Case for Diagnosis
Diffuse Erythema and Acral Hyperkeratosis in a Newborn
Eritema difuso e hiperqueratosis acral en un lactante
A. Gómez-Zubiaur
, I. Spanoudi-Kitrimi, A. Torrelo
Corresponding author
Servicio de Dermatología, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
Read
5071
Timeswas read the article
2027
Total PDF
3044
Total HTML
Share statistics
array:24 [ "pii" => "S1578219018302592" "issn" => "15782190" "doi" => "10.1016/j.adengl.2018.07.007" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1961" "copyright" => "Elsevier España, S.L.U. and AEDV" "copyrightAnyo" => "2018" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:741-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 75 "HTML" => 75 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0001731018301996" "issn" => "00017310" "doi" => "10.1016/j.ad.2017.04.035" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1961" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:741-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 293 "formatos" => array:2 [ "HTML" => 212 "PDF" => 81 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Casos para el diagnóstico</span>" "titulo" => "Eritema difuso e hiperqueratosis acral en un lactante" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "741" "paginaFinal" => "742" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Diffuse Erythema and Acral Hyperkeratosis in a Newborn" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1171 "Ancho" => 2500 "Tamanyo" => 365070 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Gómez-Zubiaur, I. Spanoudi-Kitrimi, A. Torrelo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Gómez-Zubiaur" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Spanoudi-Kitrimi" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Torrelo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1578219018302592" "doi" => "10.1016/j.adengl.2018.07.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018302592?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731018301996?idApp=UINPBA000044" "url" => "/00017310/0000010900000008/v1_201810020614/S0001731018301996/v1_201810020614/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1578219018302610" "issn" => "15782190" "doi" => "10.1016/j.adengl.2018.07.008" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1975" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:743-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2 "formatos" => array:2 [ "EPUB" => 1 "HTML" => 1 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case for Diagnosis</span>" "titulo" => "Multiple Acquired Hypopigmented Nodules on the Anterior Chest" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "743" "paginaFinal" => "744" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulos múltiples hipopigmentados adquiridos en la cara anterior del tórax" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 338 "Ancho" => 450 "Tamanyo" => 16708 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Quintana-Codina, G. Melé-Ninot, C. Santonja" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Quintana-Codina" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Melé-Ninot" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Santonja" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731018302138" "doi" => "10.1016/j.ad.2017.06.026" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731018302138?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018302610?idApp=UINPBA000044" "url" => "/15782190/0000010900000008/v1_201810020631/S1578219018302610/v1_201810020631/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219018302385" "issn" => "15782190" "doi" => "10.1016/j.adengl.2018.07.003" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1858" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:e11-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 13 "formatos" => array:2 [ "HTML" => 12 "PDF" => 1 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">e- Case Report</span>" "titulo" => "Blisters Induced by PUVA: A Report of 5 Cases" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e11" "paginaFinal" => "e16" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ampollas inducidas por PUVA. Presentación de 5 casos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 937 "Ancho" => 1733 "Tamanyo" => 158474 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A, Patient 4: small blisters on healthy skin on the anterior aspect of both legs (black arrows) and secondary erosion (blue arrow). B, Patient 1: multiple blisters of various sizes grouped on the lateral aspect of the left leg.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Vázquez-Osorio, S. González-Delgado, C. Suárez-García, P. Gonzalvo-Rodríguez, E. Rodríguez-Díaz" "autores" => array:5 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Vázquez-Osorio" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "González-Delgado" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Suárez-García" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Gonzalvo-Rodríguez" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Rodríguez-Díaz" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731017306294" "doi" => "10.1016/j.ad.2017.10.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731017306294?