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alprazolam&#44; and lorazepam&#44; was referred from gynecology for asymptomatic skin lesions that had arisen a year earlier on her external genitalia&#46; Whitish&#44; atrophic&#44; alopecic plaques with hyperpigmented borders were observed on the labia majora &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; In addition&#44; examination revealed erythematous edematous plaques on her arms and scarring alopecic on her scalp&#46; A biopsy taken from the genital region showed hyperkeratosis&#44; a lichenoid infiltrate&#44; vacuolar degeneration of the basal layer&#44; and mucin deposits &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; In the blood tests&#44; the antinuclear antibody titer was 1&#58;160&#44; and antiribonucleoprotein antibodies were positive&#46; With a diagnosis of discoid LE &#40;DLE&#41;&#44; treatment was started with topical clobetasol for 2 months plus hydroxychloroquine&#44; 400<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; for 5 months&#44; leading to an improvement in the edematous plaques on the arms and in the erythema of the alopecia on the scalp&#44; while the genital lesions remained stable&#46; At the time of writing&#44; the patient was taking hydroxychloroquine&#44; 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; and had no active DLE lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A woman aged 35 years&#44; diagnosed with systemic LE &#40;SLE&#41; 10 years earlier&#44; had presented numerous distinct cutaneous manifestations of SLE and DLE&#44; for which she had received treatment with chloroquine&#44; hydroxychloroquine&#44; methotrexate&#44; thalidomide&#44; and immunoglobulins&#46; She was seen for a 3-month history of painful genital ulcers that appeared to be related to menstruation and lasted for about 10 days&#46; Examination revealed bilateral erosions at the introitus &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#44; labia minora&#44; and perianal region&#46; Herpesvirus culture was negative and biopsy showed parakeratosis&#44; focal ulceration&#44; and vacuolar degeneration of the basal layer&#44; with apoptotic keratinocytes in the epidermis and a chronic inflammatory infiltrate in the superficial dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#44; consistent with<span class="elsevierStyleHsp" style=""></span>LE&#46; Topical clobetasol was prescribed for the outbreaks of genital lesions&#44; leading to an improvement in the pain and duration of the ulcers&#44; though they continued to appear intermittently&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The genital manifestations of LE have been described on few occasions in the literature&#46; In 1989&#44; Burge et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> estimated a prevalence of 5&#37; in patients with chronic DLE&#44; whereas Fresko et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> in 1993&#44; found no genital lesions in a series of 48 women with SLE&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We have found only 8 published cases &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;6</span></a> of which 7 were women&#46; Five of those patients had DLE and 3 SLE&#46; Clinically the lesions include ulcers and erosions&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;4</span></a> as well as erythematous atrophic plaques with scarring alopecia characteristic of DLE&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;6</span></a> Both the ulcers and the plaques typical of DLE can appear in patients with SLE or DLE&#46; Although they are usually asymptomatic&#44; 2 women reported dyspareunia<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;5</span></a> and one described pruritus and discomfort on passing urine or defecating&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The histology is typical of LE&#44; with hyperkeratosis&#44; a perivascular and periadnexal inflammatory infiltrate&#44; vacuolar degeneration of the basal layer&#44; apoptotic keratinocytes&#44; and mucin deposits&#44; although not all findings are always present&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;6</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A recent publication from 2015 described a series of 22 patients with bullous LE&#44; in which 2 of the patients presented genital lesions&#46; However&#44; the morphology&#44; site&#44; duration&#44; and time since onset of the genital manifestations were not reported&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> We have found no cases of subacute LE affecting the genitalia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our 2 patients illustrate the 2 identified profiles of genital manifestations in LE&#58; one of them had the typical plaques of DLE&#44; which enabled us to make the diagnosis&#44; while the other patient presented ulcers&#44; leading to a broader differential diagnosis&#44; mainly including sexually transmitted infections such as herpes simplex and syphilis&#44; and aphthous disorders&#44; including Beh&#231;et disease&#44; fixed pigmented erythema&#44; and erosive lichen planus&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogenic mechanisms responsible for the skin lesions of LE are not fully understood&#46; In one study&#44; no differences were found in cytokine expression between the lips &#40;sun-exposed area&#41; and the oral mucosa &#40;sun-protected area&#41;&#46; This would suggest that although UV light may be the most relevant environmental factor in the induction of skin lesions&#44; there could be other intrinsic mechanisms that are similar in the 2 areas&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> In addition&#44; other factors&#44; such as the K&#246;ebner phenomenon&#44; could be the key to involvement