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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Erythema multiforme &#40;EM&#41; is an acute mucocutaneous syndrome that runs a self-limiting&#44; usually mild&#44; course&#46; It is considered a hypersensitivity reaction to different antigenic stimuli&#44; the most common of which is herpes simplex virus &#40;HSV&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a> It is clinically characterized by a polymorphous eruption of crops of erythematous macules and papules that tend to be symmetric and located predominantly in acral regions&#46; The most characteristic lesions&#44; known as target or iris lesions&#44; are round&#44; erythematous&#44; edematous papules with concentric color variations&#46; The condition is known as erythema <span class="elsevierStyleItalic">multiforme</span> because patients have lesions at different stages of development&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">EM is classified among the photoaggravated or photoaccentuated dermatoses&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> These are different from other photodermatoses in that they can also occur in the absence of exposure to UV radiation or visible light&#59; indeed&#44; only a few individuals experience eruptions triggered by light&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> In some cases&#44; the lesions are confined to sun-exposed areas&#44; with a clear division between these and unexposed areas&#46; This explains why the use of the term <span class="elsevierStyleItalic">photodistributed &#40;</span>or <span class="elsevierStyleItalic">photosensitive&#41; erythema multiforme</span> &#40;PEM&#41; is justified&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> In our review of the literature&#44; we identified 18 cases of PEM&#46; The triggers identified were HSV reactivation&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> drug use&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;15&#8211;22</span></a> and polymorphous light eruption &#40;PMLE&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> In this article&#44; we review the epidemiologic&#44; clinical&#44; etiologic&#44; diagnostic&#44; and therapeutic aspects of PEM&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><p id="par0015" class="elsevierStylePara elsevierViewall">The prevalence of EM and PEM is unknown&#46; EM is a relatively common condition&#44; and while the existence of PEM has been recognized for many years&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14</span></a> few cases have been described&#44; possibly due to its low prevalence or to the fact that many cases go undiagnosed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">PEM affects individuals of both sexes and all ages&#46; In the cases reported in the literature&#44; the mean age at diagnosis was 41&#46;7 years&#44; with a range of 9 to 75 years&#46; In the case of HSV-associated PEM&#44; the mean age was considerably lower&#44; at 15 years &#40;range&#44; 9-25 years&#41; while in that of drug-induced PEM&#44; it was higher &#40;53&#46;9 years&#59; range&#44; 36-75 years&#41;&#46; PEM secondary to PMLE and idiopathic PEM were observed in middle-aged individuals&#46; Overall&#44; there was a slight male predominance &#40;male to female ratio of 10&#58;8&#41;&#46; Approximately 39&#37; of patients with PEM experience recurrences&#44; particularly when there is associated HSV infection or no identifiable cause&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Etiology</span><p id="par0025" class="elsevierStylePara elsevierViewall">PEM has been described in association with drugs&#44; HSV infection&#44; and other conditions&#44; such as PMLE &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46; Of the cases described to date&#44; 55&#46;5&#37; were induced by drugs&#44; 22&#46;2&#37; by HSV reactivation&#44; and 5&#46;5&#37; by PMLE&#46; The remaining cases were classified as idiopathic&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Drug-Induced PEM</span><p id="par0030" class="elsevierStylePara elsevierViewall">Drugs are the most common cause of PEM&#46; Of the 18 cases of PEM reported to date&#44; 10 were induced by topical or systemic drugs &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The drugs implicated were phenylbutazone&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> trichlocarban&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> afloqualone&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> bufexamac&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> paclitaxel&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> simvastin&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> pravastatin&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> paroxetin&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and naproxene&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Drug-induced PEM is generally characterized by a single outbreak of lesions&#46; However&#44; when the condition is misdiagnosed and administration of the drug is continued&#44; the disease can become chronic&#44; with recurrent eruptions over many years triggered by sun exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The time from the start of treatment to the appearance of lesions is variable&#44; with reports in the literature ranging from 15 days<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;17</span></a> to 4 years&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> There is usually no personal or family history of photodermatoses or recurrent HSV infection&#46; While there may be a history of herpes labialis&#44; there does not appear to be an association between this condition and PEM&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical characteristics of drug-induced PEM are identical to those of PEM with other precipitating factors&#46; The lesions are located in sun-exposed areas and may be accompanied by systemic symptoms<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and mucosal involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Lesions due to topical drugs are usually observed at the application site&#46; One patient described by Leroy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> developed EM-like contact dermatitis in the genital area following the use of a soap containing triclocarban in this area&#59; 48<span class="elsevierStyleHsp" style=""></span>hours later&#44; the lesions spread to sun-exposed areas&#46; Kurumaji et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> described a similar case in which a patient developed eczematous contact dermatitis in the groin area after the application of topical bufexamac&#46; He then developed EM-like lesions around the affected area and in areas that had been exposed to the sun&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Herpes Simplex Virus</span><p id="par0045" class="elsevierStylePara elsevierViewall">Recurrent HSV infection is the second most common cause of PEM&#46; Of the 18 cases of PEM described in the literature&#44; 4 were triggered by HSV&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> The main association is with herpes labialis&#44; but cases have also been described in patients with genital herpes and herpes in other areas&#46; HSV-associated PEM tends to affect young men who do not have a personal or family history of photodermatosis and who report not having taken drugs&#46; It is typically characterized by recurrent outbreaks that occur once or twice a year&#44; normally in the sunniest months of the year and coinciding with sun exposure&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Herpes