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018302385?idApp=UINPBA000044" "url" => "/15782190/0000010900000008/v1_201810020631/S1578219018302385/v1_201810020631/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case for Diagnosis</span>" "titulo" => "Diffuse Erythema and Acral Hyperkeratosis in a Newborn" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "741" "paginaFinal" => "742" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Gómez-Zubiaur, I. Spanoudi-Kitrimi, A. Torrelo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Gómez-Zubiaur" "email" => array:1 [ 0 => "agomezubiaur@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Spanoudi-Kitrimi" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Torrelo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eritema difuso e hiperqueratosis acral en un lactante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1163 "Ancho" => 2500 "Tamanyo" => 440654 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 2-month-old infant with no personal or family history of interest was referred from a correctional facility for assessment of extensive skin lesions that first appeared in the second week of life. The patient exhibited loss of appetite, was very irritable, and his constant crying interfered with sleep. The patient had not previously been assessed for this condition and no specific treatment had been administered.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed thick, yellowish, crusted, hyperkeratotic, adherent plaques on the palms (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), soles, and scalp. Diffuse erythema, minute papules, superficial desquamation, and a few erosions were observed on the trunk and limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). All 10 fingernails exhibited onychodystrophy and considerable distal thickening of the nail plate.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A lesion on the trunk was removed by manual scraping and observed under an optical microscope (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory tests revealed marked leukocytosis (27 000 cells/mm<span class="elsevierStyleSup">3</span>), with 36% eosinophils (absolute count 10 000 cells/mm<span class="elsevierStyleSup">3</span>). A complete blood count and biochemistry profile showed no other abnormal findings. Levels of IgA, IgG, and IgM were within the normal range. The results of serologic tests for hepatitis B and C, syphilis, and human immunodeficiency virus were negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Crusted or hyperkeratotic scabies in an infant.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was prescribed 5% permethrin cream, which was applied to the entire body, from the scalp to the feet, except for the perioral region. The first application was carried out in the hospital on the day of the consultation. Seven days later, the treatment was repeated at the correctional facility. After 1 month, the lesions had resolved.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Crusted scabies—also known as hyperkeratotic or Norwegian scabies—is a variant of scabies first described in 1848 by Boeck and Danielssen in a group of Norwegian patients with leprosy. It is a rare, severe form of massive infestation of the ectoparasite <span class="elsevierStyleItalic">Sarcoptes scabiei</span> var<span class="elsevierStyleItalic">. hominis</span>, which also causes classic scabies. The main difference between the two forms is the number of mites per individual, which in the Norwegian variant can exceed 1 million.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Four weeks after initial contact with the ectoparasite, the host develops a type IV hypersensitivity reaction that limits the spread of the mites. In individuals with crusted scabies, this mechanism is altered, generating an ineffective inflammation and an unbalanced immune response.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Most cases of Norwegian scabies have been reported in immunocompromised patients; however, an immature immune system, the difficulty of scraping (the mechanism for elimination of mites and burrows), overcrowded living conditions, malnutrition, and institutionalization can lead to the appearance of the disease in newborns and infants.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The clinical presentation is characterized by the presence of diffuse erythema and desquamation associated with adherent crusts with acral predominance. Onychodystrophy and distal thickening of the nail plate—which can be a reservoir for mites, eggs, and feces—are reported in most cases.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> The lesions associated with classic scabies, such as burrows and pearly vesicles, can be obscured by hyperkeratotic plaques or may not be present.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This atypical clinical presentation delays diagnosis, especially in young children.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> If laboratory tests are carried out, marked eosinophilia is a common finding, possibly with elevated levels of immunoglobulins (especially IgE and IgG). However, simply by scraping off flakes of skin and placing them under an optical microscope—where a large number of mites, eggs, and feces can be observed, as in our patient—a diagnosis of scabies can be confirmed and other entities such as psoriasis, palmoplantar keratoderma, chronic eczema, pityriasis rubra pilaris, Netherton syndrome, and Omenn syndrome can be ruled out.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">It is important that crusted scabies be treated properly to prevent persistence, recurrence, and superinfection of the lesions. The first-line treatment—even in newborns and infants—is 5% permethrin cream, which has a good safety profile due to its low percutaneous absorption. It can be necessary to combine this treatment with the use of topical keratolytics (10% urea cream) or oral ivermectin, which is approved for use in children older than 5 years who weigh more than 15<span class="elsevierStyleHsp" style=""></span>kg (at a dosage of 0.2<span class="elsevierStyleHsp" style=""></span>mg/kg on the first and seventh days of treatment).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> It is fundamental to insist that all members of the household undergo treatment and that fomites and clothing be handled properly.