Diagnostic Utility of Dermoscopy in Pigmented Actinic Keratosis

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Imagen dermatoscópica de la lesión en el dorso nasal derecho del caso 4. Se aprecian estructuras romboidales sobre una base eritematosa y una granulación de color marrón-grisáceo de distribución difusa. B. Imagen dermatoscópica de la lesión en el dorso nasal izquierdo. En la parte inferior de la lesión se observan estructuras romboidales y un patrón anular-granular. En la parte superior se observan estas mismas estructuras con una tonalidad más rojiza y algunos vasos finos y ondulados." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Ciudad, J.A. Avilés, R. Suárez, P. Lázaro" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Ciudad" ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Avilés" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Suárez" ] 3 => array:2 [ "nombre" => "P." 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Ciudad, J.A. Avilés, R. Suárez, P. Lázaro" "autores" => array:4 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Ciudad" "email" => array:1 [ 0 => "critxi@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Avilés" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Suárez" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Lázaro" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad de la dermatoscopia en el diagnóstico de las queratosis actínicas pigmentadas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1251 "Ancho" => 2826 "Tamanyo" => 414212 ] ] "descripcion" => array:1 [ "en" => "A, Clinical image of the lesion in patient 1. There is a dark brown, pigmented macule of 5mm diameter, with well-defined borders and a slightly rough surface. Part of the border of the lesion is moth-eaten. B, Dermoscopic image of the lesion in patient 1, showing rhomboidal structures and an annular-granular pattern." ] ] ] "textoCompleto" => "IntroductionActinic keratosis is considered to be an in situ epidermal dysplasia that develops in sun-exposed areas in individuals with a fair skin phototype. In its pigmented forms it can be difficult to differentiate from lentigo maligna melanoma as the clinical features may be similar. As there is a marked difference in the prognosis and treatment of the 2 conditions, it would be very helpful if we could improve the accuracy of clinical diagnosis. Although the definitive diagnosis of skin tumors can only be established by histology, dermoscopy is a very useful tool that aids clinical diagnosis.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> We describe the clinical, dermoscopic, and histological features of 5 pigmented actinic keratoses in 4 patients and compare our findings with those reported in the literature.Case DescriptionsThe 4 patients, 2 men and 2 women aged between 64 and 82 years, had pigmented facial lesions that had appeared 1 to 2 years earlier. Three patients had 1 lesion and 1 patient had 2 lesions. The clinical features are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The most common dermoscopic finding, present in all the lesions, was a grayish-brown perifollicular granulation; this was followed by rhomboidal structures (present in 4 lesions) and an annular-granular pattern (present in 3 lesions). Asymmetrically pigmented follicular openings were not observed in any of the lesions. Histology revealed a loss of the normal stratification of the epidermis, with atypical, melanin-laden keratinocytes in the basal layers. An inflammatory infiltrate of lymphocytes, histiocytes, and melanophages was observed in the dermis (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–3</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>DiscussionThe pigmented forms of actinic keratosis are relatively rare variants that can present similar clinical features to malignant lesions, such as melanoma, or benign lesions, such as senile lentigo or seborrheic keratosis.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>Dermoscopy has been shown to improve accuracy in the diagnosis of pigmented lesions, particularly melanoma.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Pigmented lesions on the face are characterized by the presence of a pigmented pseudonetwork caused by a lower density of rete ridges and a higher density of adnexal structures in this region.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> These characteristics of the facial skin mean that the criteria applied to pigmented facial lesions are different from those used for other areas of the body.There are many publications that describe the dermoscopic features of facial melanoma and their histological correlations.<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> According to the model for melanoma progression, asymmetrically pigmented follicular openings, rhomboidal structures, and an annular-granular pattern are the most frequently observed dermoscopic findings.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> However, there are few studies on the use of dermoscopy in pigmented actinic keratosis.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,8</a> A pigmented pseudonetwork of grayish-brown color has been reported in some lesions; this corresponds histologically with hyperpigmentation of the Malpighian layer interrupted by the follicular openings. Other studies describe multiple grayish-brown dots and globules around the hair follicles<a class="elsevierStyleCrossRef" href="#bib0010">2</a>; this finding was present in all the actinic keratoses in our series. The coalescence of these dots and globules, which have been shown histologically to be due to the presence of aggregates of melanin and macrophages in the papillary dermis, produces the annular-granular pattern. Another feature, the moth-eaten border typical of senile lentigo and seborrheic keratosis, has also been described in pigmented actinic keratosis<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and was observed in 1 of the lesions in this study.The principal differential diagnosis of pigmented actinic keratosis is with lentigo maligna, though senile lentigo, seborrheic keratosis, and lichenoid keratosis should also be considered. Dermoscopy can reveal certain details that help to differentiate between these conditions (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Asymmetrically pigmented follicular openings can be seen in the early stages of lentigo maligna, but they have not been observed in pigmented actinic keratosis and were not seen in any of the lesions in our series. This sign indicates invasion of the hair follicles by malignant melanocytes.