lesions precede the skin eruption by approximately 7 to 10 days&#46; The eruption affects sun-exposed areas and is generally not accompanied by systemic or mucosal involvement&#46; In 1 case described in the literature&#44; the lesions were limited to areas previously affected by sunburn&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Polymorphous Light Eruption</span><p id="par0050" class="elsevierStylePara elsevierViewall">Three cases of EM and PEM secondary to PMLE have been reported to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> The patients&#44; a man and 2 women aged between 28 and 38 years&#44; had had recurrent PMLE for years but had more recently developed a second type of eruption that was clinically compatible with EM and occurred 1 to 2 weeks after the episode of PMLE&#46; In 2 of the patients&#44; the EM-like lesions were recurrent and affected both sun-exposed and covered areas&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The third patient experienced 2 episodes of EM following 1 of the episodes of PMLE&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The first affected sun-exposed areas and the second occurred a week later&#44; with lesions observed in the area that had been covered by the woman&#39;s bathing suit&#46; The patient had not been in the sun during the intervening week&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Idiopathic PEM</span><p id="par0055" class="elsevierStylePara elsevierViewall">Several cases of PEM have been reported in patients without herpes reactivation&#44; drug use&#44; or any other known trigger&#46; These idiopathic cases tend to recur over several years&#46; The lesions are commonly located mainly in sun-exposed areas&#44; although they may also affect covered parts of the body as well as the palms of the hands and mucous membranes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our review of the literature&#44; we found 3 cases of recurrent PEM with no identifiable cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;25&#44;26</span></a> In 1 case&#44; however&#44; elevated serum titers of immunoglobulin &#40;Ig&#41; G and IgM for HSV were identified&#44; suggesting the possible presence of subclinical HSV reactivation that might have been the source of the antigenic stimulus&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In another case&#44; the patient developed PEM when she started to work as an aromatherapist&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Consequently&#44; and despite the negative photopatch results&#44; the involvement of a topical photoallergen cannot be ruled out&#46; In the third case&#44; Akarsu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> described a patient who developed 2 outbreaks of target lesions histologically compatible with EM in sun-exposed areas&#59; the authors classified the lesions as EM-like PMLE based on the presence of pruritus&#44; the location of lesions in sun-exposed areas only&#44; and the absence of mucosal involvement&#46; However&#44; the patient also had lesions on her face and the dorsum of her hands and PMLE does not usually affect areas subject to chronic sun exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> We therefore believe that this case could possibly be classified as idiopathic PEM&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Pathogenesis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The pathogenesis of EM is not fully understood&#44; but it appears to be a hypersensitivity reaction of the skin to a variety of stimuli&#46; In PEM&#44; UV radiation might contribute to the development of lesions by inducing the release of inflammatory mediators&#44; such as quinines&#44; prostaglandins&#44; and histamine&#44; which would increase vascular permeability&#44; thereby facilitating the passage of skin antigens into the bloodstream and favoring the formation of circulating antibodies in sun-exposed areas&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The source of the antigenic stimulus is not always known&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Short sequences of viral DNA have been detected in keratinocytes in patients with HSV-associated EM&#44; leading to the hypothesis that these sequences might act as antigens and induce the release of interferon &#947;&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In drug-induced PEM&#44; either a photoproduct or the actual drug activated by UV radiation might act as an antigen&#44; triggering the immune response&#44; or as a phototoxic agent&#44; favoring the rupture of cells and the release of nuclear antigens&#44; which would then pass into the bloodstream&#44; facilitated by the increased vascular permeability induced by sun radiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;20</span></a> It has also been speculated that alterations of porphyrin metabolism induced by several drugs might be involved in the development of lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> In PEM secondary to the topical application of drugs&#44; the absorption of the drug through the skin or mucosa could cause systemic contact dermatitis&#44; which might manifest as EM-like lesions&#46; Finally&#44; the location of lesions in sun-exposed areas could be due to the photo Koebner phenomenon&#44; with light acting as a traumatic stimulus&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In such cases&#44; once the acute episode has been treated and the offending drug withdrawn&#44; the patient does not generally experience further episodes&#46; Recurrence following exposure to other antigens and sunlight has been reported in just 2 cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;21</span></a> In 1 of these&#44; Rodr&#237;guez-Pazos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> described a patient who developed 2 consecutive episodes of PEM related to 2 different antigens&#58; paroxetine and HSV reactivation&#46; In the other case&#44; Shiohara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> described a patient who experienced PEM in association with afloqualone and exposure to <span class="elsevierStyleItalic">Rhus verniciflua</span>&#44; to which he had been previously sensitized&#46; It has been postulated that following the initial episodes of PEM&#44; the skin might retain traces of photoactive substances&#44; but not in sufficient quantities to cause the development of lesions&#46; The presence of additional&#44; nonspecific&#44; antigenic stimuli&#44; such as HSV reactivation or contact dermatitis due to <span class="elsevierStyleItalic">R verniciflua</span> might then have an add-on effect and trigger the development of skin photosensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">It has also been suggested that PMLE might be an immune response to as yet unknown endogenous or photoinduced antigens&#44; and that associated cases of EM or PEM could be triggered by the same antigenic stimulus&#46; Another theory is that the sun exposure that triggers PMLE could cause subclinical HSV reactivation and the subsequent development of EM&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> However&#44; in all the cases described to date&#44; PEM and EM occurred after PMLE&#46; Furthermore&#44; although 1 of the patients had a history of recurrent herpes labialis&#44; he had had no episodes in the preceding year that might explain the EM lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Subclinical reactivation of HSV has also been implicated in the etiology of several cases of idiopathic PEM&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and HSV DNA has been detected by polymerase chain reaction in 