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the most frequent being inflammatory bowel disease and seronegative arthritis&#44; followed by lymphoproliferative syndromes and paraproteinemias&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> There are 4 clinical forms of PG&#58; ulcerative &#40;classic form&#41;&#44; bullous&#44; pustulous&#44; and vegetative &#40;superficial granulomatous form&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> It is usually treated with immunosuppressant drugs&#44; generally corticosteroids or ciclosporin&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Due to the relatively low incidence of PG&#44; only limited information is available on its epidemiology&#46; Notably&#44; no reports have been published describing clinical findings and treatment response in Spanish patients&#46; Furthermore&#44; almost no clinical trials are available that would allow an evidence-based treatment algorithm to be established&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to investigate the clinical and epidemiologic characteristics and the treatments used in a series of patients with PG seen over a 10-year period in the Department of Dermatology at Hospital Cl&#237;nico Virgen de la Victoria in Malaga&#44; Spain&#44; and to compare the findings with those described in other regions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A retrospective&#44; observational study was undertaken in the Department of Dermatology at Hospital Cl&#237;nico Universitario Virgen de la Victoria in M&#225;laga&#44; Spain between January 2000 and December 2009 and included all patients diagnosed with PG during that period&#46; The health care area covered by the hospital serves a population of 460&#160;000&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Data were collected by review of patient records and pathology reports&#46; In all cases included in the study&#44; diagnosis was based on clinical suspicion and histopathology to establish compatibility of the diagnosis and rule out infections&#44; tumors&#44; or other conditions such as vasculitis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The following variables were recorded&#58; sex&#44; age&#44; time since appearance of symptoms&#44; source of referral&#44; and presence or absence of systemic disease&#46; Treatment was also recorded&#44; along with treatment response over a minimum follow-up period of 1 year&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data were analyzed using SPSS 17&#46;0 to obtain descriptive statistics &#40;frequencies&#44; percentages&#44; and means&#41; and between-group comparisons&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the clinical characteristics of the patients&#46; Of the 15 patients included in the study&#44; 7 &#40;43&#37;&#41; were men and 8 &#40;57&#37;&#41; were women&#44; which corresponds to a female to male ratio of 1&#46;14 to 1&#46; The mean &#40;SD&#41; age at diagnosis was 49&#46;2 &#40;17&#46;4&#41; years &#40;range&#44; 25-75 years&#41; in the complete group&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The mean age at diagnosis was 44&#46;4 &#40;18&#46;7&#41; years &#40;range&#44; 25-75 years&#41; in men and 45&#46;3 &#40;15&#46;4&#41; years &#40;range&#44; 28-75 years&#41; in women&#46; Comparison of age groups revealed that 80&#37; of patients were between 20 and 40 &#40;6 patients&#41; or between 60 and 80 years of age &#40;6 patients&#41;&#59; there were no patients younger than 25 or older than 75 years&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Ulcerative PG was the most common clinical form&#44; accounting for 80&#37; of the sample &#40;12 cases&#41;&#46; Peristomal PG was diagnosed in 3 patients &#40;20&#37;&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Inflammatory bowel disease was the most common associated systemic condition and was found in 40&#37; of patients with PG &#40;6 cases&#41;&#46; Ulcerative colitis was present in 33&#37; &#40;5 cases&#41; and Crohn disease in 7&#37; &#40;1 case&#41;&#46; A surgical procedure had previously been carried out in the affected area in 20&#37; of patients &#40;3 cases&#41;&#44; all of whom had peristomal PG&#46; Only 1 patient had ankylosing spondylitis&#46; The remaining 5 cases &#40;33&#37;&#41; were idiopathic and there was no associated systemic disease&#46; Consequently&#44; if we exclude patients with prior surgical procedures&#44; we find that 47&#37; of patients &#40;7 cases&#41; had PG associated with a systemic condition&#46; Comparison of those patients by age group showed that the majority &#40;5 cases&#44; 71&#46;5&#37;&#41; were in the younger age group &#40;20-40 years&#41;&#59; 1 patient &#40;14&#46;25&#37;&#41; was in the middle age group &#40;40-60&#41; and another &#40;14&#46;25&#37;&#41; was in the older age group &#40;60-80&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In patients with ulcerative colitis&#44; the appearance of PG was linked to a flare of the disease&#44; except in 1 case&#44; where PG preceded the diagnosis of ulcerative colitis by 6 months&#46; In contrast&#44; no relationship between PG and the course of the systemic disease was observed in patients with Crohn disease or ankylosing spondylitis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Only 20&#37; of patients &#40;3 cases&#41; were referred directly to the dermatology department from primary care or the emergency department&#46; The most common primary referral was to gastroenterology &#40;4 patients&#44; 26&#37;&#41; or general surgery &#40;4 patients&#44; 26&#37;&#41;&#44; followed by vascular surgery &#40;3 cases&#44; 20&#37;&#41; and urology &#40;1 case&#44; 8&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In patients with underlying systemic disease such as inflammatory bowel disease or ankylosing spondylitis&#44; immunosuppressant drugs were chosen in consultation with the gastroenterology or rheumatology department&#44; taking into consideration the activity of the disease and prior treatments&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the immunosuppressant drugs used for the treatment of PG and the associated level of evidence&#46; Dressings were an important part of treatment in all patients in order to reduce infection and favor repair of destroyed tissue&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In 8 patients &#40;53&#46;3&#37;&#41;&#44; treatment was initiated with oral corticosteroids &#40;prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#46; Of those&#44; only 2 had systemic disease &#40;ulcerative colitis&#41;&#44; and 1 had been diagnosed 6 months after the appearance of PG&#46; All patients showed significant improvements within 2 weeks of initiation of oral corticosteroids&#46; In all patients&#44; ulcers were replaced by brownish plaques of scar tissue after 6 to 8 weeks of treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Two patients with ulcerative colitis were initially treated with infliximab&#46; In one of those patients&#44; infliximab was replaced with adalimumab after the patient experienced severe urticaria and hypotension&#46; In the other patient&#44; the lesions were completely resolved after 6 weeks of treatment with infliximab in combination with topical tacrolimus &#40;0&#46;03&#37;&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Adalimumab was used as first-line treatment in 4 patients &#40;26&#46;65&#37;&#41;&#46; Two of those patients had ulcerative colitis&#44; 1 had ankylosing spondylitis&#44; and 1 had Crohn disease&#46; In the 2 patients with ulcerative colitis&#44; complete resolution of PG was achieved 30 days after initiation of treatment&#44; although adjuvant sulfasalazine &#40;3<span class="elsevierStyleHsp" style=""></span>g&#47;d&#41; was required in 1 patient&#46; The patient with Crohn disease&#44; who had additional concomitant disease &#40;hypertension&#44; insulin-dependent diabetes with diabetic nephropathy&#44; and sulfasalazine intolerance due to headaches&#41;&#44; required weekly dosing of adalimumab to control her intestinal disease and peristomal PG&#46; The patient with ankylosing spondylitis required combined adalimumab and sulfasalazine when positive results were not obtained with adalimumab and oral prednisone or ciclosporin &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Finally&#44; 2 patients were treated with topical immunosuppressant drugs &#40;0&#46;05&#37; clobetasol cream and dermojet injection of triamcinolone&#41;&#46; One patient died 1 month after diagnosis of PG due to stage III carcinoma of the bladder&#44; and the other showed significant improvement after 2 intralesional dermojet injections of triamcinolone &#40;40<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41; 14 days apart&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">In our study&#44; only 15 patients