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although crusted scabies in infants is exceptionally rare in Spain, dermatologists should be familiar with the clinical presentation of this entity in order to establish the correct diagnosis and begin appropriate treatment, thereby preventing complications and transmission.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => 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: Gómez-Zubiaur A, Spanoudi-Kitrimi I, Torrelo A. Eritema difuso e hiperqueratosis acral en un lactante. Actas Dermosifiliogr. 2018;109:741–742.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1163 "Ancho" => 2500 "Tamanyo" => 440654 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 563 "Ancho" => 750 "Tamanyo" => 53363 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A papulopustular, vesicular, crusted rash in a 4-week-old neonate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Subramaniam" 1 => "M.S. Rutman" 2 => "J.K. Wenger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PEC.0b013e3182aa1411" "Revista" => array:6 [ "tituloSerie" => "Pediatr Emerg Care" "fecha" => "2013" "volumen" => "29" "paginaInicial" => "1210" "paginaFinal" => "1212" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24196092" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Crusted scabies: A review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. Jouret" 1 => "R. Bounemeur" 2 => "A. Presle" 3 => "R. Takin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.annder.2016.02.001" "Revista" => array:6 [ "tituloSerie" => "Ann Dermatol Venereol" "fecha" => "2016" "volumen" => "143" "paginaInicial" => "251" "paginaFinal" => "256" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26948093" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sarna costrosa en un lactante desnutrido" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Fontenelle" 1 => "A.D. Figuereido-Roisman" 2 => "A.P. Moura De Almeida" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatol Pediatr Lat" "fecha" => "2007" "volumen" => "5" "paginaInicial" => "125" "paginaFinal" => "129" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Crusted (Norwegian) scabies: Treatment of nail involvement" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.T. De Paoli" 1 => "V.J. Marks" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1987" "volumen" => "17" "paginaInicial" => "136" "paginaFinal" => "139" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2956293" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scabies in infants and small children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.S. Paller" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Semin Dermatol" "fecha" => "1993" "volumen" => "12" "paginaInicial" => "3" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7682835" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Crusted scabies: clinical and immunological findings in seventy-eight patients and a review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.J. Roberts" 1 => "S.E. Huffam" 2 => "S.F. Walton" 3 => "B.J. Currie" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jinf.2004.08.033" "Revista" => array:6 [ "tituloSerie" => "J Infect" "fecha" => "2005" "volumen" => "50" "paginaInicial" => "375" "paginaFinal" => "381" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15907543" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Generalized scaling and redness in a 2-month-old boy. Crusted (Norwegian) scabies (CS)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.K. Ghosh" 1 => "D. Bandyopadhyay" 2 => "S.K. Biswas" 3 => "R.K. Mandal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1525-1470.2010.01284.x" "Revista" => array:6 [ "tituloSerie" => "Pediatr Dermatol." "fecha" => "2010" "volumen" => "27" "paginaInicial" => "525" "paginaFinal" => "526" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21182645" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000008/v1_201810020631/S1578219018302592/v1_201810020631/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000008/v1_201810020631/S1578219018302592/v1_201810020631/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018302592?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 7 | 13 |
| 2024 October | 79 | 44 | 123 |
| 2024 September | 78 | 34 | 112 |
| 2024 August | 120 | 64 | 184 |
| 2024 July | 86 | 45 | 131 |
| 2024 June | 97 | 31 | 128 |
| 2024 May | 82 | 40 | 122 |
| 2024 April | 62 | 23 | 85 |
| 2024 March | 79 | 27 | 106 |
| 2024 February | 57 | 36 | 93 |
| 2024 January | 75 | 35 | 110 |
| 2023 December | 57 | 8 | 65 |
| 2023 November | 71 | 23 | 94 |
| 2023 October | 60 | 27 | 87 |
| 2023 September | 64 | 27 | 91 |
| 2023 August | 44 | 18 | 62 |
| 2023 July | 67 | 32 | 99 |
| 2023 June | 59 | 23 | 82 |
| 2023 May | 61 | 22 | 83 |
| 2023 April | 53 | 25 | 78 |
| 2023 March | 56 | 27 | 83 |
| 2023 February | 44 | 35 | 79 |
| 2023 January | 48 | 47 | 95 |
| 2022 December | 64 | 44 | 108 |
| 2022 November | 39 | 27 | 66 |
| 2022 October | 31 | 28 | 59 |
| 2022 September | 23 | 36 | 59 |
| 2022 August | 24 | 31 | 55 |
| 2022 July | 22 | 47 | 69 |
| 2022 June | 24 | 30 | 54 |
| 2022 May | 53 | 49 | 102 |
| 2022 April | 49 | 44 | 93 |
| 2022 March | 53 | 51 | 104 |
| 2022 February | 54 | 37 | 91 |
| 2022 January | 63 | 46 | 109 |
| 2021 December | 51 | 56 | 107 |
| 2021 November | 50 | 49 | 99 |
| 2021 October | 48 | 53 | 101 |
| 2021 September | 38 | 48 | 86 |
| 2021 August | 47 | 35 | 82 |
| 2021 July | 52 | 44 | 96 |
| 2021 June | 28 | 36 | 64 |
| 2021 May | 50 | 52 | 102 |
| 2021 April | 70 | 72 | 142 |
| 2021 March | 65 | 51 | 116 |
| 2021 February | 89 | 47 | 136 |
| 2021 January | 54 | 38 | 92 |
| 2020 December | 33 | 36 | 69 |
| 2020 November | 43 | 48 | 91 |
| 2020 October | 22 | 14 | 36 |
| 2020 September | 45 | 29 | 74 |
| 2020 August | 47 | 27 | 74 |
| 2020 July | 30 | 18 | 48 |
| 2020 June | 43 | 41 | 84 |
| 2020 May | 19 | 34 | 53 |
| 2020 April | 17 | 14 | 31 |
| 2020 March | 22 | 15 | 37 |
| 2020 February | 2 | 0 | 2 |
| 2019 May | 1 | 0 | 1 |
| 2018 October | 74 | 0 | 74 |
Show all