40&#37; of recurrent&#44; apparently idiopathic EM&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Some of the cases responded to prophylactic antiviral treatment&#44; strongly suggesting that they were triggered by subclinical HSV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical Manifestations</span><p id="par0095" class="elsevierStylePara elsevierViewall">The skin lesions that characterize PEM are identical to those seen in EM&#46; They start out as erythematous macules and then develop into erythematous&#44; edematous papules&#46; They can grow and acquire a characteristic target-like appearance&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;32</span></a> These target lesions may be few in number&#44; and may not even be apparent in the first few days after the onset of the rash&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> As these lesions are a key diagnostic clue&#44; a thorough skin examination is essential&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In PEM&#44; the lesions are limited to sun-exposed areas&#46; They typically affect the face&#44; the neckline&#44; the back of the arms and the forearms&#44; but they can occur on any part of the body that has been exposed to the sun &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Certain physical findings can help to classify the condition as photodistributed&#58; <span class="elsevierStyleItalic">a</span>&#41; sparing of areas not exposed to the sun&#44; such as under the chin or behind the ears&#44; the nasolabial triangle&#44; and the upper eyelids&#59; <span class="elsevierStyleItalic">b</span>&#41; a clear division between exposed areas &#40;with lesions&#41; and unexposed areas &#40;without lesions&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#59; and <span class="elsevierStyleItalic">c</span>&#41;&#44; typical absence of lesions on the palms of the hands and the mucous membranes&#46; Nevertheless&#44; in cases of idiopathic PEM&#44; there have been reports of isolated lesions in covered areas &#40;trunk and scrotum&#41; and on the palms of the hands&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;25</span></a> Albeit rarely&#44; some patients also develop fever&#44; joint pain&#44; and headache<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> or lesions affecting the oral and&#47;or genital mucosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;23&#44;25</span></a> Onycholysis has been described in cases of paclitaxel-induced PEM&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Patients with PEM can experience single or recurrent episodes that can occur at any time of the year&#44; although they are more common in the sunnier months&#46; Patients typically report previous sun exposure or the practice of outdoor activities&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis</span><p id="par0105" class="elsevierStylePara elsevierViewall">When EM is suspected&#44; the first step is to establish whether or not it is photodistributed and the second step is to identify the cause&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The diagnosis of EM is based on clinical history and physical examination and is greatly facilitated when the characteristic target lesions are detected&#46; Laboratory tests do not generally reveal any distinctive alterations&#46; Histology findings are characteristic but nonspecific and are particularly useful for excluding other diagnoses&#46; Histologic features vary according to the type and site of the lesion biopsied and to the age of the lesion&#46; A predominantly mononuclear inflammatory infiltrate is seen in early erythematous macules or papules&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;33</span></a> In lesions of longer duration and in the central area of target lesions&#44; hydropic degeneration of the basal layer and necrosis of keratinocytes are observed&#46; There may also be subepidermal blisters with keratinocytic necrosis in the adjacent area&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;33</span></a> The presence of a predominantly neutrophilic infiltrate or of leukocytoclastic vasculitis suggests a diagnosis other than EM&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Once a diagnosis of EM has been established&#44; the next step is to examine the lesions to determine whether or not they follow a photodistributed pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Clinical history&#44; physical examination&#44; and laboratory tests are useful for ruling out other photodermatoses&#46; The following factors should all be considered&#58; age at onset of the lesions&#44; possible exposure to photosensitizing agents&#44; exposure to light sources&#44; time between exposure to the sun and development of the lesions&#44; time since onset of the lesions&#44; and a personal or family history of photodermatosis&#46; The laboratory workup should include testing for antinuclear antibodies &#40;ANAs&#41; and anti-SSA &#40;Ro&#41; and anti-SSB &#40;La&#41; antibodies and measurement of plasma porphyrins&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The last step in the diagnostic workup is the identification of precipitating factors&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">A diagnosis of drug-induced PEM must be confirmed by photobiologic testing&#44; with at least 2 phototests performed at different times&#46; Ideally&#44; the first test should be conducted during the first visit &#40;when the patient is still taking the suspect drug&#41; and the second test after the drug has been withdrawn&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Diagnosis is confirmed when response to UV radiation is altered in the first test and normal in the second one&#46; It is easy to suspect PEM in patients who are taking just 1 recently introduced drug&#46; In patients on several drugs that were prescribed simultaneously&#44; however&#44; it may be more difficult to identify the offending agent&#46; In such cases&#44; it is important to perform a sequential investigation until the drug responsible for the PEM is identified&#46; The wavelength involved will vary according to the drug and it is therefore important to investigate response to both UV-B and UV-A radiation&#46; The phototests should be performed on a part of the body that is usually covered by clothing&#44; such as the buttocks or the lower back&#46; If the patient has lesions at the time of testing&#44; it is not necessary to wait for these to clear&#46; The time it takes for phototest results to normalize after withdrawal of the drug responsible for PEM varies&#44; and may be as long as a year&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It is therefore important to repeat the tests regularly until the UV response is completely normal&#59; at this point&#44; it will be possible to establish a definitive diagnosis of systemic photosensitivity and at the same time exclude persistent light reactivity or chronic actinic dermatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;36</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Photopatch testing with a standard series of photoallergens and the suspect drug allows the dermatologist to exclude other diagnoses and determine whether or not the condition is immune mediated&#46; The tests should be performed between 6 weeks and 6 months after resolution of the skin lesions&#44; and at least a month after withdrawal of systemic corticosteroids or oral antihistamines&#46; Phototest results must be normal before the photopatch tests are performed to prevent erythema from developing in the irradiated area&#46; Photopatch testing can be performed using either the commercial