<a class="elsevierStyleCrossRefs" href="#bib0005">1,9</a> In addition, the perifollicular dots and globules of lentigo maligna are less regular in diameter, color, and distribution than those observed in pigmented actinic keratosis.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Another finding in favor of a diagnosis of melanoma is the presence of a hyperpigmented ring around the follicular openings, a sign not reported in pigmented actinic keratosis.<a class="elsevierStyleCrossRefs" href="#bib0030">6,9</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Grayish-brown perifollicular granules were observed in all the lesions in our series. The granules were homogeneous in color and diameter and tended to occur in an ordered and uniform annular-granular pattern. We did not observe any asymmetrically pigmented follicular openings or homogeneous areas of pigmentation. Rhomboidal structures were a common finding in our patients. These patterns coincide with those reported in previous studies and may be defined as typical dermoscopic features of pigmented actinic keratosis.In conclusion, the main value of dermoscopy in pigmented actinic keratosis is in the differential diagnosis with lentigo maligna, particularly in complex cases in which the clinical presentation is ambiguous. A single dermoscopic criterion may be insufficient, but the correlation between the clinical presentation of the lesion and the dermoscopic patterns observed could improve the accuracy of the noninvasive diagnosis of pigmented facial lesions.Conflicts of InterestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres95359" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec82520" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres95360" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec82519" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Descriptions" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "Bibliografía" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82520" "palabras" => array:3 [ 0 => "Pigmented actinic keratosis" 1 => "Dermoscopy" 2 => "Dermatopathology" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82519" "palabras" => array:3 [ 0 => "Queratosis actínica pigmentada" 1 => "Dermatoscopia" 2 => "Dermatopatología" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The diagnosis of pigmented actinic keratosis can be complicated in clinical practice. The differential diagnosis with lentigo maligna melanoma can be difficult due to common clinical and dermoscopic characteristics. We present 5 cases of pigmented actinic keratosis in 4 patients. The most common dermoscopic finding was a grayish-brown granulation with a perifollicular distribution, present in all lesions, followed by rhomboidal structures in 4 cases, and an annular-granular pattern in 3. In no case were asymmetrical pigmented follicular openings observed. We draw attention to key findings that aid preoperative diagnosis of pigmented actinic keratosis." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El diagnóstico de las queratosis actínicas pigmentadas puede resultar complicado en la práctica clínica. El diagnóstico diferencial con el lentigo maligno melanoma plantea dificultades, tanto clínica como dermatoscópicamente, ya que ambas entidades pueden presentar características en común. Presentamos 5 casos de queratosis actínicas pigmentadas en 4 pacientes. El hallazgo dermatoscópico más frecuente fue una granulación marrón-grisácea de distribución perifolicular presente en todas las lesiones, seguido de estructuras romboidales en 4 y un patrón anular-granular en 3. En ningún caso se apreciaron salidas foliculares asimétricamente pigmentadas. Destacamos algunas claves que facilitan el diagnóstico preoperatorio de las queratosis actínicas pigmentadas." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ciudad C, et al. Utilidad de la dermatoscopia en el diagnóstico de las queratosis actínicas pigmentadas. Actas Dermosifiliogr.2011;102:623-6." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1251 "Ancho" => 2826 "Tamanyo" => 414212 ] ] "descripcion" => array:1 [ "en" => "A, Clinical image of the lesion in patient 1. There is a dark brown, pigmented macule of 5mm diameter, with well-defined borders and a slightly rough surface. Part of the border of the lesion is moth-eaten. B, Dermoscopic image of the lesion in patient 1, showing rhomboidal structures and an annular-granular pattern." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1251 "Ancho" => 1669 "Tamanyo" => 174619 ] ] "descripcion" => array:1 [ "en" => "Dermoscopic image of the lesion in patient 2, in which grayish-brown perifollicular dots, rhomboidal structures, and an annular-granular pattern are visible." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1168 "Ancho" => 3154 "Tamanyo" => 283641 ] ] "descripcion" => array:1 [ "en" => "A, Dermoscopic image of the lesion on the right side of the bridge of the nose in patient 4. Rhomboidal structures can be seen on an erythematous background and there is a diffuse grayish-brown granulation. B, Dermoscopic image of the lesion on the left side of the bridge of the nose, showing rhomboidal structures and an annular-granular pattern in the inferior part of the lesion. The same structures were observed in the superior part of the lesion, but with a more reddish color and with a number of fine wavy vessels." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sex/Age, y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical Presentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Dermoscopy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Histopathology \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 1 \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">Male/64 \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">Pigmented macule of 5mm diameter, with a rough surface, on the tip of the nose (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). \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">Rhomboidal structures. Grayish-brown perifollicular dots. Annular-granular pattern. Moth-eaten border (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). \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">Architectural disorder of the epidermis. Atypical keratinocytes in the basal layers. Melanophages in the dermis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 2 \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">Male/76 \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">Pigmented macule of 4mm diameter, with an irregular border, on the tip of the nose. \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">Rhomboidal structures. Grayish-brown perifollicular dots. Annular-granular pattern (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) \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">Loss of normal stratification of the epidermis. Atypical, melanin-laden keratinocytes in the basal layers. Melanophages in the dermis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 3 \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">Female/73 \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">Pigmented plaque of 7mm diameter, with irregular, poorly defined borders, on the bridge of the nose. \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">Grayish-brown perifollicular granulation on an erythematous background. \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">Thinning of the epidermis and parakeratosis. Keratinocytes with cellular atypia and abundant melanin pigment in the basal layers. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 4 \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">Female/82 \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">1. Pigmented plaque with irregular, poorly defined borders on the right side of the bridge of the nose. \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">1. Rhomboidal structures. Diffuse grayish-brown granulation (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). \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">1. Loss of normal stratification of the epidermis. Atypical, melanin-laden keratinocytes in the basal layers. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">2. Pigmented plaque on the left side of the bridge of the nose. \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">2. Rhomboidal structures. Annular-granular pattern on an erythematous background. Fine wavy vessels (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). \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">2. Atypical keratinocytes in the deeper layers. Melanophages in the dermis. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab181813.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Epidemiological, Clinical, Dermoscopic, and Histological Features of Pigmented Actinic Keratosis." ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Pigmented Actinic Keratosis<a class="elsevierStyleCrossRefs" href="#bib0005">1,2,8</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Lentigo Maligno Melanoma<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Senile Lentigo<a class="elsevierStyleCrossRef" href="#bib0045">9</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Seborrheic Keratosis<a class="elsevierStyleCrossRef" href="#bib0045">9</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Lichenoid Keratosis<a class="elsevierStyleCrossRef" href="#bib0050">10</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rhomboidal structures \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">+ \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">+ \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">- \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">- \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">+/- \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grayish-brown granulation \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">Uniform perifollicular distribution \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">Diffuse distribution \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">- \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">- \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">Diffuse distribution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Annular-granular pattern \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">+ \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">+ \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">- \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">- \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">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asymmetric follicular pigmentation \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">- \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">+ \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">- \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">- \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">- \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Homogeneous areas of pigment \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">- \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">+ \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">- \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">- \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">- \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moth-eaten border \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">+/- \t\t\t\t\t\t\n 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Estadísticas

