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Prevalence of actinic keratosis among dermatology outpatients in Spain
Prevalencia de queratosis actínica en pacientes ambulatorios de dermatología en España
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Serie de 14 casos y revisión de la literatura" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e57" "paginaFinal" => "e63" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Extrafacial Lentigo Maligna: A Report on 14 Cases and a Review of the Literature" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "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" => 1125 "Ancho" => 1502 "Tamanyo" => 357982 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Caso 2: paciente de 88 años de edad, con mácula pigmentada en la mano de años de evolución. A. Mácula pigmentada, asimétrica tanto en morfología como en pigmentación. B. En la dermatoscopia se aprecia pigmentación anular granular en uno de los márgenes, con estructuras romboidales y áreas de regresión. C. Extirpación de una lesión tumoral constituida por una proliferación individual de melanocitos con halo claro sobre una piel con daño actínico (intensa elastosis solar) y atrofia epidérmica (H-E ×<span class="elsevierStyleHsp" style=""></span>20). D. A mayor aumento observamos esta proliferación de células epitelioides que ascienden a capas altas, y fibrosis subepidérmica (H-E ×<span class="elsevierStyleHsp" style=""></span>200).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Martínez-Leboráns, J. Garcías-Ladaria, V. Oliver-Martínez, V. Alegre de Miquel" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Martínez-Leboráns" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Garcías-Ladaria" ] 2 => array:2 [ "nombre" => "V." 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Ferrándiz, M.J. Plazas, M. Sabaté, R. Palomino" "autores" => array:5 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Ferrándiz" "email" => array:1 [ 0 => "cferrandiz.germanstrias@gencat.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.J." "apellidos" => "Plazas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Sabaté" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Palomino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 4 => array:1 [ "colaborador" => "on behalf of EPIQA Study Group" ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Dermotología, Hospital Universitari Germans Trias i Pujol, Badalona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Medical Department Spain, Almirall, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "TFS Develop, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Área de investigación aplicada, GOC Networking, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prevalencia de queratosis actínica en pacientes ambulatorios de dermatología en España" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0025" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 435 "Ancho" => 2213 "Tamanyo" => 103220 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Actinic keratoses (AKs) are common skin lesions primarily caused by non-ionizing radiation, in particular ultraviolet light associated with chronic sun exposure. People with AK have an increased risk of developing squamous cell carcinoma (SCC) and other skin malignancies.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> A systematic review showed that the progression rate of AK to invasive SCC was between 0% and 0.075% per lesion-year,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> with a higher rate of progression for immunosuppressed patients.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Studies of AK prevalence in Europe are scarce and reported prevalence rates vary greatly; ranging from 1% to 3% reported in Italy and Germany<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,6</span></a> to 29% to 49% in men and 24% to 28% in women in Austria and Netherlands, respectively.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7,8</span></a> This variability is most likely due to differences in methodology, population phototype, and the geographic location of the sample.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5–9</span></a> Currently, there are no data available on the AK prevalence in Spain and AK is thought to be underdiagnosed due to the asymptomatic nature of the lesions.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The main aim of this study was to determine the prevalence of AK in a Spanish population attending general dermatology outpatient clinics for any reason.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was an observational, cross-sectional, and multicentre study.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Estimating a 15% of AK prevalence in patients aged 45 years or over and an alpha risk of 95% for an accuracy of 1% in bilateral contrast, a sample of 4032 patients was planned according to the protocol.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In order to ensure minimal geographic misrepresentation (and avoid potential climate bias), 19 out of 20 Hospitals with dermatology services were selected (1 centre retired before starting of the study) from the different autonomous communities across the northern, central, southern and Mediterranean areas of Spain.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Each hospital aimed to include 204 Caucasian patients, aged 45 years or older, who consecutively attended a general dermatology outpatient clinic for any reason, at any time from October 2013 to April 2014. Immunosuppressed patients were excluded. Written informed consent was obtained from every participant.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Whole-body examinations were performed by certified dermatologists. Patients were screened for the presence of AK lesions at pre-defined anatomical sites (face, scalp, ears, back of the hands and forearms, neck and others). Standardised interviews regarding personal and medical history were conducted and included the following topics: profession, sun exposure habits, use of artificial light sources, and personal history of non-melanoma skin cancer.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Point prevalence was given as percent values; corresponding 95% confidence intervals (95% CI) were computed by a general method using normal distribution.