drug or the pure substance&#46; As a general rule&#44; the commercial form of the drug can be applied directly or added to petrolatum or water at a concentration of 30&#37;&#46; Pure substances must be diluted at 10&#37; in petrolatum&#44; and if possible&#44; also at 10&#37; in water or alcohol&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;38</span></a> Each drug must be patch tested in triplicate&#46; The 3 sets of patches are removed after 48<span class="elsevierStyleHsp" style=""></span>hours&#46; One of the sets is irradiated with 5<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> of UV-A&#44; while the other is irradiated with a sub-MED dose of UV-B &#40;dose just below the dose that produces erythema&#44; equivalent to 80&#37; of the minimal erythemal dose&#44; or MED&#41;&#46; The third set serves as the control&#46; It is important to perform the patch tests in controls&#44; as a negative result will add credibility to a positive result in a patient&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Photoprovocation can be useful for confirming diagnosis in both drug-induced and idiopathic cases&#46; Based on data in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;17</span></a> some authors have postulated that it might only be possible to reproduce lesions during the initial eruption&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However&#44; there has been a report of lesions being provoked 4 weeks after the acute episode&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Photoprovocation involves the performance of phototesting following the administration of the test drug at therapeutic doses over a period of 3 to 5 days&#46; An alternative is phototesting performed 1&#44; 3&#44; and 5<span class="elsevierStyleHsp" style=""></span>hours after the administration of a single dose of the suspect drug&#46; The expected result would be a qualitative and&#47;or quantitative pathologic response to the UV radiation&#46; Informed consent must be obtained from the patient in all cases&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In our review of the literature&#44; the diagnosis of drug-induced PEM was confirmed by photobiologic testing in 7 patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Three patients showed a decrease in UV-B-MED and&#47;or a qualitatively pathologic response to UV-A while the patient was taking the drug and normalization of results after its discontinuation&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> In another case&#44; the patient had already stopped treatment with the offending drug at the time of his visit&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The phototest was therefore performed a posteriori&#44; 3<span class="elsevierStyleHsp" style=""></span>hours after the administration of a single dose of the drug&#46; The result was a decrease in UV-B-MED&#46; The time between discontinuation of the drug and normalization of the UV response varied among the patients&#46; In 1 patient&#44; the UV-B-MED returned to normal within 6 weeks&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> whereas in another&#44; it took 12 weeks&#46; In the third patient&#44; UV-B-MED had normalized by week 8&#44; but normal results were not seen on repeated UV-A-MED tests until month 9&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Two of the 7 patients had a normal UV-B and UV-A response&#44; but diagnosis was confirmed following the reproduction of EM lesions in the irradiated area&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;17</span></a> Photopatch tests with the suspect drug yielded positive results in 4 patients&#58; 2 had a positive reaction in the area irradiated with a sub-MED dose of UV-B&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;21</span></a> 1 had a positive reaction in the area irradiated with UV-A&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and 1 had a positive reaction in the areas irradiated with UV-B and UV-A&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">HSV-induced PEM is diagnosed on the basis of a compatible clinical history and the exclusion of other possible causes of PEM&#46; The skin eruption is usually preceded by HSV lesions and sun exposure&#46; Elevated anti-HSV IgG titers are usually the only abnormal finding on blood tests&#46; Photobiologic tests have been negative in all cases in which these tests were performed&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with PEM secondary to PMLE have a history consistent with PMLE that will probably have been present for several years&#46; Laboratory and photobiologic test results are normal&#46; A photobiologic study was reported for just 1 of the cases described in the literature&#59; it was performed 2 months after the skin eruption and the patient showed a normal response to both UV-A and UV-B&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Idiopathic PEM is diagnosed after all other known causes have been ruled out&#46; Photoprovocation can reproduce lesions in some cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;26</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment</span><p id="par0160" class="elsevierStylePara elsevierViewall">The goal of treatment in EM is to reduce the duration of the skin lesions&#44; alleviate symptoms&#44; and prevent recurrence&#46; To achieve this&#44; it is necessary to eliminate the causative agent and treat the symptoms with antihistamines and topical and&#47;or systemic corticosteroids&#46; Sun protection measures are also important in the case of PEM&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In drug-induced PEM&#44; avoidance of sun exposure and withdrawal of the offending drug tend to be sufficient to achieve resolution of lesions&#46; Topical or systemic corticosteroids can also be used&#46; There has also been a report of a successful outcome with dapsone and oral corticosteroids in 1 patient&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> A risk-benefit assessment should be performed before withdrawing the drug definitively&#44; because&#44; as was shown by Cohen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> treatment may be maintained if sun protection measures are taken&#46; Patients do not generally experience recurrent episodes once treatment has been stopped&#46; There have been just 2 reports of lesions returning following exposure to other antigens and sunlight&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;21</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In HSV-induced PEM&#44; symptomatic treatment with topical corticosteroids and antihistamines achieves resolution of lesions within days&#46; Prophylactic treatment with acyclovir can prevent HSV reactivation and new episodes of PEM&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">As in drug-induced PEM&#44; avoidance of sun exposure and the administration of antihistamines and oral and topical corticosteroids lead to the resolution of lesions&#46; Short cycles of corticosteroids can be prescribed on detection of the first signs of PMLE&#44; as these will interrupt the eruption within a matter of hours and prevent PEM from developing&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Suppression of PMLE with prophylactic psoralen plus UV-A therapy also prevents the development of PEM&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Idiopathic cases are logically more complicated to manage as the cause is not known&#46; Patients tend to respond to oral corticosteroids&#44; but lesions recur very soon after cessation of treatment&#46; The prophylactic administration of hydroxychloroquine<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;25</span></a> and