Case and Research Letters
Arthroderma benhamiae, an emerging dermatophyte cause of tinea
Arthroderma benhamiae, un dermatofito causante de una tiña emergente
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Lozano-Masdemont, B. Carrasco-Fernández, I. Polimón-Olabarrieta, M.T. Durán-Valle" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Lozano-Masdemont" "email" => array:1 [ 0 => "belenmasdemont@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Carrasco-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Polimón-Olabarrieta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M.T." "apellidos" => "Durán-Valle" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "<span class="elsevierStyleItalic">Arthroderma benhamiae,</span> un dermatofito causante de una tiña emergente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 841 "Ancho" => 805 "Tamanyo" => 68014 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tinea faciei on a 9-year-old boy. Note the inflammatory component, with micropustules.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 9-year-old boy was assessed because of an erythematous plaque next to the left eye, with micropustules and peripheral scaling (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesion had been present for 2 months. A sample was taken for direct examination and another sample for fungal culture by scraping the edge of the lesion with a scalpel and wad of sterile cotton wool. In direct microscopic examination of the sample, with potassium hydroxide 20% and dimethyl sulfoxide 40%, mycelia consistent with a dermatophytic fungus were observed. Scales from the lesion were cultured on Sabouraud chloramphenicol actidione agar plates. After 7 days, flat colonies with a starburst-like pattern at the edge had grown, with a bright yellow color on the front and reverse side of the colony (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B). A powdery white superficial mycelium developed with light radial folds at the center of the colonies (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The fungus hydrolyzed urea (Christensen and Maslen urea broth) after 7 days and sporulation did not present on the dextrose potato agar plate after 21 days of incubation. With a VITEK MS (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry [MALDI-TOF MS], BioMérieux), <span class="elsevierStyleItalic">Arthroderma benhamiae</span> (99.9%) was identified after 7 days of incubation on the potato dextrose agar. Molecular identification of the microorganism was performed in the Mycology Unit of the Spanish Microbiology Center in Majadahonda.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The lesion was treated for 1 month with terbinafine cream, but follicular involvement still persisted. Finally, the infection resolved with oral terbinafine 125 mg/d for 4 weeks.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The microbiology department of our hospital has recorded 15 cases of ringworm caused by <span class="elsevierStyleItalic">A. benhamiae</span> between 2005 and 2017, mainly in children with transmission by guinea pigs; the first case was in 2010 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). As in cases reported in the literature, all were cases of inflammatory ringworm.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Dermatophytic fungi are usually identified using conventional techniques based on macroscopic and microscopic morphology, although in some cases, absence of sporulation and morphological similarities between species requires identification using molecular techniques or the use of MALDI-TOF MS. In the present case, MALDI-TOF MS was used for identification due to the absence of fungal sporulation in the culture media. MALDI-TOF MS is a widely used technique in the field of bacteriology. The technique is based on obtaining a protein profile of the isolate and comparing this with a database. The use of this technique has expanded to mycology, with results equivalent to DNA sequence analyses, provided that the reference spectra for the species to be identified are included in the library used.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleItalic">A. benhamiae</span> is represented in the commercial library (V3) of the VITEK MS, which enabled its identification with a concordance of 99.9%.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A. benhamiae</span>, basionym (or previously denominated) <span class="elsevierStyleItalic">Trichophyton benhamiae</span>, is an emerging dermatophytic fungus that causes zoonotic epidemics from infected pets.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> Since 2002, there have been reports of inflammatory ringworm such as tinea corporis and faciei (more frequently), and tinea capitis and Kerion celsi. Onychomycoses are rare. In Japan, where the first cases were reported, contagion occurs through rabbits, rodents, and white-bellied hedgehogs, all of which are popular pets in that country. In Germany, guinea pigs are the main source of contagion.