with any type of PG were seen over a 10-year period &#40;2000-2010&#41;&#46; This low frequency represents a limitation when analyzing the results obtained&#46; The incidence of PG in our reference population is 3&#46;26 cases per million inhabitants per year&#46; In our review of the literature&#44; studies reported an estimated incidence of PG of between 2 and 3 cases per million inhabitants per year&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The incidence observed in our population is therefore consistent with published reports&#46; PG has traditionally been thought to be slightly more common in women&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#8211;7</span></a> In our study&#44; we observed a female to male ratio of 1&#46;14 to 1&#46; PG usually appears in patients aged between 30 and 50 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a> The mean age at diagnosis in our study was 49&#46;2 &#40;17&#46;4&#41; years &#40;range&#44; 25&#8211;75 years&#41;&#46; We nevertheless observed a peak incidence in patients aged between 60 and 80 years &#40;6 cases&#44; 40&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Only 20&#37; of cases &#40;3 patients&#41; were referred first to the dermatology department&#44; indicating that dermatology plays a secondary role in the care of patients with PG&#46; This may be because almost half of the patients included in our study had gastrointestinal disease&#44; with PG coinciding with periods of worsening of the systemic disease&#46; Nevertheless&#44; these findings may also reflect a lack of knowledge of the condition among nondermatologists&#44; who may confuse it with infections or consider it as secondary to vascular disease and therefore make an inappropriate referral&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In between 50&#37; and 70&#37; of cases&#44; PG is associated with systemic disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;9</span></a> Ruocco et al<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> report that idiopathic PG occurs in 25&#37; to 50&#37; of cases&#46; In our study&#44; 5 cases &#40;33&#37;&#41; were not associated with systemic disease&#46; We also did not observe any cases in which PG was associated with hematologic disease&#46; In 3 cases &#40;20&#37;&#41;&#44; PG was preceded by surgery&#58; 1 sternotomy &#40;aortic stenosis&#41;&#44; 1 ileostomy &#40;Crohn disease&#41;&#44; and 1 nephrostomy &#40;bladder carcinoma&#41;&#46; The development of PG following surgery has been reported previously&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> The most common systemic disease in our patients was inflammatory bowel disease &#40;40&#37;&#59; 5 cases of ulcerative colitis and 1 case of Crohn disease&#41;&#44; and in most of those &#40;4 cases with ulcerative colitis&#41;&#44; PG developed during a disease flare&#46; This finding differs from previous reports&#44; since PG has always been described as independent of the activity of inflammatory bowel disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a> Following initiation of immunosuppressant therapy in those 4 patients&#44; control of both PG and ulcerative colitis was achieved&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">None of the articles we found in the literature discussed a relationship between age and associated systemic disease in patients with PG&#46; In our study&#44; 5 cases &#40;71&#46;5&#37; of patients classed as having associated systemic disease after exclusion of those with prior surgery&#41; involved patients aged between 20 and 40 years&#46; Due to the small number of patients included in the study &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&#44; however&#44; we were unable to assess a possible association between these 2 variables&#46; It will be possible to examine such an association in future studies that pool data from multiple populations&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Given the low incidence of PG&#44; there are no studies available to support the development of a standard treatment algorithm&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;12</span></a> Nevertheless&#44; before choosing local or systemic therapy&#44; the following patient characteristics should be taken into consideration&#58; history&#44; presence of concomitant systemic disease&#44; depth and size of ulcers&#44; and disease course&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The use of dressings with hydrocolloids or hydrogels is particularly important&#44; since they increase the production of collagen&#44; improve the process of angiogenesis&#44; optimize pain control&#44; and reduce the likelihood of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; was the most frequently used immunosuppressant drug &#40;8 patients&#44; 53&#46;3&#37;&#41;&#46; Complete resolution of the lesions was observed within 45 days of treatment initiation in all patients&#46; In the literature&#44; prednisone is considered the first-line systemic treatment&#44; with a level of evidence of 2&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;12</span></a> and this is confirmed by our results&#46; Ciclosporin can be used to lower the dose of corticosteroids&#44; but its use should be restricted to idiopathic PG&#44; since long-term ciclosporin therapy is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">TNF inhibitors are used in patients with systemic disease and concomitant PG&#46; Infliximab is the only biologic drug with demonstrated efficacy in double-blind placebo-controlled trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;14</span></a> We only used infliximab in 2 patients&#44; and the drug had to be withdrawn in one of them due to a severe infusion reaction&#46; The use of adalimumab has also been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;12&#44;15</span></a> The regimen used is that applicable to inflammatory bowel disease or ankylosing spondylitis&#46; In inflammatory bowel disease&#44; an initial dose of 80<span class="elsevierStyleHsp" style=""></span>mg followed by 40<span class="elsevierStyleHsp" style=""></span>mg every 2 weeks is used&#44; whereas in ankylosing spondylitis&#44; there is no loading dose and a dose of 40<span class="elsevierStyleHsp" style=""></span>mg every 2 weeks is used&#46; We prescribed adalimumab in 4 cases &#40;26&#46;65&#37;&#41;&#59; in 2 of those it was necessary to prescribe the drug in combination with sulfasalazine in order to obtain complete control of the associated systemic disease and resolution of the lesions&#46; We did not observe adverse reactions with adalimumab&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Treatment with local immunosuppressants is indicated for superficial lesions or in patients with multiple diseases&#44; in whom there is an unacceptable likelihood of adverse reactions to systemic therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Our experience with local immunosuppressants is limited&#46; One of our patients died 1 month after diagnosis of peristomal PG and it was not possible to assess the response to application of clobetasol 0&#46;05&#37;&#59; the other patient was lost to follow-up after 3 months&#44; although partial improvement had been observed at 1 month following 2 dermojet injections of triamcinolone&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">In summary&#44; PG is a rare condition in Spain&#46; It affects similar numbers of men and women and is normally associated with systemic disease&#44; particularly inflammatory bowel disease&#46; All of these findings agree with the results reported in the literature&#46; Notably&#44; however&#44; in our study there was a larger proportion of patients aged over 60 years than reported in the literature&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">According to our findings&#44; age younger than 40 years appears to be related to an increase in the probability of having an associated systemic disease in patients with PG&#46; Nevertheless&#44; further studies in a much larger sample of patients are required to confirm this hypothesis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Although systemic corticosteroids continue to be the treatment of choice&#44; we consider adalimumab to be a good alternative for the treatment of PG with concomitant systemic disease&#44; given that it is effective&#44; can be used in combination with other immunosuppressant drugs and dressings&#44; is well tolerated&#44; and has a favorable safety profile&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2011-01-23"
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            0 => "Pyoderma gangrenosum"
            1 => "Epidemiology"
            2 => "Treatment"
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          "palabras" => array:3 [