long-term oral corticosteroids administered at low doses on alternate days in association with physical sun protection measures has been successful&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Sulfapyridine and dapsone have not produced good results&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Likewise&#44; prophylactic narrow-band UV-B radiation<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and topical sunscreens used with or without oral antihistamines do not appear to be useful&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Differential Diagnosis</span><p id="par0185" class="elsevierStylePara elsevierViewall">The differential diagnosis for PEM should include other photoaggravated dermatoses&#44; certain idiopathic photodermatoses&#44; and skin disorders that present with annular maculopapular lesions&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">EM-like PMLE&#46; PMLE is a common idiopathic photodermatosis characterized by pruritic lesions in the form of erythematous papules&#44; papulovesicles&#44; vesicles&#44; or plaques that develop in sun-covered areas hours or days after exposure to sunlight&#46; Patients tend to report the development of lesions following exposure to the sun at the beginning of the summer&#46; The episodes typically recur over successive years and the appearance of lesions is usually followed by what is known as the <span class="elsevierStyleItalic">hardening phenomenon</span>&#46; Diagnosis is generally straightforward and is based on a compatible clinical history&#46; Histology can help in doubtful cases&#46; As already mentioned&#44; PEM can be triggered by PMLE&#46; Furthermore&#44; it can sometimes be difficult to distinguish between the 2 entities&#46; PMLE has many morphologic variants&#44; some of which mimic EM&#46; Furthermore&#44; EM-like PLE and EM may be indistinguishable histologically&#46; In such cases&#44; investigation of viral DNA in skin biopsy specimens may be of use&#44; as results are positive in between 32&#37; and 72&#37; of cases of EM and negative in PMLE&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The absence of mucosal involvement in PMLE<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> can also be a useful pointer&#46; Finally&#44; phototesting is negative in PMLE but not in drug-induced PEM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Juvenile spring eruption&#46; This is a localized form of MPLE that tends to affect children aged between 5 and 12 years&#46; It starts as erythematous papules that are located on the ears and can develop into vesicles or blisters&#46; The detection of mucosal involvement and a history of HSV reactivation can help to establish a diagnosis of PEM rather than juvenile spring eruption&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Subacute cutaneous lupus erythematosus&#46; This is a subtype of lupus erythematosus with distinctive clinical&#44; histologic&#44; and immunologic features&#46; The most noteworthy of these are photosensitivity and the presence of anti-Ro &#40;SSA&#41; and anti-La &#40;SSB&#41; antibodies&#46; Patients develop psoriasiform or annular lesions typically located in sun-exposed areas such as the neckline&#44; the shoulders&#44; the lateral aspect of the arms&#44; and the dorsum of the hands&#44; with sparing of the face&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> Small annular lesions can mimic the characteristic target lesions of EM&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Subacute cutaneous lupus erythematosus can also be triggered by photosensitizing drugs&#44; some of which have also been implicated in PEM&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;40</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Rowell syndrome&#46; Patients with lupus erythematosus can develop lesions that are not only similar in appearance to those seen in EM but also follow an identical clinical course&#46; Rowell syndrome was first described in patients with discoid lupus erythematosus&#44; but it has also been seen in association with subacute cutaneous lupus erythematosus and systemic lupus erythematosus&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;43</span></a> Several authors do not consider Rowell syndrome to be a separate entity but rather a morphologic variant of subacute cutaneous lupus erythematosus with target lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;43</span></a> The presence of ANAs&#44; anti-LA &#40;SSB&#41; or anti-Ro &#40;SSA&#41; antibodies&#44; rheumatoid factor&#44; and perniotic lesions are typical findings in Rowell syndrome41 and can be useful in the differential diagnosis&#46;</p></li></ul></p><p id="par0210" class="elsevierStylePara elsevierViewall">Other diseases with target lesions that should be included in the differential diagnosis are acute hemorrhagic edema of infancy&#44; EM-like contact dermatitis&#44; paraneoplastic pemphigus&#44; IgA pemphigus&#44; pruritic urticarial papules and plaques of pregnancy&#44; syphilis&#44; fixed drug eruption&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> ecthyma gangrenosum&#44; erythema chronicum migrans&#44; and granuloma annulare&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#8211;49</span></a> In their very early stages and depending on their distribution&#44; urticarial lesions&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> urticarial vasculitis&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and rosacea may also resemble PEM lesions&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall">PEM is an uncommon&#44; probably underdiagnosed&#44; skin condition that can affect both sexes and patients of all ages&#46; It has been associated with drugs&#44; HSV reactivation&#44; and PMLE&#46; Diagnosis is based on clinical history&#44; physical findings&#44; histopathology&#44; and photobiologic tests&#46; The condition runs a self-limiting&#44; benign course but can recur over successive several years if the cause is not eliminated&#46; Treatment is symptomatic&#44; with avoidance of triggers and the use of sun protection measures&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of Interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:15 [
        0 => array:2 [
          "identificador" => "xres276223"
          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec258197"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres276222"
          "titulo" => "Resumen"
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        3 => array:2 [
          "identificador" => "xpalclavsec258198"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Etiology"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Drug-Induced PEM"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Herpes Simplex Virus"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Polymorphous Light Eruption"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Idiopathic PEM"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Pathogenesis"
        ]
        8 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Clinical Manifestations"
        ]
        9 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Diagnosis"
        ]
        10 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Treatment"
        ]
        11 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Differential Diagnosis"
        ]
        12 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Conclusions"
        ]
        13 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflicts of Interest"
        ]
        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-09-20"