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Description of qualitative variables was performed using absolute frequencies and percentages. Standard descriptive statistics such as mean and standard deviation (SD) were also calculated. Qualitative variables were analysed by the Chi-square test or the Fisher exact test, as appropriate, and quantitative variables were analysed using the <span class="elsevierStyleItalic">t</span>-test or the Mann–Whitney test. Values of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 were considered statistically significant. No imputations to missing data were performed. Statistical analysis was performed using IBM SPSS statistics V.19 (SPSS, an IBM company, Chicago, Illinois, USA).</p><p id="par0055" class="elsevierStylePara elsevierViewall">The study was conducted in accordance with the Declaration of Helsinki and local laws and regulations. All patients provided written informed consent before study entry. The study was approved by the Ethical Committee of Hospital Universitari Germans Trias i Pujol.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">A total of 3877 patients were recruited and all of them were included. Of the 20 hospitals selected, 19 participated in the study (one hospital retired from the study without including any patients). Patients’ mean (SD) age was 66.1 (12.2) years and, 55.6% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2156) were women. The presence of AK lesions was the reason for consultation for 748 (19.3%) patients, with the remaining 3129 (80.7%) patients citing “other reasons” for the consultation (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Prevalence of AK</span><p id="par0065" class="elsevierStylePara elsevierViewall">Among the 3877 patients included, 1110 had confirmed AK (28.6%, 95% CI 27.2–30.1). This point prevalence was significantly higher in men than women (38.4%, 95% CI 36.1–40.7 vs. 20.8%, 95% CI 19.1–22.6, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001) and increased with age (4.5% in the age group 45–50 years old to 60.4% in those over 80 years old) [<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>].</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The distribution of AK according to geographical distribution showed the highest prevalence in the Mediterranean and southern areas of Spain (31.4% and 28.1%, respectively), compared to the northern and central areas (27.5% and 24.9%, respectively).</p><p id="par0075" class="elsevierStylePara elsevierViewall">A positive correlation between age group and AK prevalence was observed (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.985, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01), and was significantly higher for men compared to women in all age groups (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001) except for patients between 45 and 50 years old (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients with confirmed AK had a mean age of 74.3 (10.1) years and 59.5% were male. More than one-third of patients had high recreational sun exposure (35.7%). The most frequent phototypes were II and III (45.7% and 43.6%, respectively) and 32.0% had a personal history of non-melanoma skin cancer. Thirty-five percent of patients were unaware of having AK and attended the dermatology consultation for other reasons (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Anatomical site distribution</span><p id="par0085" class="elsevierStylePara elsevierViewall">The frequency of AK according to anatomical location was most common on the face (77.3%, with the forehead being the most frequent [46.3%]), followed by the scalp (32.0%). Comparisons by sex according to location showed significant differences (men vs. women) for the scalp (51.9% vs. 2.7%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001), and ears (16.9% vs. 2.4%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001). By contrast, nose and cheek were significantly more affected in women compared to men (43.0% vs. 24.8%, and 46.3% vs. 34.0%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001 in both cases), as was the neckline (5.3% vs.1.8%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.0020) [<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>].</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Extent of disease</span><p id="par0090" class="elsevierStylePara elsevierViewall">Only one out of four patients with AK presented with a single lesion. Thirty-four percent of patients had 2–4 lesions, and 26.9% 5–10 lesions. The mean age of patients according to the number of lesions was statistically significant, that is, as age increased, the number of lesions significantly increased (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001) [<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>].</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The number of affected areas was statistically associated with age (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001) [<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>]. Men had a significant higher frequency of having two or more affected areas compared to women (42.7% vs. 20.3%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">In this study the overall prevalence of AK was 28.6% in a dermatology outpatient population aged ≥45 years old (38.4% in men and 20.8% in women). These results reflect similar overall AK prevalence rates from other recent studies conducted in Netherlands and Austria (2061 inhabitants and 4449 dermatology patients, respectively) that showed a prevalence of 37.5% (49.0% in men and 28.1% in women, in patients >50 years old) and 31.0% (39.2% in men and 24.3% in women, aged ≥30), respectively.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7,8</span></a> By contrast, several studies have found lower prevalence rates within other study populations. For example, a study in the North of England found an AK prevalence of 15.4% in men and 5.9% in women, in a sample of 968 subjects >40 years attending outpatient clinics.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Furthermore, large studies in Germany (determined in a cohort of 90,800 employees from 300 companies) and Italy (which included a total of 12,483 subjects selected from electoral rolls) displayed much a lower AK prevalence of 2.7% (3.9% in men and 1.5% in women, patients aged 16–70 years) and 1.4% (1.5% in men and 1.4% in women, in patients aged ≥45), respectively.