            0 => "Pioderma gangrenoso"
            1 => "Epidemiolog&#237;a"
            2 => "Tratamiento"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pyoderma gangrenosum is a condition that is included among the neutrophilic dermatoses&#46; Given its low incidence&#44; few studies have addressed its epidemiology or treatment&#46;</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the epidemiological and clinical characteristics of patients with pyoderma gangrenosum along with our experience of treating the condition in a referral hospital in Malaga&#44; Spain&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A retrospective&#44; observational study was undertaken in the Department of Dermatology at Hospital Cl&#237;nico Universitario Virgen de la Victoria in Malaga&#44; Spain between January 2000 and December 2009 and included all patients diagnosed with pyoderma gangrenosum&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The incidence of pyoderma gangrenosum in our reference population is 3&#46;26 cases per million inhabitants per year&#46; The most frequent concomitant systemic disease was ulcerative colitis &#40;5 cases&#44; 33&#37;&#41;&#46; In 4 patients with that disease&#44; pyoderma gangrenosum appeared during a flare-up&#46; In 80&#37; of cases&#44; patients were not referred to a dermatologist during the initial phase of pyoderma gangrenosum&#44; and most referrals were from gastroenterology or general surgery &#40;4 patients each&#44; 52&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Patients with pyoderma gangrenosum are often referred to dermatologists by other specialists after a varying period of time has elapsed without achieving an accurate diagnosis&#46; In these patients&#44; especially those between 20 and 40 years of age&#44; it is essential to rule out concomitant disease&#46; Adalimumab is a good treatment option for pyoderma gangrenosum&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El pioderma gangrenoso &#40;PG&#41; es un proceso incluido en el grupo de las denominadas dermatosis neutrof&#237;licas&#44; del que existen pocos trabajos epidemiol&#243;gicos y de abordaje terap&#233;utico en la bibliograf&#237;a dada su relativa escasa incidencia&#46;</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir las caracter&#237;sticas epidemiol&#243;gicas y cl&#237;nicas y exponer nuestra experiencia terap&#233;utica en los pacientes con PG de un hospital de segundo nivel de M&#225;laga &#40;Espa&#241;a&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El estudio observacional y retrospectivo incluy&#243; todos los pacientes diagnosticados de PG en el Servicio de Dermatolog&#237;a del Hospital Cl&#237;nico Universitario Virgen de la Victoria &#40;M&#225;laga&#41; en un periodo de 10 a&#241;os&#44; comprendido entre enero de 2000 y diciembre de 2009&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La incidencia del PG en nuestra poblaci&#243;n de referencia es de 3&#44;26 casos por mill&#243;n de habitantes y a&#241;o&#46; La enfermedad sist&#233;mica asociada con mayor frecuencia a la aparici&#243;n del PG fue la colitis ulcerosa &#40;5 casos&#44; 33&#37;&#41;&#46; En 4 pacientes con colitis ulcerosa el PG apareci&#243; durante un brote de la enfermedad&#46; El 80&#37; de los pacientes no fueron derivados a Dermatolog&#237;a en la fase inicial del PG&#44; siendo los servicios con m&#225;s derivaciones Digestivo y Cirug&#237;a general&#44; con 4 pacientes cada uno &#40;52&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El PG a menudo llega al dermat&#243;logo remitido por otros especialistas tras un tiempo variable sin diagn&#243;stico correcto&#46; Ante este proceso es b&#225;sico descartar la existencia de alguna patolog&#237;a asociada&#44; especialmente en pacientes entre 20 y 40 a&#241;os&#46; Adalimumab es una buena opci&#243;n terap&#233;utica en el tratamiento del PG&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Su&#225;rez-P&#233;rez JA&#44; et al&#46; Pioderma gangrenoso&#58; Presentaci&#243;n de 15 casos y revisi&#243;n de la literatura&#58; Actas Dermosifiliogr&#46;2012&#59;103&#58;120-126&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Biopsy of the edge of an ulcer diagnosed as pyoderma gangrenosum&#46; A notable neutrophilic inflammatory infiltrate is visible in the upper dermis&#46; A&#44; Hematoxylin-eosin&#59; original magnification &#215;4&#46; B&#44; Hematoxylin-eosin&#59; original magnification &#215;10&#46;</p>"
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        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1083
            "Ancho" => 2236
            "Tamanyo" => 131508
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Relationship between age and association of pyoderma gangrenosum with systemic disease&#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" => 870
            "Ancho" => 2337
            "Tamanyo" => 234639
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Appearance before &#40;A&#41; and after &#40;B&#41; treatment with oral prednisone&#46;</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" => 885
            "Ancho" => 2337
            "Tamanyo" => 213795
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Appearance before &#40;A&#41; and after &#40;B&#41; treatment with adalimumab in combination with sulfasalazine in a patient with pyoderma gangrenosum and ankylosing spondylitis&#46;</p>"
        ]
      ]
      4 => 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">Patient&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">Primary Referral&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&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">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">Systemic Disease&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">Temporal Relationship With Systemic Disease&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">Treatment&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">Course&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">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">Ulcerative&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">Surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">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">Ulcerative&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">Surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&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">Ulcerative colitis&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">Preceding&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">Oral prednisone&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">No lesions after 2 months of treatment&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">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">Ulcerative&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">Vascular surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">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">Ulcerative&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">Gastroenterology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&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">Ulcerative colitis&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">Flare&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">Infliximab&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">No lesions after 6 weeks of treatment&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">5&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">Ulcerative&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">Dermatology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&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">Ankylosing spondylitis&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">None&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">Adalimumab&#47;sulfasalazine&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">No lesions after 2 months of treatment&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">6&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">Ulcerative&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">Gastroenterology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&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">Ulcerative colitis&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">Flare&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">Oral prednisone&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">No lesions after 2 months of treatment&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">7&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">Peristomal&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">Surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&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">Crohn