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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Vulvar lichen sclerosus &#40;VLS&#41; is an underdiagnosed and undertreated chronic dermatosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> It has an estimated prevalence of 0&#46;1&#37;&#8211;1&#46;7&#37;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and a bimodal age distribution&#44; predominantly affecting prepubertal girls and postmenopausal women&#46; It is characterized by itching and scarring lesions that hinder normal sexual and urinary function&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Overregulation of the Th1 pathway gives rise to a chronic proinflammatory state in keratinocytes&#46; Inactivation of tumor suppression genes such as the p53 gene and <span class="elsevierStyleItalic">CDKN2A</span> leads to dysplastic changes that may facilitate subsequent development of vulvar squamous cell carcinoma &#40;vSCC&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;4</span></a> The purpose of the various therapies used &#40;including topical corticosteroids&#44; calcineurin inhibitors&#44; and photodynamic therapy&#41; is to relieve symptoms&#44; prevent scarring&#44; and avoid malignant transformation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> High-potency topical corticosteroids constitute the treatment of choice &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;5</span></a> While their use may hinder transformation to vSCC&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> it is not known whether they can reduce vSCC recurrence&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Chin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> recently published the results of a cohort study in patients with VLS with a history of excised vSCC or differentiated vulvar intraepithelial neoplasia &#40;dVIN&#41;&#46; The authors studied the association between indefinite therapy with topical corticosteroids &#40;daily use with a subsequent adjustment upon achieving disease control&#44; defined as skin with normal texture and no white discoloration&#41; and the risk of recurrence of vSCC or dVIN&#46; Patients excluded &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41; were those with vSCC or dVIN associated with papillomavirus&#44; those with poor adherence to corticosteroid treatment&#44; and those with less than 5 years of follow-up&#46; Eight patients &#40;73&#37;&#41; remained free of recurrence&#44; with a mean follow-up duration of 10&#46;5 years &#40;range&#44; 5&#46;1&#8211;16&#46;5 y&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Two patients &#40;18&#37;&#41; experienced recurrence&#58; one &#40;9&#37;&#41; had multiple recurrences of vSCC&#44; and the other &#40;9&#37;&#41; experienced recurrence of dVIN&#46; In total&#44; 27&#37; experienced some form of recurrence&#46; This rate differs from the 5-year recurrence rates reported in the literature for patients who did not undergo maintenance treatment &#40;44&#37;&#8211;47&#37;&#41;&#46; Only one patient &#40;9&#37;&#41; experienced multiple recurrences&#44; a much lower percentage than that reported in other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;4</span></a> No significant adverse effects associated with topical corticosteroid therapy were described&#46; One of the limitations of the study is its small sample size&#44; although the long follow-up period adds to the robustness of the findings&#46; Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> reported better clinical outcomes in patients receiving indefinite treatment with high potency corticosteroids&#44; which reduced anatomical alterations and symptoms and prevented the development of vSCC&#44; compared with previous studies in which topical corticosteroids were used only when patients presented clinical signs&#46; Prolonged use of topical corticosteroids could reduce chronic inflammation associated with the development of vSCC&#44; thereby decreasing health costs and morbidity&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A growing number of physicians are opting for indefinite treatment with topical corticosteroids&#44; although many remain wary of possible side effects and opt to discontinue treatment once symptoms are controlled&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> We wish to emphasize the importance of chronic topical corticosteroid treatment in patients with VLS&#44; especially those with prior vSCC&#47;dVIN&#44; to avoid recurrences and post-surgical sequelae&#46;</p></span>"
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                  \t\t\t\t">Recommended treatment&nbsp;\t\t\t\t\t\t\n
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                  \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
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Daily topical application for 1&#8211;3 months&#44; depending on clinical response&#44; subsequently on alternate days&#44; and ultimately twice per week as a maintenance regimen&nbsp;\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">Potential benefits&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Reduction in symptomsReduction in associated structural changes&#44; such as synechiae and scarringDecreased development of vSCCReduced recurrence of vSCC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Not defined&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cutaneous atrophy&#44; telangiectasias&#44; irritation&#44; and pigmentation alterations&#44; and other local secondary effects&#46; However&#44; studies with lengthy follow-up periods have reported no serious adverse effects&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Other alternatives include other topical corticosteroids&#44; such as 0&#46;1&#37; mometasone fuorate&#44; intralesional corticosteroids&#44; topical calcineurin inhibitors&#44; 2&#37; topical testosterone&#44; 2&#37; or 8&#37; topical progesterone&#44; topical retinoids and cyclosporine&#44; phototherapy&#44; and photodynamic therapy&#46; Systemic treatments used include various immunosuppressants such as glucocorticoids&#44; cyclosporine and methotrexate&#46; Surgery and CO<span class="elsevierStyleInf">2</span> laser are reserved for the treatment of associated complications&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">Additional recommendations include use of emollients and soft underwear &#40;silk or similar&#41;&#44; and avoidance of rubbing&#44; scratching&#44; soap&#44; and frequent washing with water&#46;</p> <p class="elsevierStyleNotepara" id="npar0015">Abbreviations&#58; vSCC&#44; vulvar squamous cell carcinoma&#46; Source&#58; Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p>"
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                            0 => "J&#46;M&#46; Krapf"
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RF - Importance of Topical Corticosteroid Treatment for Vulvar Lichen Sclerosus to Prevent Recurrences of Vulvar Carcinoma
FR - La importancia del tratamiento con corticoides tópicos en pacientes con liquen escleroso vulvar en la prevención de recurrencias de carcinoma vulvar
M. Luque-Luna, X. Bosch-Amate, D. Morgado-Carrasco
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morgadodaniel8@gmail.com

Corresponding author.