    "fechaAceptado" => "2012-01-07"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec258197"
          "palabras" => array:5 [
            0 => "Erythema multiforme"
            1 => "Photosensitivity"
            2 => "Herpes simplex virus"
            3 => "Drugs"
            4 => "Adverse drug reaction"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec258198"
          "palabras" => array:5 [
            0 => "Eritema multiforme"
            1 => "Fotosensibilidad"
            2 => "Virus herpes simple"
            3 => "F&#225;rmacos"
            4 => "Reacci&#243;n adversa a f&#225;rmacos"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although the existence of photodistributed erythema multiforme has been recognized for years&#44; few cases have been described to date&#46; It is an uncommon&#44; and probably underdiagnosed&#44; skin disorder that can affect individuals of both sexes and all ages&#46; It has been associated with drugs&#44; reactivation of herpes simplex virus infection&#44; and polymorphous light eruption&#46; A diagnosis is made on the basis of history&#44; physical examination&#44; histology&#44; and phototesting&#46; The condition runs a benign&#44; self-limiting course but patients may experience outbreaks for several years if the causative agent is not eliminated&#46; It is treated symptomatically and patients are advised to avoid triggers and excessive sun exposure&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A pesar de que la fotodistribuci&#243;n del eritema multiforme se conoce desde hace muchos a&#241;os&#44; pocos casos de eritema multiforme fotodistribuido &#40;EMF&#41; han sido descritos hasta la fecha&#46; El EMF es una dermatosis infrecuente&#44; y probablemente infradiagnosticada&#44; que puede afectar a sujetos de ambos sexos y de todas las edades&#46; Se ha relacionado con f&#225;rmacos&#44; reactivaciones del virus herpes simple y erupci&#243;n polimorfa lum&#237;nica&#46; Su diagn&#243;stico se basa en la anamnesis&#44; la exploraci&#243;n f&#237;sica&#44; la histopatolog&#237;a y el estudio fotobiol&#243;gico&#46; Su curso es benigno y autolimitado&#44; pero pueden aparecer brotes durante varios a&#241;os si no se suprime el agente causal&#46; Se trata de forma sintom&#225;tica&#44; evitando los desencadenantes y adoptando medidas de fotoprotecci&#243;n&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Pazos L&#44; et al&#46; Eritema multiforme fotodistribuido&#46; Actas Dermosifiliogr&#46; 2013&#59;104&#58;645&#8211;53&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 664
            "Ancho" => 1000
            "Tamanyo" => 125224
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lesions in sun-exposed areas in a patient with photodistributed erythema multiforme&#46; Erythematous&#44; edematous papules&#44; several with a target-like morphology&#44; in the facial region &#40;A&#41; and on the forearms &#40;B&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 712
            "Ancho" => 950
            "Tamanyo" => 103699
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Photodistributed erythema multiforme after a herpes simplex virus infection and sun exposure&#46; Note the clear division between the sun-exposed and covered areas&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; F&#44; female&#59; IV&#44; intravenous&#59; M&#44; male&#59; MED&#44; minimal erythemal dose&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Study&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">Drug&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">Time on Drug&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">Lesion Site&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&#47;Mucosal Symptoms&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 Course&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">Photobiologic Study&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">Photopatch Testing&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">Leroy et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> 1985&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phenylbutazone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diagnosis based on clinical features and exclusion &#40;no photobiologic study or testing with the causative drug&#41;&#46; Photobiologic study with other drugs being taken by the patient &#40;normal results&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&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">Leroy et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> 1987&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Triclocarban &#40;topical&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Application site and sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;oral mucosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative phototest results with drug but reproduction of lesions in area irradiated with UV-B&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;<span class="elsevierStyleHsp" style=""></span>UV-B&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">Shiohara et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> 1990&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Afloqualone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug not performed&#46; Photoprovocation after single dose of drug led to a decrease in UV-B-MED and reproduction of lesions following sun exposure&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&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">Kurumaji&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 1998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bufexamac &#40;topical&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Application site and sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative phototest with drug but reproduction of lesions in area irradiated with UV-B&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;<span class="elsevierStyleHsp" style=""></span>UV-A&#47;UV-B&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">Cohen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> 2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paclitaxel &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&#59; onycholysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical diagnosis &#40;photobiologic study not performed&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not done&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">Cohen&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paclitaxel &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&#59; onycholysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical diagnosis &#40;photobiologic study not performed&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not done&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">Rodr&#237;guez-Pazos et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> 2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" 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">Simvastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 12 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug led to a decrease in UV-B-MED and abnormal UV-A response&#46; Normalization of UV-B MED and UV-A response at 2 mo and 9 mo&#44; respectively&#44; after withdrawal of the drug&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&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">Rodr&#237;guez-Pazos et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> 2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pravastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug led to a decrease in UV-B-MED&#44; with normalization 3 mo after withdrawal of the drug&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&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">Rodr&#237;guez-Pazos et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> 2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paroxetine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug led to a decrease in UV-B-MED&#44; with normalization 6 wk after withdrawal of the drug&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;<span class="elsevierStyleHsp" style=""></span>UV-B&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">Guti&#233;rrez-Gonz&#225;lez et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> 2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Naproxen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug not performed&#46; Negative photoprovocation test after 2 doses of the drug&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;<span class="elsevierStyleHsp" style=""></span>UV-A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab397363.