Disease&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">None&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">Adalimumab&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">No lesions after 1 month of treatment Required weekly dosing&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">8&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">Ulcerative&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">Gastroenterology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&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">Ulcerative colitis&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">Flare&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">Adalimumab&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">No lesions after 1 month of treatment&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">9&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">Ulcerative&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">Vascular surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">10&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">Peristomal&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">Vascular surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">Surgical intervention&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">11&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">Ulcerative&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">Gastroenterology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&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">Ulcerative colitis&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">Flare&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">Adalimumab&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">No lesions after 1 month of treatment&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">12&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">Peristomal&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">Surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&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">Surgical intervention&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">&#8211;&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">Triamcinolone dermojet injection&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">Improvement without complete resolution of lesions after 1 month of treatment&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">13&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">Ulcerative&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">Dermatology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">14&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">Ulcerative&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">Dermatology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">15&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">Peristomal&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">Urology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&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">Surgical intervention&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">&#8211;&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
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                  \t\t\t\t">Topical corticosteroids&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Died during the first month of follow-up&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46; Moschella"
                            1 => "M&#46; Davis"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Dermatology"
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                        "paginaFinal" => "387"
                        "serieFecha" => "2008"
                      ]
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              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pyoderma gangrenosum associated with hidradenitis suppurativa&#58; a case report and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46;E&#46; Garcia-Rabasco"
                            1 => "A&#46; Esteve-Martinez"
                            2 => "V&#46; Zaragoza-Ninet"
                            3 => "J&#46;L&#46; Sanchez-Carazo"
                            4 => "V&#46; Alegre-de-Miquel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr"
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                        "volumen" => "101"
                        "paginaInicial" => "717"
                        "paginaFinal" => "721"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20965015"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pyoderma gangrenosum&#58; an updated review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46; Ruocco"
                            1 => "S&#46; Sangiuliano"
                            2 => "A&#46;G&#46; Gravina"
                            3 => "A&#46; Miranda"
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                          ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1468-3083.2009.03199.x"
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                        "volumen" => "23"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19470075"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Pyoderma gangrenosum&#58; a review and update on new therapies"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Miller"
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                            2 => "A&#46; Clark"
                            3 => "J&#46;L&#46; Jorizzo"
                            4 => "S&#46;R&#46; Feldman"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2009.05.030"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20227580"
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                0 => array:2 [
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                      "titulo" => "Pyoderma gangrenosum&#58; a review"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;N&#46; Crowson"
                            1 => "M&#46;C&#46; Mihm Jr&#46;"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46; Brooklyn"
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                            2 => "C&#46; Probert"
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                    0 => array:2 [
                      "doi" => "10.1136/bmj.333.7560.181"
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                        "tituloSerie" => "BMJ"
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                        "volumen" => "333"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Pyoderma gangrenosum&#46; A comparison of typical and atypical forms with an emphasis on time to remission&#46; Case review of 86 patients from 2 institutions"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
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                            1 => "J&#46;M&#46; Jackson"
                            2 => "J&#46;L&#46; Jorizzo"
                            3 => "A&#46;B&#46; Fleischer Jr&#46;"
                            4 => "W&#46;L&#46; White"
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                  "host" => array:1 [
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                      "titulo" => "Treatment of pyoderma gangrenosum with infliximab in Crohn&#39;s disease"
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                          "autores" => array:3 [
                            0 => "C&#46; Sanz-Munoz"
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                            2 => "A&#46; Miranda-Romero"
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                      "titulo" => "Pyoderma gangrenosum over a saphenectomy scar in a cANCA-positive patient with diverticulitis"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
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                            2 => "F&#46; Camacho"
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                0 => array:2 [
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                      "titulo" => "Treatment recommendations for pyoderma gangrenosum&#58; an evidence-based review of the literature based on more than 350 patients"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                    0 => array:2 [
                      "titulo" => "Treating the chronic wound&#58; A practical approach to the care of nonhealing wounds and wound care dressings"
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                          "etal" => false
                          "autores" => array:6 [
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Original Article
Pyoderma Gangrenosum: A Report of 15 Cases and Review of the Literature
Pioderma gangrenoso: Presentación de 15 casos y revisión de la literatura
J.A. Suárez-Péreza,
Autor para correspondencia
jasuape@hotmail.com

Corresponding author.