Case report

Diagnostic Utility of Dermoscopy in Pigmented Actinic Keratosis

Utilidad de la dermatoscopia en el diagnóstico de las queratosis actínicas pigmentadas

C. Ciudad

Autor para correspondencia

critxi@yahoo.es

Corresponding author.

, J.A. Avilés, R. Suárez, P. Lázaro

Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Actinic keratosis is considered to be an in situ epidermal dysplasia that develops in sun-exposed areas in individuals with a fair skin phototype&#46; In its pigmented forms it can be difficult to differentiate from lentigo maligna melanoma as the clinical features may be similar&#46; As there is a marked difference in the prognosis and treatment of the 2 conditions&#44; it would be very helpful if we could improve the accuracy of clinical diagnosis&#46; Although the definitive diagnosis of skin tumors can only be established by histology&#44; dermoscopy is a very useful tool that aids clinical diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We describe the clinical&#44; dermoscopic&#44; and histological features of 5 pigmented actinic keratoses in 4 patients and compare our findings with those reported in the literature&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Descriptions</span><p id="par0010" class="elsevierStylePara elsevierViewall">The 4 patients&#44; 2 men and 2 women aged between 64 and 82 years&#44; had pigmented facial lesions that had appeared 1 to 2 years earlier&#46; Three patients had 1 lesion and 1 patient had 2 lesions&#46; The clinical features are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The most common dermoscopic finding&#44; present in all the lesions&#44; was a grayish-brown perifollicular granulation&#59; this was followed by rhomboidal structures &#40;present in 4 lesions&#41; and an annular-granular pattern &#40;present in 3 lesions&#41;&#46; Asymmetrically pigmented follicular openings were not observed in any of the lesions&#46; Histology revealed a loss of the normal stratification of the epidermis&#44; with atypical&#44; melanin-laden keratinocytes in the basal layers&#46; An inflammatory infiltrate of lymphocytes&#44; histiocytes&#44; and melanophages was observed in the dermis &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">The pigmented forms of actinic keratosis are relatively rare variants that can present similar clinical features to malignant lesions&#44; such as melanoma&#44; or benign lesions&#44; such as senile lentigo or seborrheic keratosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Dermoscopy has been shown to improve accuracy in the diagnosis of pigmented lesions&#44; particularly melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Pigmented lesions on the face are characterized by the presence of a pigmented pseudonetwork caused by a lower density of rete ridges and a higher density of adnexal structures in this region&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> These characteristics of the facial skin mean that the criteria applied to pigmented facial lesions are different from those used for other areas of the body&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There are many publications that describe the dermoscopic features of facial melanoma and their histological correlations&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> According to the model for melanoma progression&#44; asymmetrically pigmented follicular openings&#44; rhomboidal structures&#44; and an annular-granular pattern are the most frequently observed dermoscopic findings&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However&#44; there are few studies on the use of dermoscopy in pigmented actinic keratosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;8</span></a> A pigmented pseudonetwork of grayish-brown color has been reported in some lesions&#59; this corresponds histologically with hyperpigmentation of the Malpighian layer interrupted by the follicular openings&#46; Other studies describe multiple grayish-brown dots and globules around the hair follicles<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; this finding was present in all the actinic keratoses in our series&#46; The coalescence of these dots and globules&#44; which have been shown histologically to be due to the presence of aggregates of melanin and macrophages in the papillary dermis&#44; produces the annular-granular pattern&#46; Another feature&#44; the moth-eaten border typical of senile lentigo and seborrheic keratosis&#44; has also been described in pigmented actinic keratosis<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and was observed in 1 of the lesions in this study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The principal differential diagnosis of pigmented actinic keratosis is with lentigo maligna&#44; though senile lentigo&#44; seborrheic keratosis&#44; and lichenoid keratosis should also be considered&#46; Dermoscopy can reveal certain details that help to differentiate between these conditions &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Asymmetrically pigmented follicular openings can be seen in the early stages of lentigo maligna&#44; but they have not been observed in pigmented actinic keratosis and were not seen in any of the lesions in our series&#46; This sign indicates invasion of the hair follicles by malignant melanocytes&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9</span></a> In addition&#44; the perifollicular dots and globules of lentigo maligna are less regular in diameter&#44; color&#44; and distribution than those observed in pigmented actinic keratosis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Another finding in favor of a diagnosis of melanoma is the presence of a hyperpigmented ring around the follicular openings&#44; a sign not reported in pigmented actinic keratosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Grayish-brown perifollicular granules were observed in all the lesions in our series&#46; The granules were homogeneous in color and diameter and tended to occur in an ordered and uniform annular-granular pattern&#46; We did not observe any asymmetrically pigmented follicular openings or homogeneous areas of pigmentation&#46; Rhomboidal structures were a common finding in our patients&#46; These patterns coincide with those reported in previous studies and may be defined as typical dermoscopic features of pigmented actinic keratosis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; the main value of dermoscopy in pigmented actinic keratosis is in the differential diagnosis with lentigo maligna&#44; particularly in complex cases in which the clinical presentation is ambiguous&#46; A single dermoscopic criterion may be insufficient&#44; but the correlation between the clinical presentation of the lesion and the dermoscopic patterns observed could improve the accuracy of the noninvasive diagnosis of pigmented facial lesions&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico de las queratosis act&#237;nicas pigmentadas puede resultar complicado en la pr&#225;ctica cl&#237;nica&#46; El diagn&#243;stico diferencial con el lentigo maligno melanoma plantea dificultades&#44; tanto cl&#237;nica como dermatosc&#243;picamente&#44; ya que ambas entidades pueden presentar caracter&#237;sticas en com&#250;n&#46; Presentamos 5 casos de queratosis act&#237;nicas pigmentadas en 4 pacientes&#46; El hallazgo dermatosc&#243;pico m&#225;s frecuente fue una granulaci&#243;n marr&#243;n-gris&#225;cea de distribuci&#243;n perifolicular presente en todas las lesiones&#44; seguido de estructuras romboidales en 4 y un patr&#243;n anular-granular en 3&#46; En ning&#250;n caso se apreciaron salidas foliculares asim&#233;tricamente pigmentadas&#46; Destacamos algunas claves que facilitan el diagn&#243;stico preoperatorio de las queratosis act&#237;nicas pigmentadas&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic image of the lesion in patient 2&#44; in which grayish-brown perifollicular dots&#44; rhomboidal structures&#44; and an annular-granular pattern are visible&#46;</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" => 1168
