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    "titulo" => "Discoid Lupus Erythematosus in a Patient With Alopecia Totalis"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; Alopecia totalis on the scalp and erythema scattered on the cheek&#44; nose&#44; and lips&#46; &#40;b&#41; Infiltrative erythemas on the upper cheek&#46; &#40;c&#41; A biopsy specimen showing epidermal atrophy&#44; liquefaction of the basement membrane&#44; dyskeratotic epidermal cells&#44; and focal mononuclear cell infiltration in the dermis&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We herein describe a rare case of discoid lupus erythematosus &#40;DLE&#41; in a patient with alopecia totalis&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 42-year-old female developed alopecia on the scalp&#44; which worsened and involved all areas of the scalp 10 years previously&#46; She received various treatments&#44; such as topical corticosteroids&#44; topical carpronium chloride&#44; oral prednisolone&#44; intra-lesional triamcinolone acetonide&#44; and cryotherapy&#44; for five years without success&#44; and thus discontinued therapy a few years previously&#46; She visited the dermatology clinic at Hanawa Kousei Hospital&#44; complaining of asymptomatic facial erythemas which appeared one year previously&#46; Physical examination revealed infiltrative scaly erythemas on the cheek&#44; nose&#44; lips&#44; and upper back &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#44;b&#41;&#46; Total alopecia of the scalp was also observed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#46; Her eyebrows fell out&#44; while the eyelashes remained intact&#46; Laboratory examination showed positive anti-nuclear antibody &#40;ANA&#41; &#40;1&#58;1280&#44; speckled&#41;&#44; whereas other data such as complete blood count&#44; liver and renal function&#44; serum complement levels&#44; anti-double strand DNA antibody&#44; anti-Sm antibody&#44; anti-SS-A antibody&#44; anti-SS-B antibody&#44; and antiphospholipid antibody were all within normal range&#46; A biopsy specimen taken from the cheek revealed individual cell keratinization&#44; liquefaction of epidermal basal membranes&#44; and focal mononuclear cell infiltration in the dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c&#41;&#46; Examination by direct immunofluorescence showed linear deposition of IgG&#44; IgM&#44; and C3&#46; A diagnosis of DLE was made&#46; Facial and back erythemas much improved by oral hydroxychloroquine &#40;Plaquenil<span class="elsevierStyleSup">R</span>&#44; Sanofi&#44; Swiss&#41; &#40;200&#8239;mg and 400&#8239;mg per alternate day&#41; six months later&#59; however&#44; her alopecia remained unchanged&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient suffering alopecia totalis developed DLE with nearly nine years&#8217; interval&#44; and alopecia was already stable when the DLE lesions appeared&#46; Her scalp alopecia was non-scarring without erythema&#44; and was therefore not identified as lupus alopecia&#44; although biopsy was not carried out&#46; Alopecia areata is sometimes associated with other autoimmune or allergic diseases&#44; and there has been increased incidence of alopecia areata and lupus erythematosus&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> To date&#44; several cases of DLE in association with alopecia have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Among patients with severe types of alopecia such as alopecia totalis and universalis&#44; thyroid disease was most prevalent&#44; followed by vitiligo&#44; diabetes&#44; atopic dermatitis&#44; dyslipidemia&#44; hypertension&#44; psoriasis&#44; and internal malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; to our knowledge&#44; co-existence of DLE and alopecia totalis has not yet been reported&#46; The present case showed a high titer of ANA &#40;1&#58;1280&#41;&#44; suggesting that immunological abnormalities may have developed the DLE&#46; She did not have any other specific autoantibodies&#44; or other symptoms suggestive of systemic autoimmune diseases&#46; Regarding the pathogenesis of alopecia areata&#44; Th2 type cytokine predominance is seen in localized type while Th1 predominance in generalized type&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Furthermore&#44; recent findings suggest an important role of IL-17 in alopecia&#59;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> however&#44; the role of Th17 cells in DLE remains unclear&#46; The cutaneous inflammatory infiltrates are dominated by Th1&#44; but not Th17 cells&#44; in the DLE lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> A genome-wide study has suggested that several genomic regions are significantly associated with alopecia areata&#44; lupus erythematosus&#44; and other autoimmune diseases&#46; Such immune-mediated imbalance may have contributed to the development of alopecia totalis and DLE in our case&#46; The facial lesions of our patient were eventually improved with hydroxychloroquine&#44; which did not show any effects on the alopecia lesions&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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Case and Research Letters
Discoid Lupus Erythematosus in a Patient With Alopecia Totalis
Lupus eritematoso discoide en una paciente con alopecia totalis
M. Yamamoto
Corresponding author
toyamade@fmu.ac.jp

Corresponding author.