, E. Herrera-Acostaa, N. López-Navarroa, F. Vilchez-Márqueza, J.D. Prietob, R.J. Boscha, E. Herreraa
a Servicio de Dermatología, Hospital Clínico Virgen de la Victoria, Málaga, Spain
b Servicio de Anatomía Patológica, Hospital Clínico Virgen de la Victoria, Málaga, Spain
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        "titulo" => "Pioderma gangrenoso&#58; Presentaci&#243;n de 15 casos y revisi&#243;n de la literatura"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Appearance before &#40;A&#41; and after &#40;B&#41; treatment with oral prednisone&#46;</p>"
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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">Pyoderma gangrenosum &#40;PG&#41; is a skin condition characterized by the presence of single or multiple erythematous pustules that progress rapidly to form necrotic ulcers with a depressed violaceous border&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The incidence of PG is estimated at 2 to 3 cases per million inhabitants per year&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> It is most frequent in individuals aged between 30 and 50 years and is slightly more common in women&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Half of all cases are associated with systemic disease&#44; the most frequent being inflammatory bowel disease and seronegative arthritis&#44; followed by lymphoproliferative syndromes and paraproteinemias&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> There are 4 clinical forms of PG&#58; ulcerative &#40;classic form&#41;&#44; bullous&#44; pustulous&#44; and vegetative &#40;superficial granulomatous form&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> It is usually treated with immunosuppressant drugs&#44; generally corticosteroids or ciclosporin&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Due to the relatively low incidence of PG&#44; only limited information is available on its epidemiology&#46; Notably&#44; no reports have been published describing clinical findings and treatment response in Spanish patients&#46; Furthermore&#44; almost no clinical trials are available that would allow an evidence-based treatment algorithm to be established&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to investigate the clinical and epidemiologic characteristics and the treatments used in a series of patients with PG seen over a 10-year period in the Department of Dermatology at Hospital Cl&#237;nico Virgen de la Victoria in Malaga&#44; Spain&#44; and to compare the findings with those described in other regions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A retrospective&#44; observational study was undertaken in the Department of Dermatology at Hospital Cl&#237;nico Universitario Virgen de la Victoria in M&#225;laga&#44; Spain between January 2000 and December 2009 and included all patients diagnosed with PG during that period&#46; The health care area covered by the hospital serves a population of 460&#160;000&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Data were collected by review of patient records and pathology reports&#46; In all cases included in the study&#44; diagnosis was based on clinical suspicion and histopathology to establish compatibility of the diagnosis and rule out infections&#44; tumors&#44; or other conditions such as vasculitis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The following variables were recorded&#58; sex&#44; age&#44; time since appearance of symptoms&#44; source of referral&#44; and presence or absence of systemic disease&#46; Treatment was also recorded&#44; along with treatment response over a minimum follow-up period of 1 year&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data were analyzed using SPSS 17&#46;0 to obtain descriptive statistics &#40;frequencies&#44; percentages&#44; and means&#41; and between-group comparisons&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the clinical characteristics of the patients&#46; Of the 15 patients included in the study&#44; 7 &#40;43&#37;&#41; were men and 8 &#40;57&#37;&#41; were women&#44; which corresponds to a female to male ratio of 1&#46;14 to 1&#46; The mean &#40;SD&#41; age at diagnosis was 49&#46;2 &#40;17&#46;4&#41; years &#40;range&#44; 25-75 years&#41; in the complete group&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The mean age at diagnosis was 44&#46;4 &#40;18&#46;7&#41; years &#40;range&#44; 25-75 years&#41; in men and 45&#46;3 &#40;15&#46;4&#41; years &#40;range&#44; 28-75 years&#41; in women&#46; Comparison of age groups revealed that 80&#37; of patients were between 20 and 40 &#40;6 patients&#41; or between 60 and 80 years of age &#40;6 patients&#41;&#59; there were no patients younger than 25 or older than 75 years&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Ulcerative PG was the most common clinical form&#44; accounting for 80&#37; of the sample &#40;12 cases&#41;&#46; Peristomal PG was diagnosed in 3 patients &#40;20&#37;&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Inflammatory bowel disease was the most common associated systemic condition and was found in 40&#37; of patients with PG &#40;6 cases&#41;&#46; Ulcerative colitis was present in 33&#37; &#40;5 cases&#41; and Crohn disease in 7&#37; &#40;1 case&#41;&#46; A surgical procedure had previously been carried out in the affected area in 20&#37; of patients &#40;3 cases&#41;&#44; all of whom had peristomal PG&#46; Only 1 patient had ankylosing spondylitis&#46; The remaining 5 cases &#40;33&#37;&#41; were idiopathic and there was no associated systemic disease&#46; Consequently&#44; if we exclude patients with prior surgical procedures&#44; we find that 47&#37; of patients &#40;7 cases&#41; had PG associated with a systemic condition&#46; Comparison of those patients by age group showed that the majority &#40;5 cases&#44; 71&#46;5&#37;&#41; were in the younger age group &#40;20-40 years&#41;&#59; 1 patient &#40;14&#46;25&#37;&#41; was in the middle age group &#40;40-60&#41; and another &#40;14&#46;25&#37;&#41; was in the older age group &#40;60-80&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In patients with ulcerative colitis&#44; the appearance of PG was linked to a flare of the disease&#44; except in 1 case&#44; where PG preceded the diagnosis of ulcerative colitis by 6 months&#46; In contrast&#44; no relationship between PG and the course of the systemic disease was observed in patients with Crohn disease or ankylosing spondylitis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Only 20&#37; of patients &#40;3 cases&#41; were referred directly to the dermatology department from primary care or the emergency department&#46; The most common primary referral was to gastroenterology &#40;4 patients&#44; 26&#37;&#41; or general surgery &#40;4 patients&#44; 26&#37;&#41;&#44; followed by vascular surgery &#40;3 cases&#44; 20&#37;&#41; and urology &#40;1 case&#44; 8&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In patients with underlying systemic disease such as inflammatory bowel disease or ankylosing spondylitis&#44; immunosuppressant drugs were chosen in consultation with the gastroenterology or rheumatology department&#44; taking into consideration the activity of the disease and prior treatments&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the immunosuppressant drugs used for the treatment of PG and the associated level of evidence&#46; Dressings were an important part of treatment in all patients in order to reduce infection and favor repair of destroyed tissue&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In 8 patients &#40;53&#46;3&#37;&#41;&#44; treatment was initiated with oral corticosteroids &#40;prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#46; Of those&#44; only 2 had systemic disease &#40;ulcerative colitis&#41;&#44; and 1 had been diagnosed 6 months after the appearance of PG&#46; All patients showed significant improvements within 2 weeks of initiation of oral corticosteroids&#46; In all patients&#44; ulcers were replaced by brownish plaques of scar tissue after 6 to 8 weeks of treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Two patients with ulcerative colitis were initially treated with infliximab&#46; In one of those patients&#44; infliximab was replaced with adalimumab after the patient experienced severe urticaria and hypotension&#46; In the other patient&#44; the lesions were completely resolved after 6 weeks of treatment with infliximab in combination with topical tacrolimus &#40;0&#46;03&#37;&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Adalimumab was used as first-line treatment in 4 patients &#40;26&#46;65&#37;&#41;&#46; Two of those patients had ulcerative colitis&#44; 1 had ankylosing spondylitis&#44; and 1 had Crohn disease&#46; In the 2 patients with ulcerative colitis&#44; complete resolution of PG was achieved 30 days after initiation of treatment&#44; although adjuvant sulfasalazine &#40;3<span class="elsevierStyleHsp" style=""></span>g&#47;d&#41; was required in 1 patient&#46; The patient with Crohn disease&#44; who had additional concomitant disease &#40;hypertension&#44; insulin-dependent diabetes with diabetic nephropathy&#44; and sulfasalazine intolerance due to headaches&#41;&#44; required weekly