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,6</span></a> The low AK prevalence observed in Germany may be underestimated due to the age range of the selected population – employees aged 16–70 years old that did not include retirees, where AK is most prevalent, and included young people, in whom AK is very rare. More surprising is the low prevalence reported in Italy, given its similar climate to Spain. One possible explanation for the disparity results presented here and those of the Italian study is the staff who assessed the AK lesions; in this study the assessment was performed by certified dermatologists, whereas the Italian study assessments were performed by trained interviewers (2-h teaching session) who conducted a face-to-face interview at the subjects house.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Taken together, the results reported here and in other European studies suggest a highly variable prevalence that may be enhanced by subject selection which, among other factors, included different age groups. Moreover, in some studies the subject selection involved those attending dermatology services, while in other studies subjects were selected from electoral rolls, insurance companies’ data, or districts. In addition, the examination procedure in some studies was performed by dermatologists while in others it was performed by trained interviewers. Finally, the geographical location with different levels of UV radiation and different phototypes could also be a factor which contributed to the heterogeneity of the prevalence results reported.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In this study the prevalence of AK was observed to increase with age for both sexes, reaching 60.4% of patients older than 80. Similar observations were previously reported in other studies.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6,7,9</span></a> Moreover, in line with previous results, our data showed a higher prevalence of AK in men (38.4%) compared to women (20.8%).<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5–10</span></a> A possible explanation for this higher AK prevalence in men could be an increased occupational lifetime sun exposure associated with outdoor work. Studies conducted in Austria and the UK demonstrated higher AK prevalence rates in outdoor workers.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">11,12</span></a> Consistent with this, Harvey et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> also found cumulative sun exposure to be a significant risk factor associated to AK. Furthermore, a presumed lower-compliance with sun protection measures in men, differing hair coverage of the scalp and ears, and a much higher prevalence of baldness in men could also contribute to these sex differences.</p><p id="par0115" class="elsevierStylePara elsevierViewall">With regard to anatomical location, in this study AK lesions were correlated with the most intense chronic UV light exposure such as the forehead and scalp. The most frequently reported locations in men were the scalp and ears whereas for women the nose, cheek and neckline were more common. This data agrees with previous work which reported that the scalp was the most frequent location in bald men vs. women (47.5% in men vs. 0.0% in women<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a>). The difference in the frequency of lesions on the ears in men compared to women was also consistent with previous data from Youl et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> and Eder et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> who reported that ears were 3.4 and 5.8 times, respectively, more commonly affected in men than women with AK. In this study, it should be noted that the frequency of lesions in the nose, cheek and neckline was significantly higher in women than in men. These results are in agreement with previous studies that found that lesions on the face were more frequent in women than in men and scalp and ears were more frequent in men versus women.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> These differences in AK locations could be explained as areas like scalp and ears are more frequently uncovered in men than in women.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In relation to the number of lesions, an increase with age was observed. Patients with only one lesion had a mean age of 71 years of age, whereas in those patients with more than 30 lesions a mean of 82 years of age was recorded. These results are in accordance with those reported by Flohil et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> which showed that age was significantly associated with extensive actinic damage (≥10 AKs). Moreover, it was observed that the number of affected areas increases with age, as previously reported.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">It should be pointed out that 35% of patients with AK lesions ignored their presence. This shows that AK is an underdiagnosed disease and that a proactive strategy is required by the physician for the diagnosis and treatment of these lesions.</p><p id="par0130" class="elsevierStylePara elsevierViewall">This study has some limitations that should be noted. Firstly, the population of this study was restricted to patients visiting dermatology outpatient clinics, which may overestimate the number of patients with AK and might be not representative for the general population. Secondly, AK can be similar to SCC which may in some cases lead to misclassification. Nevertheless, some studies have showed a high predictive value for clinical AK diagnosis.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Thirdly, AK prevalence was determined using a cross-section of participants attending an outpatient clinic, thus it was unknown whether participants were previously treated for AK, which could have resulted in an underestimation of the AK prevalence.</p><p id="par0135" class="elsevierStylePara elsevierViewall">To the best of our knowledge, this is the first study to estimate of the prevalence of AK in adult dermatology outpatients in Spain. Nearly a quarter of 45-year-old patients or older were found to be affected with AK and this proportion increased with age. Knowledge about characteristics of patients with AK, geographic distribution, and AK locations will help to improve prevention, early detection and contribute to the development of effective treatment strategies to optimise clearance of AK lesions. Furthermore, early detection may have further downstream benefit in developing therapeutic interventions to prevent progression to invasive cutaneous neoplasia. Finally, it should be noted that almost than one-third of patients in this study have ignored the presence of these lesions, which suggest that AK is underdiagnosed and an early proactive detection and early treatment of AK lesions is needed in order to prevent the further development of invasive SCC.