Case and Research Letters
Urticarial Dermatitis. A Cutaneous Reaction Pattern
Dermatitis urticante. Un patrón de reacción cutánea
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Un patrón de reacción cutánea" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "929" "paginaFinal" => "932" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Urticarial Dermatitis. A Cutaneous Reaction Pattern" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 686 "Ancho" => 900 "Tamanyo" => 176662 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epidermis normal e infiltrado perivascular linfocitario denso con abundantes eosinófilos. 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A Cutaneous Reaction Pattern" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "929" "paginaFinal" => "932" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.C. García del Pozo, I. Poveda, P. Álvarez, J.F. Silvestre" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.C." "apellidos" => "García del Pozo" "email" => array:1 [ 0 => "sakuragarciadelpozo@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" => "I." "apellidos" => "Poveda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J.F." "apellidos" => "Silvestre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario Universitario de Albacete, Albacete, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General de Alicante–ISABIAL, Alicante, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dermatitis urticante. Un patrón de reacción cutánea" ] ] "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" => 1326 "Ancho" => 1050 "Tamanyo" => 138515 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Excoriated erythematous papules on the back of a patient. B, Use of the Fric test to confirm dermographism on the back of a patient with prurigo lesions at different stages of progression.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2006, Kossard and coworkers coined the term <span class="elsevierStyleItalic">urticarial dermatitis</span> (UD) to describe a histological skin reaction pattern with a broad clinical spectrum. UD is primarily characterized by the presence of urticarial, erythematous, pruritic papules or plaques and eczematous lesions.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Biopsy of urticarial areas reveals a normal stratum corneum, minimal spongiosis, and perivascular lymphocytic infiltrate of the papillary dermis with eosinophils (with or without neutrophils)<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In this descriptive observational study we describe the clinical and histological findings in 6 patients with a diagnosis suggestive of UD who were treated at the Eczema Unit of the Dermatology Service of a tertiary hospital in 2015 and 2016. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows corresponding data on epidemiology, comorbidities, clinical presentation, initial clinical suspicion, diagnostic tests, final diagnosis, disease duration at the time of diagnosis, follow-up period, treatment, and progression.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The mean age at UD onset was 70 years (range, 45–88 years). None of the patients had a personal or family history of atopy, urticaria, or any other skin disease. All patients reported having pruritus and in all cases physical examination confirmed the presence of urticarial papules or plaques and clinical signs of dermatitis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Dermographism was detected in 4 patients (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The initial clinical suspicions included UD, chronic spontaneous urticaria (CSU), bullous pemphigoid, and eczema. Other clinical entities included in the differential diagnosis were drug reactions, urticaria-vasculitis, scabies, and dermatitis herpetiformis.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In all cases, a final diagnosis was established based on the results of diagnostic tests (CSU in 3 patients, drug reaction in 2 patients, and Schnitzler syndrome in 1 patient). The mean time from disease onset to final diagnosis was 7 months (range, 3–13 months) and the mean duration of follow-up was 11.3 months (range, 5–20 months). All patients were initially treated with oral antihistamines and corticosteroids. Improvement was observed in only 2 patients, both of whom were later diagnosed with CSU. All but 1 patient responded well to targeted treatment once the definitive diagnosis had been established.</p><p id="par0020" class="elsevierStylePara elsevierViewall">UD is not a discrete disorder, but a group of skin diseases that share similar clinical and histological manifestations. In many patients with clinically suspected UD a clinical-pathological correlation can be reached through accurate diagnostic assessment,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> although this can take several months. Pathologists have used the term <span class="elsevierStyleItalic">dermal hypersensitivity reaction pattern</span> to describe UD, despite the absence of a clinical or histological correlation between these presentations.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3</span></a> All cases in this series initially posed a diagnostic challenge, as none could be classified as a specific inflammatory disorder. Ultimately, a final diagnosis was established in all cases. The most common diagnosis was CSU, followed by drug reaction. Our results differ from those previously reported in the literature: Kossard and coworkers found that the most frequent clinical associations were eczema and drug reactions,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> while 47% of the cases in the series by Hannon and coworkers were of idiopathic origin.