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The fungus has also been isolated from dogs and cats. Children and adolescents are the individuals most often affected, and cases in immunosuppressed individuals may also occur. The fungus can be confused macroscopically with <span class="elsevierStyleItalic">Microsporum canis</span> (yellow colonies) and microscopically with <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>/<span class="elsevierStyleItalic">Trichophyton interdigitale</span> (rounded conidia and urea hydrolysis), and so its incidence may be underestimated if not correctly identified. Even so, in some regions of Germany, it may already be the most widespread zoophilic dermatophyte.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In tinea capitis caused by <span class="elsevierStyleItalic">A. benhamiae</span> or extensive infections, oral terbinafin is the treatment of choice, followed by fluconazole or itraconazole,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> although few studies are available. Griseofulvin has also been used. The minimum duration of treatment is usually 4–6 weeks. For other types of lesions, topical antimycotic agents used in other dermatophytoses can be used, such as terbinafine, imidazoles, and ciclopirox.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is likely that the incidence of this dermatophytic fungus will increase, and so dermatologists should bring themselves up to date regarding relevant clinical and epidemiological aspects, methods of identification, and potential diagnostic errors.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" 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: Lozano-Masdemont B, et al. <span class="elsevierStyleItalic">Arthroderma benhamiae</span>, un dermatofito causante de una tiña emergente. Actas Dermosifiliogr. 2020;111:167–168.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 841 "Ancho" => 805 "Tamanyo" => 68014 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tinea faciei on a 9-year-old boy. Note the inflammatory component, with micropustules.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 691 "Ancho" => 1305 "Tamanyo" => 99559 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Scale culture on Sabouraud chloramphenicol actidione agar plates for 15 days (28 °C). Flat colonies with starburst-like pattern at the edge can be observed, with a bright yellow color on the front (A) and reverse (B) side of the colony. In the middle of the colonies, a powdery white superficial mycelium developed with light radial folds.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">A</span>. <span class="elsevierStyleItalic">benhamiae</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total number of cases (2005–2017) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of cases per year</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2010) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (2011) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (2012) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2013) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (2014) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (2015) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (2016) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2017) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Age range and number of cases</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Children \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5–12 years 13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Adults \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19–35 years 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical form</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tinea corporis 9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tinea faciei 4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tinea capitis with tinea faciei 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tinea manuum 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2273252.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Summary of demographic and clinical data of ringworm caused by <span class="elsevierStyleItalic">A. benhamiae</span> in our center between 2005 and 2017.