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical disclosure</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">This study was funded by Almirall S.A.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflict of interests</span><p id="par0160" class="elsevierStylePara elsevierViewall">Carlos Ferrandiz has received honoraria for lectures and/or consultancy Almirall, Leo Pharma and Spherium Biomed. Maria Jose Plazas is employed by Almirall. The other authors have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres735152" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres735153" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Aim" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusions" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec738880" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres735154" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0035" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0040" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0045" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0050" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0055" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec738881" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 7 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Prevalence of AK" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Anatomical site distribution" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Extent of disease" ] ] ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 9 => array:3 [ "identificador" => "sec0040" "titulo" => "Ethical disclosure" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interests" ] 12 => array:2 [ "identificador" => "xack244419" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-19" "fechaAceptado" => "2016-05-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec738880" "palabras" => array:5 [ 0 => "Actinic keratosis" 1 => "Prevalence" 2 => "Skin lesions" 3 => "Outpatient population" 4 => "Spain" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec738881" "palabras" => array:5 [ 0 => "Queratosis actínica" 1 => "Prevalencia" 2 => "Lesiones cutáneas" 3 => "Población ambulatoria" 4 => "España" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Background</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Actinic keratoses (AKs) are common skin lesions associated with an increased risk of developing squamous cell carcinoma. Few studies in Europe have focused on AK prevalence.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Aim</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">To determine the point prevalence of AKs in a dermatology outpatient population in Spain, to describe the clinical characteristics of these lesions and to characterise the profile of AK patients.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Methods</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Observational, cross-sectional, multicentre study conducted in 19 hospitals (dermatology outpatient services) around Spain. A total of 204 consecutive patients per hospital who were ≥45 years old were screened for the presence of AKs.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">3877 patients were assessed and the overall AKs prevalence was 28.6%. Prevalence was significantly higher in men than women (38.4% vs. 20.8%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001) and increased with age for both sexes (45.2% in 71–80 years). Scalp and ear lesion locations were significantly more frequent in men (51.9% vs. 2.7% and 16.9% vs. 2.4%, respectively, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001 both cases) and the cheek, nose and neckline in women (46.3% vs. 34.0% [<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001], 43.0% vs. 24.8% [<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001] and 5.3% vs. 1.8% [<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002]). Men showed a significantly higher frequency of ≥2 affected areas than women (42.7% vs. 20.3%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001). Among patients with AK lesions, only 65% confirmed that they were the reason for the visit to the clinic.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Approximately a quarter of the dermatology outpatient population in Spain aged ≥45 years old have AKs, with the prevalence rate being highest in men and in older age groups. AK is underdiagnosed and a proactive strategy is needed for the diagnosis and early treatment of these lesions.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Aim" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Antecedentes</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las queratosis actínicas (QA) son lesiones cutáneas comunes asociadas a un mayor riesgo de desarrollar carcinoma de células escamosas. Hay pocos estudios en Europa sobre la prevalencia de QA.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Objetivos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Determinar la prevalencia de QA en una población de pacientes ambulatorios dermatológicos en España y describir las características clínicas de los pacientes con QA.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional, transversal, multicéntrico (19 hospitales, servicios de consultas externas de dermatología) en España. Se incluyeron 204 pacientes consecutivamente por centro, edad ≥<span class="elsevierStyleHsp" style=""></span>45 años y se determinó la presencia de QA.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se evaluaron 3.877 pacientes. La prevalencia de QA fue de 28,6% y esta fue más alta en hombres que en mujeres (38,4% vs. 20,8%, p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,0001), incrementándose con la edad en ambos sexos (45,2%, 71-80 años). Las lesiones en el cuero cabelludo y en la oreja fueron más frecuentes en hombres (51,9% vs. 2,7% y 16,9% vs. 2,4%, respectivamente, p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,0001 ambos casos) y la mejilla, la nariz y el escote en mujeres (46,3% vs. 34,0% [p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,0001], 43,0% vs. 24,8% [p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,0001] y 5,3% vs. 1,8% [p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,002]). Los hombres presentaron una mayor frecuencia de ≥<span class="elsevierStyleHsp" style=""></span>2 zonas afectadas vs. mujeres (42,7% vs. 20,3%, p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,0001). Entre los pacientes con QA solo el 65% confirmó que esta era el motivo de la visita.