            "Ancho" => 3154
            "Tamanyo" => 283641
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A&#44; Dermoscopic image of the lesion on the right side of the bridge of the nose in patient 4&#46; Rhomboidal structures can be seen on an erythematous background and there is a diffuse grayish-brown granulation&#46; B&#44; Dermoscopic image of the lesion on the left side of the bridge of the nose&#44; showing rhomboidal structures and an annular-granular pattern in the inferior part of the lesion&#46; The same structures were observed in the superior part of the lesion&#44; but with a more reddish color and with a number of fine wavy vessels&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sex&#47;Age&#44; y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Dermoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Histopathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patient 1&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">Male&#47;64&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">Pigmented macule of 5<span class="elsevierStyleHsp" style=""></span>mm diameter&#44; with a rough surface&#44; on the tip of the nose &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46;&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">Rhomboidal structures&#46; Grayish-brown perifollicular dots&#46; Annular-granular pattern&#46; Moth-eaten border &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;&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">Architectural disorder of the epidermis&#46; Atypical keratinocytes in the basal layers&#46; Melanophages in the dermis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patient 2&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">Male&#47;76&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">Pigmented macule of 4<span class="elsevierStyleHsp" style=""></span>mm diameter&#44; with an irregular border&#44; on the tip of the nose&#46;&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">Rhomboidal structures&#46; Grayish-brown perifollicular dots&#46; Annular-granular pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&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">Loss of normal stratification of the epidermis&#46; Atypical&#44; melanin-laden keratinocytes in the basal layers&#46; Melanophages in the dermis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patient 3&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">Female&#47;73&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">Pigmented plaque of 7<span class="elsevierStyleHsp" style=""></span>mm diameter&#44; with irregular&#44; poorly defined borders&#44; on the bridge of the nose&#46;&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">Grayish-brown perifollicular granulation on an erythematous background&#46;&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">Thinning of the epidermis and parakeratosis&#46; Keratinocytes with cellular atypia and abundant melanin pigment in the basal layers&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patient 4&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">Female&#47;82&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">1&#46; Pigmented plaque with irregular&#44; poorly defined borders on the right side of the bridge of the nose&#46;&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">1&#46; Rhomboidal structures&#46; Diffuse grayish-brown granulation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46;&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">1&#46; Loss of normal stratification of the epidermis&#46; Atypical&#44; melanin-laden keratinocytes in the basal layers&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">2&#46; Pigmented plaque on the left side of the bridge of the nose&#46;&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">2&#46; Rhomboidal structures&#46; Annular-granular pattern on an erythematous background&#46; Fine wavy vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46;&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">2&#46; Atypical keratinocytes in the deeper layers&#46; Melanophages in the dermis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab181813.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Epidemiological&#44; Clinical&#44; Dermoscopic&#44; and Histological Features of Pigmented Actinic Keratosis&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pigmented Actinic Keratosis<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Lentigo Maligno Melanoma<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Senile Lentigo<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Seborrheic Keratosis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Lichenoid Keratosis<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rhomboidal structures&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">&#43;&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">&#43;&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">-&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">-&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">&#43;&#47;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Grayish-brown granulation&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">Uniform perifollicular distribution&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">Diffuse distribution&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">-&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">-&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">Diffuse distribution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annular-granular pattern&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">&#43;&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">&#43;&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">-&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">-&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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymmetric follicular pigmentation&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">-&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">&#43;&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">-&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">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \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">Homogeneous areas of pigment&nbsp;\t\t\t\t\t\t\n
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                  \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">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">-&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">-&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">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moth-eaten border&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
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                  \t\t\t\t">&#43;&#47;-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&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">&#43;&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">&#43;&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">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jelly sign&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">-&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">-&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">&#43;&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">&#43;&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">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fingerprint-like structures&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">-&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">-&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
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                  \t\t\t\t">&#43;&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
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Información del artículo