of the genitalia&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Therapy is the same as for other manifestations of lupus erythematosus&#46; The treatments of choice are a high-potency topical corticosteroids plus systemic hydroxychloroquine or chloroquine&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;4&#44;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We have presented 2 cases of LE affecting the genitalia&#46; One patient with DLE who presented asymptomatic&#44; whitish atrophic plaques&#44; and another with long-standing SLE in which painful erosions developed at the introitus&#46; Genital involvement is rare in LE and is perhaps underdiagnosed&#46; It can present in the 2 clinical forms described&#46; It is important to be aware of these presentations to make a correct diagnosis&#44; and the existence of genital lesions or discomfort should be recorded in the medical history&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; del Alc&#225;zar-Viladomiu E&#44; L&#243;pez-Pesta&#241;a A&#44; Tuneu-Valls A&#46; Lupus eritematoso con afectaci&#243;n genital&#58; una localizaci&#243;n inusual&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;78&#8211;80&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Pubic region and labia majora showing whitish&#44; atrophic plaques with scarring alopecia and hyperpigmented borders&#46; B&#44; Hyperkeratosis&#44; a lichenoid infiltrate in the superficial dermis and perifollicular regions&#44; vacuolar degeneration of the basal layer&#44; and apoptotic keratinocytes&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;100&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Bilateral ulcers at the introitus and on the labia minora&#46; B&#44; Epidermis with focal ulceration&#44; foci of parakeratosis&#44; and marked vacuolar degeneration of the basal layer&#44; with necrotic keratinocytes and a chronic inflammatory infiltrate in the superficial dermis&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;200&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; DLE&#44; discoid lupus erythematosus&#59; F&#44; female&#59; LE&#44; lupus erythematosus&#59; M&#44; male&#59; NA&#44; not available&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author and Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of LE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Genital Involvement</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical Presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other Areas Affected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Burge et al&#46;&#44; 1989<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Introitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biasi et al&#46;&#44; 1994<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right labium minus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspareunia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Butterfly rash&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bilenchi et al&#46;&#44; 2004<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right labium majus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspareunia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Auricle of the ear&#44; nasal fossa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jolly and Patel&#44; 2006<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right labium majus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Face&#44; back&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Darwish&#44; 2008<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Labia minora&#44; anus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain and pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Romiti et al&#46;&#44; 2014<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pubis&#44; labia majora&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Preputial balanic sulcus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Face&#44; ears&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Our cases</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Labia majora&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arms&#44; scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Introitus&#44; labia minora&#44; perianal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scalp&#44; face&#44; lips of the mouth&#44; hands&#44; thighs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Our Patients and of Those Described in the Literature&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:9 [
            0 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Genital discoid lupus&#58; A rare manifestation of cutaneous lupus erythematosus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Romiti"
                            1 => "A&#46; Anzai"
                            2 => "M&#46;M&#46; Nico"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/0961203314522336"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lupus"
                        "fecha" => "2014"
                        "volumen" => "23"
                        "paginaInicial" => "707"
                        "paginaFinal" => "710"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24548969"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mucosal involvement in systemic and chronic cutaneous lupus erythematosus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46;M&#46; Burge"
                            1 => "P&#46;A&#46; Frith"
                            2 => "R&#46;P&#46; Juniper"
                            3 => "F&#46; Wojnarowska"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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Case and Research Letters
Lupus Erythematosus Affecting the Genitalia: An Unusual Site
Lupus eritematoso con afectación genital: una localización inusual