</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Aproximadamente una cuarta parte de la población ambulatoria de dermatología en España ≥<span class="elsevierStyleHsp" style=""></span>45 años presenta alguna QA, con una prevalencia más alta en los hombres y los grupos de mayor edad. La QA está infradiagnosticada y se requiere de una estrategia proactiva para el diagnóstico precoz y el tratamiento.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0035" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0040" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0045" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0050" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0055" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1277 "Ancho" => 1610 "Tamanyo" => 111709 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Prevalence of AK according to age and sex.</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" => 1344 "Ancho" => 2670 "Tamanyo" => 173363 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Body-site distribution of AK according to sex.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 969 "Ancho" => 2228 "Tamanyo" => 126557 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Number of lesions according to age.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1067 "Ancho" => 1567 "Tamanyo" => 76660 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Number of affected areas by age.</p>" ] ] 4 => 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:3 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AK, actinic keratosis; SD, standard deviation.</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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Total population (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3877) \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"><span class="elsevierStyleItalic">Sex (female), n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2156 (55.6%) \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"><span class="elsevierStyleItalic">Age (years), mean (SD)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.1 (12.2) \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"><span class="elsevierStyleItalic">Median (min, max)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (45; 100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Reason for consultation, n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AK \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">748 (19.3%) \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"><span class="elsevierStyleHsp" style=""></span>Other reasons<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3129 (80.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">High solar exposure due to profession</span>,<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a><span class="elsevierStyleItalic">n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">879 (22.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">High solar exposure by occupation</span>,<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a><span class="elsevierStyleItalic">n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Farmers, ranchers, and fishermen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">404 (10.4%) \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"><span class="elsevierStyleHsp" style=""></span>Artisans, builders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">167 (4.3%) \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"><span class="elsevierStyleHsp" style=""></span>Elementary occupations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">154 (4.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">High solar exposure due to recreational activities</span>,<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1024 (26.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1213347.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">High solar exposition was considered when working all day in the open air.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">High recreational sun exposure was considered when the patient regularly participates in outdoor recreational activities year round.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The percentage of patients was calculated among the total of AK patients with other reasons for consultation (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>390): cutaneous carcinomas (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>153, 39.2%), melanoma (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12, 3.1%), inflammatory dermatitis (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>45, 11.5%), benign pigmented tumours (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21, 5.4%), other benign tumours (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>90, 23.1%), cutaneous infections (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20, 5.1%), miscellany (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>23, 5.6%), adnexal diseases (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15, 3.8%), pruritus (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8, 2.1%), and mucosal disease (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4, 1.0%).</p>" ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Only occupations with percentages of solar exposure ≥4% are shown.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Demographical and clinical characteristics of the total population.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">AK, actinic keratosis; SD, standard deviation; NMSC, non-melanoma skin cancer.</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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">AK population (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1110) \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"><span class="elsevierStyleItalic">Sex (female), n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">449 (40.5%) \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"><span class="elsevierStyleItalic">Age (years), mean (SD)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.3 (10.1) \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"><span class="elsevierStyleItalic">Median (min, max)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 (45; 100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Reason for consultation, n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AK \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">720 (64.9%) \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"><span class="elsevierStyleHsp" style=""></span>Other reasons \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">390 (35.