dosing of adalimumab to control her intestinal disease and peristomal PG&#46; The patient with ankylosing spondylitis required combined adalimumab and sulfasalazine when positive results were not obtained with adalimumab and oral prednisone or ciclosporin &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Finally&#44; 2 patients were treated with topical immunosuppressant drugs &#40;0&#46;05&#37; clobetasol cream and dermojet injection of triamcinolone&#41;&#46; One patient died 1 month after diagnosis of PG due to stage III carcinoma of the bladder&#44; and the other showed significant improvement after 2 intralesional dermojet injections of triamcinolone &#40;40<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41; 14 days apart&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">In our study&#44; only 15 patients with any type of PG were seen over a 10-year period &#40;2000-2010&#41;&#46; This low frequency represents a limitation when analyzing the results obtained&#46; The incidence of PG in our reference population is 3&#46;26 cases per million inhabitants per year&#46; In our review of the literature&#44; studies reported an estimated incidence of PG of between 2 and 3 cases per million inhabitants per year&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The incidence observed in our population is therefore consistent with published reports&#46; PG has traditionally been thought to be slightly more common in women&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#8211;7</span></a> In our study&#44; we observed a female to male ratio of 1&#46;14 to 1&#46; PG usually appears in patients aged between 30 and 50 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a> The mean age at diagnosis in our study was 49&#46;2 &#40;17&#46;4&#41; years &#40;range&#44; 25&#8211;75 years&#41;&#46; We nevertheless observed a peak incidence in patients aged between 60 and 80 years &#40;6 cases&#44; 40&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Only 20&#37; of cases &#40;3 patients&#41; were referred first to the dermatology department&#44; indicating that dermatology plays a secondary role in the care of patients with PG&#46; This may be because almost half of the patients included in our study had gastrointestinal disease&#44; with PG coinciding with periods of worsening of the systemic disease&#46; Nevertheless&#44; these findings may also reflect a lack of knowledge of the condition among nondermatologists&#44; who may confuse it with infections or consider it as secondary to vascular disease and therefore make an inappropriate referral&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In between 50&#37; and 70&#37; of cases&#44; PG is associated with systemic disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;9</span></a> Ruocco et al<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> report that idiopathic PG occurs in 25&#37; to 50&#37; of cases&#46; In our study&#44; 5 cases &#40;33&#37;&#41; were not associated with systemic disease&#46; We also did not observe any cases in which PG was associated with hematologic disease&#46; In 3 cases &#40;20&#37;&#41;&#44; PG was preceded by surgery&#58; 1 sternotomy &#40;aortic stenosis&#41;&#44; 1 ileostomy &#40;Crohn disease&#41;&#44; and 1 nephrostomy &#40;bladder carcinoma&#41;&#46; The development of PG following surgery has been reported previously&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> The most common systemic disease in our patients was inflammatory bowel disease &#40;40&#37;&#59; 5 cases of ulcerative colitis and 1 case of Crohn disease&#41;&#44; and in most of those &#40;4 cases with ulcerative colitis&#41;&#44; PG developed during a disease flare&#46; This finding differs from previous reports&#44; since PG has always been described as independent of the activity of inflammatory bowel disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a> Following initiation of immunosuppressant therapy in those 4 patients&#44; control of both PG and ulcerative colitis was achieved&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">None of the articles we found in the literature discussed a relationship between age and associated systemic disease in patients with PG&#46; In our study&#44; 5 cases &#40;71&#46;5&#37; of patients classed as having associated systemic disease after exclusion of those with prior surgery&#41; involved patients aged between 20 and 40 years&#46; Due to the small number of patients included in the study &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&#44; however&#44; we were unable to assess a possible association between these 2 variables&#46; It will be possible to examine such an association in future studies that pool data from multiple populations&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Given the low incidence of PG&#44; there are no studies available to support the development of a standard treatment algorithm&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;12</span></a> Nevertheless&#44; before choosing local or systemic therapy&#44; the following patient characteristics should be taken into consideration&#58; history&#44; presence of concomitant systemic disease&#44; depth and size of ulcers&#44; and disease course&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The use of dressings with hydrocolloids or hydrogels is particularly important&#44; since they increase the production of collagen&#44; improve the process of angiogenesis&#44; optimize pain control&#44; and reduce the likelihood of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; was the most frequently used immunosuppressant drug &#40;8 patients&#44; 53&#46;3&#37;&#41;&#46; Complete resolution of the lesions was observed within 45 days of treatment initiation in all patients&#46; In the literature&#44; prednisone is considered the first-line systemic treatment&#44; with a level of evidence of 2&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;12</span></a> and this is confirmed by our results&#46; Ciclosporin can be used to lower the dose of corticosteroids&#44; but its use should be restricted to idiopathic PG&#44; since long-term ciclosporin therapy is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">TNF inhibitors are used in patients with systemic disease and concomitant PG&#46; Infliximab is the only biologic drug with demonstrated efficacy in double-blind placebo-controlled trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;14</span></a> We only used infliximab in 2 patients&#44; and the drug had to be withdrawn in one of them due to a severe infusion reaction&#46; The use of adalimumab has also been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;12&#44;15</span></a> The regimen used is that applicable to inflammatory bowel disease or ankylosing spondylitis&#46; In inflammatory bowel disease&#44; an initial dose of 80<span class="elsevierStyleHsp" style=""></span>mg followed by 40<span class="elsevierStyleHsp" style=""></span>mg every 2 weeks is used&#44; whereas in ankylosing spondylitis&#44; there is no loading dose and a dose of 40<span class="elsevierStyleHsp" style=""></span>mg every 2 weeks is used&#46; We prescribed adalimumab in 4 cases &#40;26&#46;65&#37;&#41;&#59; in 2 of those it was necessary to prescribe the drug in combination with sulfasalazine in order to obtain complete control of the associated systemic disease and resolution of the lesions&#46; We did not observe adverse reactions with adalimumab&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Treatment with local immunosuppressants is indicated for superficial lesions or in patients with multiple diseases&#44; in whom there is an unacceptable likelihood of adverse reactions to systemic therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Our experience with local immunosuppressants is limited&#46; One of our patients died 1 month after diagnosis of peristomal PG and it was not possible to assess the response to application of clobetasol 0&#46;05&#37;&#59; the other patient was lost to follow-up after 3 months&#44; although partial improvement had been observed at 1 month following 2 dermojet injections of triamcinolone&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">In summary&#44; PG is a rare condition in Spain&#46; It affects similar numbers of men and women and is normally associated with systemic disease&#44; particularly inflammatory bowel disease&#46; All of these findings agree with the results reported in the literature&#46; Notably&#44; however&#44; in our study there was a larger proportion of patients aged over 60 years than reported in the literature&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">According to our findings&#44; age younger than 40 years appears to be related to an increase in the probability of having an associated systemic disease in patients with PG&#46; Nevertheless&#44; further studies in a much larger sample of patients are required to confirm this hypothesis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Although systemic corticosteroids continue to be the treatment of choice&#44; we consider adalimumab to be a good alternative for the treatment of PG with concomitant systemic disease&#44; given that it is effective&#44; can be used in combination with other