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MALDI-TOF-based dermatophyte identification" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. L’Ollivier" 1 => "S. Ranque" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11046-016-0080-x" "Revista" => array:6 [ "tituloSerie" => "Mycopathologia" "fecha" => "2017" "volumen" => "182" "paginaInicial" => "183" "paginaFinal" => "192" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27734185" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Molecular epidemiology of <span class="elsevierStyleItalic">Arthroderma benhamiae</span>, an emerging pathogen of dermatophytoses in Japan, by polymorphisms of the non-transcribed spacer region of the ribosomal DNA" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Mochizuki" 1 => "M. Kawasaki" 2 => "H. Ishizaki" 3 => "R. Kano" 4 => "A. Hasegawa" 5 => "H. Tosaki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0923-1811(01)00101-3" "Revista" => array:6 [ "tituloSerie" => "J Dermatol Sci" "fecha" => "2001" "volumen" => "27" "paginaInicial" => "14" "paginaFinal" => "20" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11457639" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case report. First report on human ringworm caused by <span class="elsevierStyleItalic">Arthroderma benhamiae</span> in Japan transmitted from a rabbit" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Y. Nakamura" 1 => "R. Kano" 2 => "E. Nakamura" 3 => "K. Saito" 4 => "S. Watanabe" 5 => "A. Hasegawa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1439-0507.2002.00732.x" "Revista" => array:6 [ "tituloSerie" => "Mycoses" "fecha" => "2002" "volumen" => "45" "paginaInicial" => "129" "paginaFinal" => "131" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12000518" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pets as the main source of two zoonotic species of the Trichophyton mentagrophytes complex in Switzerland, <span class="elsevierStyleItalic">Arthroderma vanbreuseghemii</span> and <span class="elsevierStyleItalic">Arthroderma benhamiae</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Drouot" 1 => "B. Mignon" 2 => "M. Fratti" 3 => "P. Roosje" 4 => "M. Monod" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-3164.2008.00691.x" "Revista" => array:6 [ "tituloSerie" => "Vet Dermatol" "fecha" => "2009" "volumen" => "20" "paginaInicial" => "13" "paginaFinal" => "18" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18699813" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trichophyton species of <span class="elsevierStyleItalic">Arthroderma benhamiae</span> – a new infectious agent in dermatology" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Nenoff" 1 => "S. Uhrlaß" 2 => "C. Krüger" 3 => "M. Erhard" 4 => "U.C. Hipler" 5 => "F. Seyfarth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ddg.12390" "Revista" => array:6 [ "tituloSerie" => "J Dtsch Dermatol Ges" "fecha" => "2014" "volumen" => "12" "paginaInicial" => "571" "paginaFinal" => "581" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24981469" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011100000002/v1_202004140647/S1578219020300032/v1_202004140647/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000011100000002/v1_202004140647/S1578219020300032/v1_202004140647/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219020300032?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 15 | 30 |
| 2024 October | 113 | 76 | 189 |
| 2024 September | 115 | 48 | 163 |
| 2024 August | 138 | 82 | 220 |
| 2024 July | 139 | 52 | 191 |
| 2024 June | 123 | 59 | 182 |
| 2024 May | 140 | 71 | 211 |
| 2024 April | 113 | 34 | 147 |
| 2024 March | 126 | 32 | 158 |
| 2024 February | 91 | 37 | 128 |
| 2024 January | 111 | 32 | 143 |
| 2023 December | 113 | 28 | 141 |
| 2023 November | 164 | 29 | 193 |
| 2023 October | 129 | 34 | 163 |
| 2023 September | 123 | 33 | 156 |
| 2023 August | 123 | 32 | 155 |
| 2023 July | 143 | 31 | 174 |
| 2023 June | 116 | 23 | 139 |
| 2023 May | 110 | 27 | 137 |
| 2023 April | 59 | 17 | 76 |
| 2023 March | 112 | 31 | 143 |
| 2023 February | 94 | 15 | 109 |
| 2023 January | 64 | 28 | 92 |
| 2022 December | 86 | 46 | 132 |
| 2022 November | 53 | 26 | 79 |
| 2022 October | 63 | 24 | 87 |
| 2022 September | 85 | 30 | 115 |
| 2022 August | 89 | 32 | 121 |
| 2022 July | 78 | 42 | 120 |
| 2022 June | 69 | 36 | 105 |
| 2022 May | 120 | 49 | 169 |
| 2022 April | 126 | 33 | 159 |
| 2022 March | 117 | 54 | 171 |
| 2022 February | 90 | 47 | 137 |
| 2022 January | 147 | 80 | 227 |
| 2021 December | 102 | 52 | 154 |
| 2021 November | 91 | 41 | 132 |
| 2021 October | 138 | 61 | 199 |
| 2021 September | 87 | 45 | 132 |
| 2021 August | 104 | 24 | 128 |
| 2021 July | 98 | 25 | 123 |
| 2021 June | 96 | 17 | 113 |
| 2021 May | 102 | 39 | 141 |
| 2021 April | 244 | 58 | 302 |
| 2021 March | 135 | 29 | 164 |
| 2021 February | 86 | 35 | 121 |
| 2021 January | 108 | 9 | 117 |
| 2020 December | 77 | 22 | 99 |
| 2020 November | 54 | 25 | 79 |
| 2020 October | 43 | 21 | 64 |
| 2020 September | 50 | 19 | 69 |
| 2020 August | 42 | 15 | 57 |
| 2020 July | 44 | 18 | 62 |
| 2020 June | 27 | 18 | 45 |
| 2020 May | 35 | 14 | 49 |
| 2020 April | 58 | 21 | 79 |
| 2020 March | 7 | 9 | 16 |
| 2020 February | 1 | 2 | 3 |
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