Servicio de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Vulvar lichen sclerosus &#40;VLS&#41; is an underdiagnosed and undertreated chronic dermatosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> It has an estimated prevalence of 0&#46;1&#37;&#8211;1&#46;7&#37;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and a bimodal age distribution&#44; predominantly affecting prepubertal girls and postmenopausal women&#46; It is characterized by itching and scarring lesions that hinder normal sexual and urinary function&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Overregulation of the Th1 pathway gives rise to a chronic proinflammatory state in keratinocytes&#46; Inactivation of tumor suppression genes such as the p53 gene and <span class="elsevierStyleItalic">CDKN2A</span> leads to dysplastic changes that may facilitate subsequent development of vulvar squamous cell carcinoma &#40;vSCC&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;4</span></a> The purpose of the various therapies used &#40;including topical corticosteroids&#44; calcineurin inhibitors&#44; and photodynamic therapy&#41; is to relieve symptoms&#44; prevent scarring&#44; and avoid malignant transformation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> High-potency topical corticosteroids constitute the treatment of choice &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;5</span></a> While their use may hinder transformation to vSCC&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> it is not known whether they can reduce vSCC recurrence&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Chin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> recently published the results of a cohort study in patients with VLS with a history of excised vSCC or differentiated vulvar intraepithelial neoplasia &#40;dVIN&#41;&#46; The authors studied the association between indefinite therapy with topical corticosteroids &#40;daily use with a subsequent adjustment upon achieving disease control&#44; defined as skin with normal texture and no white discoloration&#41; and the risk of recurrence of vSCC or dVIN&#46; Patients excluded &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41; were those with vSCC or dVIN associated with papillomavirus&#44; those with poor adherence to corticosteroid treatment&#44; and those with less than 5 years of follow-up&#46; Eight patients &#40;73&#37;&#41; remained free of recurrence&#44; with a mean follow-up duration of 10&#46;5 years &#40;range&#44; 5&#46;1&#8211;16&#46;5 y&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Two patients &#40;18&#37;&#41; experienced recurrence&#58; one &#40;9&#37;&#41; had multiple recurrences of vSCC&#44; and the other &#40;9&#37;&#41; experienced recurrence of dVIN&#46; In total&#44; 27&#37; experienced some form of recurrence&#46; This rate differs from the 5-year recurrence rates reported in the literature for patients who did not undergo maintenance treatment &#40;44&#37;&#8211;47&#37;&#41;&#46; Only one patient &#40;9&#37;&#41; experienced multiple recurrences&#44; a much lower percentage than that reported in other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;4</span></a> No significant adverse effects associated with topical corticosteroid therapy were described&#46; One of the limitations of the study is its small sample size&#44; although the long follow-up period adds to the robustness of the findings&#46; Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> reported better clinical outcomes in patients receiving indefinite treatment with high potency corticosteroids&#44; which reduced anatomical alterations and symptoms and prevented the development of vSCC&#44; compared with previous studies in which topical corticosteroids were used only when patients presented clinical signs&#46; Prolonged use of topical corticosteroids could reduce chronic inflammation associated with the development of vSCC&#44; thereby decreasing health costs and morbidity&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A growing number of physicians are opting for indefinite treatment with topical corticosteroids&#44; although many remain wary of possible side effects and opt to discontinue treatment once symptoms are controlled&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> We wish to emphasize the importance of chronic topical corticosteroid treatment in patients with VLS&#44; especially those with prior vSCC&#47;dVIN&#44; to avoid recurrences and post-surgical sequelae&#46;</p></span>"
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                  \t\t\t\t">High-potency topical corticosteroids such as clobetasol propionate 0&#46;05&#37;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\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">Recommended regimen&nbsp;\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">Daily topical application for 1&#8211;3 months&#44; depending on clinical response&#44; subsequently on alternate days&#44; and ultimately twice per week as a maintenance regimen&nbsp;\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">Potential benefits&nbsp;\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">Reduction in symptomsReduction in associated structural changes&#44; such as synechiae and scarringDecreased development of vSCCReduced recurrence of vSCC&nbsp;\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">Treatment duration&nbsp;\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">Not defined&nbsp;\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">Potential adverse effects&nbsp;\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">Cutaneous atrophy&#44; telangiectasias&#44; irritation&#44; and pigmentation alterations&#44; and other local secondary effects&#46; However&#44; studies with lengthy follow-up periods have reported no serious adverse effects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Other alternatives include other topical corticosteroids&#44; such as 0&#46;1&#37; mometasone fuorate&#44; intralesional corticosteroids&#44; topical calcineurin inhibitors&#44; 2&#37; topical testosterone&#44; 2&#37; or 8&#37; topical progesterone&#44; topical retinoids and cyclosporine&#44; phototherapy&#44; and photodynamic therapy&#46; Systemic treatments used include various immunosuppressants such as glucocorticoids&#44; cyclosporine and methotrexate&#46; Surgery and CO<span class="elsevierStyleInf">2</span> laser are reserved for the treatment of associated complications&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">Additional recommendations include use of emollients and soft underwear &#40;silk or similar&#41;&#44; and avoidance of rubbing&#44; scratching&#44; soap&#44; and frequent washing with water&#46;</p> <p class="elsevierStyleNotepara" id="npar0015">Abbreviations&#58; vSCC&#44; vulvar squamous cell carcinoma&#46; Source&#58; Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p>"
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