immunosuppressant drugs and dressings&#44; is well tolerated&#44; and has a favorable safety profile&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pyoderma gangrenosum is a condition that is included among the neutrophilic dermatoses&#46; Given its low incidence&#44; few studies have addressed its epidemiology or treatment&#46;</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the epidemiological and clinical characteristics of patients with pyoderma gangrenosum along with our experience of treating the condition in a referral hospital in Malaga&#44; Spain&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A retrospective&#44; observational study was undertaken in the Department of Dermatology at Hospital Cl&#237;nico Universitario Virgen de la Victoria in Malaga&#44; Spain between January 2000 and December 2009 and included all patients diagnosed with pyoderma gangrenosum&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The incidence of pyoderma gangrenosum in our reference population is 3&#46;26 cases per million inhabitants per year&#46; The most frequent concomitant systemic disease was ulcerative colitis &#40;5 cases&#44; 33&#37;&#41;&#46; In 4 patients with that disease&#44; pyoderma gangrenosum appeared during a flare-up&#46; In 80&#37; of cases&#44; patients were not referred to a dermatologist during the initial phase of pyoderma gangrenosum&#44; and most referrals were from gastroenterology or general surgery &#40;4 patients each&#44; 52&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Patients with pyoderma gangrenosum are often referred to dermatologists by other specialists after a varying period of time has elapsed without achieving an accurate diagnosis&#46; In these patients&#44; especially those between 20 and 40 years of age&#44; it is essential to rule out concomitant disease&#46; Adalimumab is a good treatment option for pyoderma gangrenosum&#46;</p>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El pioderma gangrenoso &#40;PG&#41; es un proceso incluido en el grupo de las denominadas dermatosis neutrof&#237;licas&#44; del que existen pocos trabajos epidemiol&#243;gicos y de abordaje terap&#233;utico en la bibliograf&#237;a dada su relativa escasa incidencia&#46;</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir las caracter&#237;sticas epidemiol&#243;gicas y cl&#237;nicas y exponer nuestra experiencia terap&#233;utica en los pacientes con PG de un hospital de segundo nivel de M&#225;laga &#40;Espa&#241;a&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El estudio observacional y retrospectivo incluy&#243; todos los pacientes diagnosticados de PG en el Servicio de Dermatolog&#237;a del Hospital Cl&#237;nico Universitario Virgen de la Victoria &#40;M&#225;laga&#41; en un periodo de 10 a&#241;os&#44; comprendido entre enero de 2000 y diciembre de 2009&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La incidencia del PG en nuestra poblaci&#243;n de referencia es de 3&#44;26 casos por mill&#243;n de habitantes y a&#241;o&#46; La enfermedad sist&#233;mica asociada con mayor frecuencia a la aparici&#243;n del PG fue la colitis ulcerosa &#40;5 casos&#44; 33&#37;&#41;&#46; En 4 pacientes con colitis ulcerosa el PG apareci&#243; durante un brote de la enfermedad&#46; El 80&#37; de los pacientes no fueron derivados a Dermatolog&#237;a en la fase inicial del PG&#44; siendo los servicios con m&#225;s derivaciones Digestivo y Cirug&#237;a general&#44; con 4 pacientes cada uno &#40;52&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El PG a menudo llega al dermat&#243;logo remitido por otros especialistas tras un tiempo variable sin diagn&#243;stico correcto&#46; Ante este proceso es b&#225;sico descartar la existencia de alguna patolog&#237;a asociada&#44; especialmente en pacientes entre 20 y 40 a&#241;os&#46; Adalimumab es una buena opci&#243;n terap&#233;utica en el tratamiento del PG&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Su&#225;rez-P&#233;rez JA&#44; et al&#46; Pioderma gangrenoso&#58; Presentaci&#243;n de 15 casos y revisi&#243;n de la literatura&#58; Actas Dermosifiliogr&#46;2012&#59;103&#58;120-126&#46;</p>"
      ]
    ]
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Biopsy of the edge of an ulcer diagnosed as pyoderma gangrenosum&#46; A notable neutrophilic inflammatory infiltrate is visible in the upper dermis&#46; A&#44; Hematoxylin-eosin&#59; original magnification &#215;4&#46; B&#44; Hematoxylin-eosin&#59; original magnification &#215;10&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Relationship between age and association of pyoderma gangrenosum with systemic disease&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Appearance before &#40;A&#41; and after &#40;B&#41; treatment with oral prednisone&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Appearance before &#40;A&#41; and after &#40;B&#41; treatment with adalimumab in combination with sulfasalazine in a patient with pyoderma gangrenosum and ankylosing spondylitis&#46;</p>"
        ]
      ]
      4 => 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">Patient&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">Primary Referral&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&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">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">Systemic Disease&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">Temporal Relationship With Systemic Disease&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">Treatment&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">Course&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">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">Ulcerative&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">Surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">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">Ulcerative&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">Surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&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">Ulcerative colitis&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">Preceding&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">Oral prednisone&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">No lesions after 2 months of treatment&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">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">Ulcerative&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">Vascular surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">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">Ulcerative&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">Gastroenterology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&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">Ulcerative colitis&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">Flare&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">Infliximab&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">No lesions after 6 weeks of treatment&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">5&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">Ulcerative&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">Dermatology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&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">Ankylosing spondylitis&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">None&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">Adalimumab&#47;sulfasalazine&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">No lesions after 2 months of treatment&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">6&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">Ulcerative&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">Gastroenterology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&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">Ulcerative colitis&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">Flare&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">Oral prednisone&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">No lesions after 2 months of treatment&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">7&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">Peristomal&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">Surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&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">Crohn Disease&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">None&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">Adalimumab&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">No lesions after 1 month of treatment Required weekly dosing&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">8&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">Ulcerative&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">Gastroenterology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&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">Ulcerative colitis&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">Flare&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">Adalimumab&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">No lesions after 1 month of treatment&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">9&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">Ulcerative&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">Vascular surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">10&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">Peristomal&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">Vascular surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">Surgical intervention&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">11&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">Ulcerative&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">Gastroenterology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&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">Ulcerative colitis&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">Flare&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">Adalimumab&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">No lesions after 1 month of treatment&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">12&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">Peristomal&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">Surgery&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&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">Surgical intervention&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">&#8211;&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">Triamcinolone dermojet injection&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">Improvement without complete resolution of lesions after 1 month of treatment&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">13&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">Ulcerative&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">Dermatology&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&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&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">No&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">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&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">14&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">Ulcerative&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">Dermatology&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&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="char" valign="\n
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                  \t\t\t\t">34&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">No&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
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                  \t\t\t\t">&#8211;&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">Oral prednisone&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">No lesions after 2 months of treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Peristomal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Urology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Male&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="char" valign="\n
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                  \t\t\t\t">75&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">Surgical intervention&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">&#8211;&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">Topical corticosteroids&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">Died during the first month of follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Clinical Characteristics of the Patients&#46;</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Ruocco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Level of Evidence&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Infliximab&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Neutrophilic Dermatoses"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46; Moschella"
                            1 => "M&#46; Davis"
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                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Dermatology"
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                        "serieFecha" => "2008"
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              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pyoderma gangrenosum associated with hidradenitis suppurativa&#58; a case report and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46;E&#46; Garcia-Rabasco"
                            1 => "A&#46; Esteve-Martinez"
                            2 => "V&#46; Zaragoza-Ninet"
                            3 => "J&#46;L&#46; Sanchez-Carazo"
                            4 => "V&#46; Alegre-de-Miquel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr"
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                        "volumen" => "101"
                        "paginaInicial" => "717"
                        "paginaFinal" => "721"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20965015"
                            "web" => "Medline"
                          ]
                        ]
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                ]
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pyoderma gangrenosum&#58; an updated review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46; Ruocco"
                            1 => "S&#46; Sangiuliano"
                            2 => "A&#46;G&#46; Gravina"
                            3 => "A&#46; Miranda"
                            4 => "G&#46; Nicoletti"
                          ]
                        ]
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1468-3083.2009.03199.x"
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                        "tituloSerie" => "J Eur Acad Dermatol Venereol"
                        "fecha" => "2009"
                        "volumen" => "23"
                        "paginaInicial" => "1008"
                        "paginaFinal" => "1017"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19470075"
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                    0 => array:2 [
                      "titulo" => "Pyoderma gangrenosum&#58; a review and update on new therapies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Miller"
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                            2 => "A&#46; Clark"
                            3 => "J&#46;L&#46; Jorizzo"
                            4 => "S&#46;R&#46; Feldman"
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                      "doi" => "10.1016/j.jaad.2009.05.030"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20227580"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;N&#46; Crowson"
                            1 => "M&#46;C&#46; Mihm Jr&#46;"
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                  ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cutan Pathol"
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                      "titulo" => "Diagnosis and treatment of pyoderma gangrenosum"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46; Brooklyn"
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                            2 => "C&#46; Probert"
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                    0 => array:2 [
                      "doi" => "10.1136/bmj.333.7560.181"
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                        "tituloSerie" => "BMJ"
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                        "volumen" => "333"
                        "paginaInicial" => "181"
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                          0 => array:2 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pyoderma gangrenosum&#46; A comparison of typical and atypical forms with an emphasis on time to remission&#46; Case review of 86 patients from 2 institutions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;L&#46; Bennett"
                            1 => "J&#46;M&#46; Jackson"
                            2 => "J&#46;L&#46; Jorizzo"
                            3 => "A&#46;B&#46; Fleischer Jr&#46;"
                            4 => "W&#46;L&#46; White"
                            5 => "J&#46;P&#46; Callen"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Medicine"
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                        "paginaInicial" => "37"
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                      "doi" => "10.1016/S0140-6736(97)10187-8"
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                        "tituloSerie" => "Lancet"
                        "fecha" => "1998"
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                    0 => array:2 [
                      "titulo" => "Treatment of pyoderma gangrenosum with infliximab in Crohn&#39;s disease"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;S&#46; Sapienza"
                            1 => "S&#46; Cohen"
                            2 => "A&#46;J&#46; Dimarino"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "2004"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46; Sanz-Munoz"
                            1 => "C&#46; Martinez-Moran"
                            2 => "A&#46; Miranda-Romero"
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