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cases of Drug-Induced Photodistributed Erythema Multiforme in the Literature&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; F&#44; female&#59; HSV&#44; herpes simplex virus&#59; M&#44; male&#59; PMLE&#44; polymorphous light eruption&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Study&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">Etiology&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">Lesion Site&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&#47;Mucosal Symptoms&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 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">Huff &#38; Weston&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> 1980&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" 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">Sun exposed areas &#40;at site of previous burn&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#47;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">Single episode&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">Wolf et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> 1994&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 7 y&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">Wolf et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> 1994&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 2 y&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">P&#233;rez-Carmona et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 5 y&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">Borges da Costa et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> 2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary to PMLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" 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">Two consecutive eruptions&#58; the first in sun-exposed areas and the second in areas covered by bathing suit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&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">Fitzpatrick et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> 1983&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&#59; occasional lesions in covered areas &#40;palms and scrotum&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#47;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">Recurrent episodes over 5 y&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">Calzavara Pint&#243;n et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> 2003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&#59; isolated lesions on palms and covered areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recurrent episodes over 10 y&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">Tamagawa-Mineoka et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> 2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 1 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab397364.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cases of Photodistributed Erythema Multiforme Not Related To Drugs in the Literature&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:50 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
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Review
Photodistributed Erythema Multiforme
Eritema multiforme fotodistribuido
L. Rodríguez-Pazos
Autor para correspondencia
ladrizos@hotmail.com

Corresponding author.
, S. Gómez-Bernal, M.T. Rodríguez-Granados, J. Toribio
Departamento de Dermatología, Complejo Hospitalario Universitario, Facultad de Medicina, Santiago de Compostela, Spain
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    "titulo" => "Photodistributed Erythema Multiforme"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lesions in sun-exposed areas in a patient with photodistributed erythema multiforme&#46; Erythematous&#44; edematous papules&#44; several with a target-like morphology&#44; in the facial region &#40;A&#41; and on the forearms &#40;B&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Erythema multiforme &#40;EM&#41; is an acute mucocutaneous syndrome that runs a self-limiting&#44; usually mild&#44; course&#46; It is considered a hypersensitivity reaction to different antigenic stimuli&#44; the most common of which is herpes simplex virus &#40;HSV&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a> It is clinically characterized by a polymorphous eruption of crops of erythematous macules and papules that tend to be symmetric and located predominantly in acral regions&#46; The most characteristic lesions&#44; known as target or iris lesions&#44; are round&#44; erythematous&#44; edematous papules with concentric color variations&#46; The condition is known as erythema <span class="elsevierStyleItalic">multiforme</span> because patients have lesions at different stages of development&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">EM is classified among the photoaggravated or photoaccentuated dermatoses&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> These are different from other photodermatoses in that they can also occur in the absence of exposure to UV radiation or visible light&#59; indeed&#44; only a few individuals experience eruptions triggered by light&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> In some cases&#44; the lesions are confined to sun-exposed areas&#44; with a clear division between these and unexposed areas&#46; This explains why the use of the term <span class="elsevierStyleItalic">photodistributed &#40;</span>or <span class="elsevierStyleItalic">photosensitive&#41; erythema multiforme</span> &#40;PEM&#41; is justified&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> In our review of the literature&#44; we identified 18 cases of PEM&#46; The triggers identified were HSV reactivation&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> drug use&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;15&#8211;22</span></a> and polymorphous light eruption &#40;PMLE&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> In this article&#44; we review the epidemiologic&#44; clinical&#44; etiologic&#44; diagnostic&#44; and therapeutic aspects of PEM&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><p id="par0015" class="elsevierStylePara elsevierViewall">The prevalence of EM and PEM is unknown&#46; EM is a relatively common condition&#44; and while the existence of PEM has been recognized for many years&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14</span></a> few cases have been described&#44; possibly due to its low prevalence or to the fact that many cases go undiagnosed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">PEM affects individuals of both sexes and all ages&#46; In the cases