, T. Yamamoto
Departamento de Dermatología, Universidad Médica de Fukushima, Fukushima, Japan
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We herein describe a rare case of discoid lupus erythematosus &#40;DLE&#41; in a patient with alopecia totalis&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 42-year-old female developed alopecia on the scalp&#44; which worsened and involved all areas of the scalp 10 years previously&#46; She received various treatments&#44; such as topical corticosteroids&#44; topical carpronium chloride&#44; oral prednisolone&#44; intra-lesional triamcinolone acetonide&#44; and cryotherapy&#44; for five years without success&#44; and thus discontinued therapy a few years previously&#46; She visited the dermatology clinic at Hanawa Kousei Hospital&#44; complaining of asymptomatic facial erythemas which appeared one year previously&#46; Physical examination revealed infiltrative scaly erythemas on the cheek&#44; nose&#44; lips&#44; and upper back &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#44;b&#41;&#46; Total alopecia of the scalp was also observed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#46; Her eyebrows fell out&#44; while the eyelashes remained intact&#46; Laboratory examination showed positive anti-nuclear antibody &#40;ANA&#41; &#40;1&#58;1280&#44; speckled&#41;&#44; whereas other data such as complete blood count&#44; liver and renal function&#44; serum complement levels&#44; anti-double strand DNA antibody&#44; anti-Sm antibody&#44; anti-SS-A antibody&#44; anti-SS-B antibody&#44; and antiphospholipid antibody were all within normal range&#46; A biopsy specimen taken from the cheek revealed individual cell keratinization&#44; liquefaction of epidermal basal membranes&#44; and focal mononuclear cell infiltration in the dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c&#41;&#46; Examination by direct immunofluorescence showed linear deposition of IgG&#44; IgM&#44; and C3&#46; A diagnosis of DLE was made&#46; Facial and back erythemas much improved by oral hydroxychloroquine &#40;Plaquenil<span class="elsevierStyleSup">R</span>&#44; Sanofi&#44; Swiss&#41; &#40;200&#8239;mg and 400&#8239;mg per alternate day&#41; six months later&#59; however&#44; her alopecia remained unchanged&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient suffering alopecia totalis developed DLE with nearly nine years&#8217; interval&#44; and alopecia was already stable when the DLE lesions appeared&#46; Her scalp alopecia was non-scarring without erythema&#44; and was therefore not identified as lupus alopecia&#44; although biopsy was not carried out&#46; Alopecia areata is sometimes associated with other autoimmune or allergic diseases&#44; and there has been increased incidence of alopecia areata and lupus erythematosus&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> To date&#44; several cases of DLE in association with alopecia have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Among patients with severe types of alopecia such as alopecia totalis and universalis&#44; thyroid disease was most prevalent&#44; followed by vitiligo&#44; diabetes&#44; atopic dermatitis&#44; dyslipidemia&#44; hypertension&#44; psoriasis&#44; and internal malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; to our knowledge&#44; co-existence of DLE and alopecia totalis has not yet been reported&#46; The present case showed a high titer of ANA &#40;1&#58;1280&#41;&#44; suggesting that immunological abnormalities may have developed the DLE&#46; She did not have any other specific autoantibodies&#44; or other symptoms suggestive of systemic autoimmune diseases&#46; Regarding the pathogenesis of alopecia areata&#44; Th2 type cytokine predominance is seen in localized type while Th1 predominance in generalized type&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Furthermore&#44; recent findings suggest an important role of IL-17 in alopecia&#59;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> however&#44; the role of Th17 cells in DLE remains unclear&#46; The cutaneous inflammatory infiltrates are dominated by Th1&#44; but not Th17 cells&#44; in the DLE lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> A genome-wide study has suggested that several genomic regions are significantly associated with alopecia areata&#44; lupus erythematosus&#44; and other autoimmune diseases&#46; Such immune-mediated imbalance may have contributed to the development of alopecia totalis and DLE in our case&#46; The facial lesions of our patient were eventually improved with hydroxychloroquine&#44; which did not show any effects on the alopecia lesions&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Yamamoto M&#44; Yamamoto T&#46; Lupus eritematoso discoide en una paciente con alopecia totalis&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;77&#8211;79&#46;</p>"
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