E. del Alcázar-Viladomiu
Corresponding author
, A. López-Pestaña, A. Tuneu-Valls
Servicio de Dermatología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
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    "titulo" => "Lupus Erythematosus Affecting the Genitalia&#58; An Unusual Site"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Bilateral ulcers at the introitus and on the labia minora&#46; B&#44; Epidermis with focal ulceration&#44; foci of parakeratosis&#44; and marked vacuolar degeneration of the basal layer&#44; with necrotic keratinocytes and a chronic inflammatory infiltrate in the superficial dermis&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;200&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Lupus erythematosus &#40;LE&#41; rarely affects the genitalia&#44; and few cases have been reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;6</span></a> In all types of LE&#44; the skin lesions typically appear in sun-exposed areas&#46; However&#44; involvement of nonexposed areas&#44; such as the scalp&#44; the oral mucosa&#44; or the palms and soles&#44; is common and has been extensively described&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Genital involvement&#44; on the other hand&#44; is rare and reports in the literature are sparse&#44; for which reason we consider it interesting to report the different genital manifestations observed in 2 patients with LE&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 65-year-old woman with a past history of depressive syndrome on treatment with venlafaxine&#44; alprazolam&#44; and lorazepam&#44; was referred from gynecology for asymptomatic skin lesions that had arisen a year earlier on her external genitalia&#46; Whitish&#44; atrophic&#44; alopecic plaques with hyperpigmented borders were observed on the labia majora &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; In addition&#44; examination revealed erythematous edematous plaques on her arms and scarring alopecic on her scalp&#46; A biopsy taken from the genital region showed hyperkeratosis&#44; a lichenoid infiltrate&#44; vacuolar degeneration of the basal layer&#44; and mucin deposits &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; In the blood tests&#44; the antinuclear antibody titer was 1&#58;160&#44; and antiribonucleoprotein antibodies were positive&#46; With a diagnosis of discoid LE &#40;DLE&#41;&#44; treatment was started with topical clobetasol for 2 months plus hydroxychloroquine&#44; 400<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; for 5 months&#44; leading to an improvement in the edematous plaques on the arms and in the erythema of the alopecia on the scalp&#44; while the genital lesions remained stable&#46; At the time of writing&#44; the patient was taking hydroxychloroquine&#44; 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; and had no active DLE lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A woman aged 35 years&#44; diagnosed with systemic LE &#40;SLE&#41; 10 years earlier&#44; had presented numerous distinct cutaneous manifestations of SLE and DLE&#44; for which she had received treatment with chloroquine&#44; hydroxychloroquine&#44; methotrexate&#44; thalidomide&#44; and immunoglobulins&#46; She was seen for a 3-month history of painful genital ulcers that appeared to be related to menstruation and lasted for about 10 days&#46; Examination revealed bilateral erosions at the introitus &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#44; labia minora&#44; and perianal region&#46; Herpesvirus culture was negative and biopsy showed parakeratosis&#44; focal ulceration&#44; and vacuolar degeneration of the basal layer&#44; with apoptotic keratinocytes in the epidermis and a chronic inflammatory infiltrate in the superficial dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#44; consistent with<span class="elsevierStyleHsp" style=""></span>LE&#46; Topical clobetasol was prescribed for the outbreaks of genital lesions&#44; leading to an improvement in the pain and duration of the ulcers&#44; though they continued to appear intermittently&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The genital manifestations of LE have been described on few occasions in the literature&#46; In 1989&#44; Burge et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> estimated a prevalence of 5&#37; in patients with chronic DLE&#44; whereas Fresko et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> in 1993&#44; found no genital lesions in a series of 48 women with SLE&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We have found only 8 published cases &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;6</span></a> of which 7 were women&#46; Five of those patients had DLE and 3 SLE&#46; Clinically the lesions include ulcers and erosions&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;4</span></a> as well as erythematous atrophic plaques with scarring alopecia characteristic of DLE&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;6</span></a> Both the ulcers and the plaques typical of DLE can appear in patients with SLE or DLE&#46; Although they are usually asymptomatic&#44; 2 women reported dyspareunia<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;5</span></a> and one described pruritus and discomfort on passing urine or defecating&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The histology is typical of LE&#44; with hyperkeratosis&#44; a perivascular and periadnexal inflammatory infiltrate&#44; vacuolar degeneration of the basal layer&#44; apoptotic keratinocytes&#44; and mucin deposits&#44; although not all findings are always present&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;6</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A recent publication from 2015 described a series of 22 