | 4 | 33 |
| 2014 January | 27 | 2 | 29 |
| 2013 December | 19 | 8 | 27 |
| 2013 November | 3 | 2 | 5 |
| 2013 October | 3 | 4 | 7 |
| 2013 September | 0 | 2 | 2 |
Show all