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Certain histological clues may facilitate the establishment of a more specific diagnosis,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> particularly if observed in earlier disease stages when the lesions are more edematous and less excoriated. The presence of spongiosis supports a diagnosis of eczema, while its absence is suggestive of urticaria or lesions secondary to either drug reaction or urticaria.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Because UD can constitute the initial signs of bullous pemphigoid,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> it is advisable to perform direct immunofluorescence studies.</p><p id="par0025" class="elsevierStylePara elsevierViewall">UD typically affects elderly patients, especially women.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,4</span></a> Because many patients are polymedicated, it can be difficult to identify the causative agent in cases of suspected drug-induced UD. UD lesions have a polymorphous appearance, and exhibit features of urticaria and concomitant or simultaneous dermatitis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Eczematous lesions may be caused in part by the use of home remedies to relieve itching. In our study, physical examination revealed dermographism in some patients. Although dermographism is typical of drug reaction, scabies and, above all, CSU, its presence can be particularly helpful in the diagnosis of UD.</p><p id="par0030" class="elsevierStylePara elsevierViewall">UD may involve a T helper 2 (Th2) lymphocyte reaction, which precedes a dominant T helper 1 (Th1) cytokine profile, particularly in cases of atopic dermatitis.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,5</span></a> This induces the production of interleukin (IL)-4, IL-5, and IL-10, all of which can give rise to eosinophilia and urticarial reactions.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The therapies most commonly used to treat UD include oral antihistamines, topical and systemic corticosteroids, narrowband ultraviolet B radiation, and topical calcineurin inhibitors, usually with unsatisfactory results.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2,4</span></a> Some reports have described good responses to treatment with other therapeutic agents, including cyclosporins, mycophenolate mofetil, azathioprine, dapsone, and hydroxyurea.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, UD is a common manifestation of several distinct skin diseases that appear to share a similar pathophysiological mechanism. A final diagnosis can be established after exhaustive evaluation of the information obtained from anamnesis, histology, and other additional tests. The detection of dermographism in the physical examination may help orient the diagnosis towards UD. However, this finding should not be considered a specific sign of any condition in particular. In our opinion, UD is a useful term to describe a skin reaction mainly observed in the elderly, the clinical characteristics of which mimic those of several skin diseases. In many cases, a definitive diagnosis can only be established after long-term follow up.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => 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: García del Pozo MC, Poveda I, Álvarez P, Silvestre JF. Dermatitis urticante. Un patrón de reacción cutánea. Actas Dermosifiliogr. 2018;109:929–932.</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" => 686 "Ancho" => 900 "Tamanyo" => 176662 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Normal epidermis and dense perivascular lymphocytic infiltrate with abundant eosinophils. Preserved dermoepidermal junction (hematoxylin-eosin, original magnification ×20).</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" => 1326 "Ancho" => 1050 "Tamanyo" => 138515 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Excoriated erythematous papules on the back of a patient. B, Use of the Fric test to confirm dermographism on the back of a patient with prurigo lesions at different stages of progression.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: BP, bullous pemphigoid; BPH, benign prostatic hyperplasia; BT, blood test; CBC, complete blood count; CSU, chronic spontaneous urticaria; DIF, direct immunofluorescence; DM, diabetes mellitus; DR, drug reaction; GF, glomerular filtrate; MTX, methotrexate; N/A, not applicable; NSAIDs, non-steroidal anti-inflammatory drugs; OA, oral antihistamines; OC, oral corticosteroids; TC, topical corticosteroids; UD, urticarial dermatitis; WM, Waldenström macroglobulinemia.</p>" "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \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">Female \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">Male \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">Female \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">Male \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">Female \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">Female \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 \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">Comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DM<br>Dyslipidemia<br>Essential hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BPH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dyslipidemia<br>DM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DM<br>BPH<br>Ischemic heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DM<br>Osteoporosis<br>WM<br>Ovarian teratoma \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">Dermographism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \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">Initial clinical