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Professional solar exposure (high)</span>,<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">401 (36.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">High solar exposure by occupation</span>,<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a><span class="elsevierStyleItalic">n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Farmers, ranchers, and fishermen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">226 (20.4%) \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"><span class="elsevierStyleHsp" style=""></span>Artisans, builders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 (6.1%) \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"><span class="elsevierStyleHsp" style=""></span>Elementary occupations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Recreational sun exposure (high)</span>,<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">396 (35.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Lesion localizations</span>,<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">d</span></a><span class="elsevierStyleItalic">n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Face \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">858 (77.3%) \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"><span class="elsevierStyleHsp" style=""></span>Scalp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">355 (32.0%) \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"><span class="elsevierStyleHsp" style=""></span>Ears \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">123 (11.1%) \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"><span class="elsevierStyleHsp" style=""></span>Back hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">118 (10.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Phototype, n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Type I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (3.6%) \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"><span class="elsevierStyleHsp" style=""></span>Type II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">507 (45.7%) \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"><span class="elsevierStyleHsp" style=""></span>Type III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">484 (43.6%) \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"><span class="elsevierStyleHsp" style=""></span>Type IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 (7.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Personal history of NMSC, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">355 (32.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1213348.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">High solar exposition was considered when working all day in the open air.</p>" ] 1 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">High recreational sun exposure was considered when the patient regularly participates in outdoor recreational activities year round.</p>" ] 2 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Only occupations with percentages of solar exposure ≥4% are shown.</p>" ] 3 => array:3 [ "identificador" => "tblfn0040" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Only locations with percentages of AK >10%.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Demographical and clinical characteristics of patients with AK.</p>" ] ] 6 => array:5 [ "identificador" => "fig0025" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 435 "Ancho" => 2213 "Tamanyo" => 103220 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actinic keratosis: rationale and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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| año/Mes | Html | Total | |
|---|---|---|---|
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| 2023 Marzo | 76 | 21 | 97 |
| 2023 Febrero | 79 | 48 | 127 |
| 2023 Enero | 76 | 52 | 128 |
| 2022 Diciembre | 72 | 62 | 134 |
| 2022 Noviembre | 89 | 64 | 153 |
| 2022 Octubre | 89 | 40 | 129 |
| 2022 Septiembre | 59 | 48 | 107 |
| 2022 Agosto | 61 | 60 | 121 |
| 2022 Julio | 70 | 56 | 126 |
| 2022 Junio | 90 | 45 | 135 |
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| 2022 Abril | 121 | 56 | 177 |
| 2022 Marzo | 146 | 74 | 220 |
| 2022 Febrero | 128 | 45 | 173 |
| 2022 Enero | 120 | 66 | 186 |
| 2021 Diciembre | 84 | 42 | 126 |
| 2021 Noviembre | 89 | 63 | 152 |
| 2021 Octubre | 69 | 69 | 138 |
| 2021 Septiembre | 51 | 53 | 104 |
| 2021 Agosto | 36 | 45 | 81 |
| 2021 Julio | 42 | 42 | 84 |
| 2021 Junio | 41 | 36 | 77 |
| 2021 Mayo | 43 | 53 | 96 |
| 2021 Abril | 176 | 98 | 274 |
| 2021 Marzo | 96 | 37 | 133 |
| 2021 Febrero | 84 | 30 | 114 |
| 2021 Enero | 49 | 25 | 74 |
| 2020 Diciembre | 43 | 25 | 68 |
| 2020 Noviembre | 41 | 31 | 72 |
| 2020 Octubre | 46 | 24 | 70 |
| 2020 Septiembre | 44 | 41 | 85 |
| 2020 Agosto | 34 | 25 | 59 |
| 2020 Julio | 44 | 31 | 75 |
| 2020 Junio | 42 | 38 | 80 |
| 2020 Mayo | 38 | 31 | 69 |
| 2020 Abril | 40 | 28 | 68 |
| 2020 Marzo | 42 | 22 | 64 |
| 2020 Febrero | 1 | 0 | 1 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 1 | 2 | 3 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 5 | 2 | 7 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 4 | 2 | 6 |
| 2019 Abril | 4 | 5 | 9 |
| 2019 Marzo | 0 | 1 | 1 |
| 2019 Febrero | 4 | 0 | 4 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 2 | 4 | 6 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Junio | 1 | 0 | 1 |
| 2018 Abril | 2 | 0 | 2 |
| 2018 Febrero | 11 | 4 | 15 |
| 2018 Enero | 16 | 11 | 27 |
| 2017 Diciembre | 12 | 22 | 34 |
| 2017 Noviembre | 17 | 6 | 23 |
| 2017 Octubre | 2 | 6 | 8 |
| 2017 Septiembre | 9 | 8 | 17 |
| 2017 Agosto | 12 | 9 | 21 |
| 2017 Julio | 8 | 5 | 13 |
| 2017 Junio | 19 | 14 | 33 |
| 2017 Mayo | 16 | 10 | 26 |
| 2017 Abril | 18 | 8 | 26 |
| 2017 Marzo | 10 | 17 | 27 |
| 2017 Febrero | 14 | 15 | 29 |
| 2017 Enero | 13 | 13 | 26 |
| 2016 Diciembre | 19 | 26 | 45 |
| 2016 Noviembre | 25 | 23 | 48 |
| 2016 Octubre | 49 | 58 | 107 |
| 2016 Septiembre | 2 | 6 | 8 |
| 2016 Agosto | 2 | 2 | 4 |
| 2016 Julio | 1 | 1 | 2 |
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