ISSN: 15782190
Idioma original: Inglés

DOI:10.1016/j.adengl.2010.11.001

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2021 Septiembre	130	57	187
2021 Agosto	103	58	161
2021 Julio	112	63	175
2021 Junio	140	56	196
2021 Mayo	184	54	238
2021 Abril	353	102	455
2021 Marzo	363	45	408
2021 Febrero	183	46	229
2021 Enero	115	43	158
2020 Diciembre	108	41	149
2020 Noviembre	91	38	129
2020 Octubre	90	35	125
2020 Septiembre	96	33	129
2020 Agosto	53	27	80
2020 Julio	71	23	94
2020 Junio	58	30	88
2020 Mayo	51	20	71
2020 Abril	34	28	62
2020 Marzo	22	25	47
2020 Febrero	7	14	21
2020 Enero	0	9	9
2019 Diciembre	4	10	14
2019 Octubre	0	3	3
2019 Septiembre	8	6	14
2019 Agosto	0	8	8
2019 Julio	0	11	11
2019 Junio	0	10	10
2019 Mayo	3	31	34
2019 Abril	0	80	80
2019 Marzo	0	39	39
2019 Febrero	2	33	35
2019 Enero	1	22	23
2018 Diciembre	0	17	17
2018 Noviembre	1	0	1
2018 Octubre	1	0	1
2018 Septiembre	2	7	9
2018 Agosto	0	39	39
2018 Julio	0	19	19
2018 Junio	0	18	18
2018 Mayo	0	4	4
2018 Abril	0	2	2
2018 Marzo	17	4	21
2018 Febrero	183	13	196
2018 Enero	262	35	297
2017 Diciembre	237	21	258
2017 Noviembre	206	16	222
2017 Octubre	206	29	235
2017 Septiembre	160	61	221
2017 Agosto	214	23	237
2017 Julio	190	40	230
2017 Junio	180	44	224
2017 Mayo	107	38	145
2017 Abril	96	34	130
2017 Marzo	105	37	142
2017 Febrero	81	32	113
2017 Enero	122	30	152
2016 Diciembre	145	20	165
2016 Noviembre	214	22	236
2016 Octubre	254	39	293
2016 Septiembre	234	43	277
2016 Agosto	294	49	343
2016 Julio	137	17	154
2016 Junio	15	12	27
2016 Mayo	11	22	33
2016 Abril	4	1	5
2016 Marzo	14	1	15
2016 Febrero	11	1	12
2016 Enero	11	3	14
2015 Diciembre	14	1	15
2015 Noviembre	33	2	35
2015 Octubre	24	3	27
2015 Septiembre	7	1	8
2015 Agosto	22	4	26
2015 Julio	165	16	181
2015 Junio	107	13	120
2015 Mayo	168	32	200
2015 Abril	105	35	140
2015 Marzo	80	21	101
2015 Febrero	103	26	129
2015 Enero	108	26	134
2014 Diciembre	113	20	133
2014 Noviembre	110	18	128
2014 Octubre	140	23	163
2014 Septiembre	119	36	155
2014 Agosto	104	15	119
2014 Julio	138	27	165
2014 Junio	148	21	169
2014 Mayo	161	18	179
2014 Abril	146	20	166
2014 Marzo	157	17	174
2014 Febrero	101	17	118
2014 Enero	137	17	154
2013 Diciembre	125	14	139
2013 Noviembre	97	19	116
2013 Octubre	60	19	79
2013 Septiembre	41	7	48
2013 Agosto	37	12	49
2013 Julio	19	12	31
2013 Junio	16	10	26
2013 Mayo	13	11	24
2013 Abril	20	15	35
2013 Marzo	14	7	21
2013 Febrero	32	7	39
2013 Enero	46	10	56
2012 Diciembre	16	3	19
2012 Noviembre	1	3	4
2012 Octubre	3	5	8
2012 Agosto	0	1	1

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