suspicion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scabies<br>Eczema<br>BP<br>UD<br>CSU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BP<br>Eczema<br>UD<br>CSU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">UD<br>CSU<br>Urticaria-vasculitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Allergic contact dermatitis<br>UD<br>BP<br>DR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scabies<br>Eczema<br>CSU<br>Dermatitis herpetiformis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CSU<br>Urticaria-vasculitis DR<br>BP \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">Histology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal epidermis<br>Superficial dermal perivascular, lymphocytic, and eosinophilic infiltrate with presence of eosinophils<br>DIF– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Focal parakeratosis, mild eosinophilic spongiosis, and poor vacuolization of the basement membrane Superficial perivascular lymphocytic infiltrate<br>Interstitial lymphocytic and eosinophilic infiltrate<br>DIF– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal epidermis<br>Superficial dermal perivascular, lymphocytic, and eosinophilic infiltrate with interstitial eosinophils<br><br>DIF– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal epidermis<br>Superficial dermal perivascular, lymphocytic, and eosinophilic infiltrate<br>DIF– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal epidermis<br>Superficial dermal perivascular, lymphocytic, and eosinophilic infiltrate with interstitial eosinophils<br>DIF– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal epidermis<br>Mild dermal edema, superficial and interstitial dermal perivascular, lymphocytic, and neutrophilic infiltrate without eosinophils<br>No signs of vasculitis<br>DIF– \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">Other diagnostic tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BT (IgE, 260 IU/mL;<br>eosinophils, 0.86 × 10<span class="elsevierStyleSup">3</span>/μL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patch test (negative) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BT:<br>normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BT (glucose, 195<span class="elsevierStyleHsp" style=""></span>mg/dL; GF, 52 mL/min; CBC, normal) \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">Final diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">UD (DR secondary to vildagliptin) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CSU<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CSU<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">UD (DR secondary to silodosin) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CSU<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Schnitzler syndrome \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">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Permethrin<br>OA<br>OC<br>TC<br>MTX<br>Vildagliptin (interrupted) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OA<br>OC<br>TC<br><br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OA<br>OC<br>NSAIDs (interrupted)<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OA<br>OC<br>TC<br>Silodosin (interrupted)<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Permethrin<br>OA<br>OC<br>TC<br>Montelukast Omalizumab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OA<br>OC<br>TC<br>MTX \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">Treatment response \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poor<br> \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">Delay between onset and diagnosis, mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \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">Follow-up, mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1915245.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Descriptive Data: Patient Characteristics, Clinical Presentation, and Treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Defining urticarial dermatitis. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 27 | 14 | 41 |
| 2024 October | 148 | 80 | 228 |
| 2024 September | 162 | 67 | 229 |
| 2024 August | 188 | 73 | 261 |
| 2024 July | 137 | 67 | 204 |
| 2024 June | 131 | 77 | 208 |
| 2024 May | 159 | 75 | 234 |
| 2024 April | 134 | 50 | 184 |
| 2024 March | 140 | 54 | 194 |
| 2024 February | 106 | 54 | 160 |
| 2024 January | 113 | 64 | 177 |
| 2023 December | 94 | 53 | 147 |
| 2023 November | 134 | 75 | 209 |
| 2023 October | 98 | 84 | 182 |
| 2023 September | 91 | 94 | 185 |
| 2023 August | 105 | 59 | 164 |
| 2023 July | 88 | 79 | 167 |
| 2023 June | 64 | 62 | 126 |
| 2023 May | 79 | 81 | 160 |
| 2023 April | 75 | 50 | 125 |
| 2023 March | 109 | 53 | 162 |
| 2023 February | 87 | 48 | 135 |
| 2023 January | 69 | 70 | 139 |
| 2022 December | 53 | 75 | 128 |
| 2022 November | 38 | 49 | 87 |
| 2022 October | 28 | 53 | 81 |
| 2022 September | 34 | 65 | 99 |
| 2022 August | 37 | 57 | 94 |
| 2022 July | 33 | 69 | 102 |
| 2022 June | 31 | 57 | 88 |
| 2022 May | 86 | 82 | 168 |
| 2022 April | 132 | 66 | 198 |
| 2022 March | 138 | 63 | 201 |
| 2022 February | 138 | 47 | 185 |
| 2022 January | 155 | 77 | 232 |
| 2021 December | 117 | 41 | 158 |
| 2021 November | 126 | 62 | 188 |
| 2021 October | 117 | 77 | 194 |
| 2021 September | 133 | 103 | 236 |
| 2021 August | 158 | 89 | 247 |
| 2021 July | 124 | 69 | 193 |
| 2021 June | 84 | 64 | 148 |
| 2021 May | 150 | 67 | 217 |
| 2021 April | 353 | 118 | 471 |
| 2021 March | 154 | 46 | 200 |
| 2021 February | 145 | 60 | 205 |
| 2021 January | 116 | 34 | 150 |
| 2020 December | 99 | 31 | 130 |
| 2020 November | 66 | 24 | 90 |
| 2020 October | 79 | 30 | 109 |
| 2020 September | 81 | 38 | 119 |
| 2020 August | 43 | 26 | 69 |
| 2020 July | 59 | 25 | 84 |
| 2020 June | 50 | 29 | 79 |
| 2020 May | 27 | 20 | 47 |
| 2020 April | 21 | 19 | 40 |
| 2020 March | 28 | 8 | 36 |
| 2020 February | 1 | 1 | 2 |
| 2019 April | 6 | 2 | 8 |
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