patients with bullous LE&#44; in which 2 of the patients presented genital lesions&#46; However&#44; the morphology&#44; site&#44; duration&#44; and time since onset of the genital manifestations were not reported&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> We have found no cases of subacute LE affecting the genitalia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our 2 patients illustrate the 2 identified profiles of genital manifestations in LE&#58; one of them had the typical plaques of DLE&#44; which enabled us to make the diagnosis&#44; while the other patient presented ulcers&#44; leading to a broader differential diagnosis&#44; mainly including sexually transmitted infections such as herpes simplex and syphilis&#44; and aphthous disorders&#44; including Beh&#231;et disease&#44; fixed pigmented erythema&#44; and erosive lichen planus&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogenic mechanisms responsible for the skin lesions of LE are not fully understood&#46; In one study&#44; no differences were found in cytokine expression between the lips &#40;sun-exposed area&#41; and the oral mucosa &#40;sun-protected area&#41;&#46; This would suggest that although UV light may be the most relevant environmental factor in the induction of skin lesions&#44; there could be other intrinsic mechanisms that are similar in the 2 areas&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> In addition&#44; other factors&#44; such as the K&#246;ebner phenomenon&#44; could be the key to involvement of the genitalia&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Therapy is the same as for other manifestations of lupus erythematosus&#46; The treatments of choice are a high-potency topical corticosteroids plus systemic hydroxychloroquine or chloroquine&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;4&#44;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We have presented 2 cases of LE affecting the genitalia&#46; One patient with DLE who presented asymptomatic&#44; whitish atrophic plaques&#44; and another with long-standing SLE in which painful erosions developed at the introitus&#46; Genital involvement is rare in LE and is perhaps underdiagnosed&#46; It can present in the 2 clinical forms described&#46; It is important to be aware of these presentations to make a correct diagnosis&#44; and the existence of genital lesions or discomfort should be recorded in the medical history&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; del Alc&#225;zar-Viladomiu E&#44; L&#243;pez-Pesta&#241;a A&#44; Tuneu-Valls A&#46; Lupus eritematoso con afectaci&#243;n genital&#58; una localizaci&#243;n inusual&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;78&#8211;80&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; DLE&#44; discoid lupus erythematosus&#59; F&#44; female&#59; LE&#44; lupus erythematosus&#59; M&#44; male&#59; NA&#44; not available&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author and Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of LE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Genital Involvement</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical Presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other Areas Affected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Burge et al&#46;&#44; 1989<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Introitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biasi et al&#46;&#44; 1994<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right labium minus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspareunia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Butterfly rash&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bilenchi et al&#46;&#44; 2004<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right labium majus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspareunia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Auricle of the ear&#44; nasal fossa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jolly and Patel&#44; 2006<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right labium majus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Face&#44; back&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Darwish&#44; 2008<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Labia minora&#44; anus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain and pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Romiti et al&#46;&#44; 2014<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pubis&#44; labia majora&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Preputial balanic sulcus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Face&#44; ears&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Our cases</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Labia majora&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arms&#44; scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Introitus&#44; labia minora&#44; perianal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scalp&#44; face&#44; lips of the mouth&#44; hands&#44; thighs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "R&#46; Romiti"
                            1 => "A&#46; Anzai"
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                      "doi" => "10.1177/096120339400300115"
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                    ]
                  ]
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                            0 => "R&#46; Bilenchi"
                            1 => "C&#46; Pisani"
                            2 => "S&#46; Poggiali"
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                            1 => "H&#46; Yazici"
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Idiomas
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