reported in the literature&#44; the mean age at diagnosis was 41&#46;7 years&#44; with a range of 9 to 75 years&#46; In the case of HSV-associated PEM&#44; the mean age was considerably lower&#44; at 15 years &#40;range&#44; 9-25 years&#41; while in that of drug-induced PEM&#44; it was higher &#40;53&#46;9 years&#59; range&#44; 36-75 years&#41;&#46; PEM secondary to PMLE and idiopathic PEM were observed in middle-aged individuals&#46; Overall&#44; there was a slight male predominance &#40;male to female ratio of 10&#58;8&#41;&#46; Approximately 39&#37; of patients with PEM experience recurrences&#44; particularly when there is associated HSV infection or no identifiable cause&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Etiology</span><p id="par0025" class="elsevierStylePara elsevierViewall">PEM has been described in association with drugs&#44; HSV infection&#44; and other conditions&#44; such as PMLE &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46; Of the cases described to date&#44; 55&#46;5&#37; were induced by drugs&#44; 22&#46;2&#37; by HSV reactivation&#44; and 5&#46;5&#37; by PMLE&#46; The remaining cases were classified as idiopathic&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Drug-Induced PEM</span><p id="par0030" class="elsevierStylePara elsevierViewall">Drugs are the most common cause of PEM&#46; Of the 18 cases of PEM reported to date&#44; 10 were induced by topical or systemic drugs &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The drugs implicated were phenylbutazone&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> trichlocarban&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> afloqualone&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> bufexamac&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> paclitaxel&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> simvastin&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> pravastatin&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> paroxetin&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and naproxene&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Drug-induced PEM is generally characterized by a single outbreak of lesions&#46; However&#44; when the condition is misdiagnosed and administration of the drug is continued&#44; the disease can become chronic&#44; with recurrent eruptions over many years triggered by sun exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The time from the start of treatment to the appearance of lesions is variable&#44; with reports in the literature ranging from 15 days<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;17</span></a> to 4 years&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> There is usually no personal or family history of photodermatoses or recurrent HSV infection&#46; While there may be a history of herpes labialis&#44; there does not appear to be an association between this condition and PEM&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical characteristics of drug-induced PEM are identical to those of PEM with other precipitating factors&#46; The lesions are located in sun-exposed areas and may be accompanied by systemic symptoms<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and mucosal involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Lesions due to topical drugs are usually observed at the application site&#46; One patient described by Leroy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> developed EM-like contact dermatitis in the genital area following the use of a soap containing triclocarban in this area&#59; 48<span class="elsevierStyleHsp" style=""></span>hours later&#44; the lesions spread to sun-exposed areas&#46; Kurumaji et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> described a similar case in which a patient developed eczematous contact dermatitis in the groin area after the application of topical bufexamac&#46; He then developed EM-like lesions around the affected area and in areas that had been exposed to the sun&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Herpes Simplex Virus</span><p id="par0045" class="elsevierStylePara elsevierViewall">Recurrent HSV infection is the second most common cause of PEM&#46; Of the 18 cases of PEM described in the literature&#44; 4 were triggered by HSV&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> The main association is with herpes labialis&#44; but cases have also been described in patients with genital herpes and herpes in other areas&#46; HSV-associated PEM tends to affect young men who do not have a personal or family history of photodermatosis and who report not having taken drugs&#46; It is typically characterized by recurrent outbreaks that occur once or twice a year&#44; normally in the sunniest months of the year and coinciding with sun exposure&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Herpes lesions precede the skin eruption by approximately 7 to 10 days&#46; The eruption affects sun-exposed areas and is generally not accompanied by systemic or mucosal involvement&#46; In 1 case described in the literature&#44; the lesions were limited to areas previously affected by sunburn&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Polymorphous Light Eruption</span><p id="par0050" class="elsevierStylePara elsevierViewall">Three cases of EM and PEM secondary to PMLE have been reported to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> The patients&#44; a man and 2 women aged between 28 and 38 years&#44; had had recurrent PMLE for years but had more recently developed a second type of eruption that was clinically compatible with EM and occurred 1 to 2 weeks after the episode of PMLE&#46; In 2 of the patients&#44; the EM-like lesions were recurrent and affected both sun-exposed and covered areas&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The third patient experienced 2 episodes of EM following 1 of the episodes of PMLE&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The first affected sun-exposed areas and the second occurred a week later&#44; with lesions observed in the area that had been covered by the woman&#39;s bathing suit&#46; The patient had not been in the sun during the intervening week&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Idiopathic PEM</span><p id="par0055" class="elsevierStylePara elsevierViewall">Several cases of PEM have been reported in patients without herpes reactivation&#44; drug use&#44; or any other known trigger&#46; These idiopathic cases tend to recur over several years&#46; The lesions are commonly located mainly in sun-exposed areas&#44; although they may also affect covered parts of the body as well as the palms of the hands and mucous membranes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our review of the literature&#44; we found 3 cases of recurrent PEM with no identifiable cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;25&#44;26</span></a> In 1 case&#44; however&#44; elevated serum titers of immunoglobulin &#40;Ig&#41; G and IgM for HSV were identified&#44; suggesting the possible presence of subclinical HSV reactivation that might have been the source of the antigenic stimulus&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In another case&#44; the patient developed PEM when she started to work as an aromatherapist&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Consequently&#44; and despite the negative photopatch results&#44; the involvement of a topical photoallergen cannot be ruled out&#46; In the third case&#44; Akarsu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> described a patient who developed 2 outbreaks of target lesions histologically compatible with EM in sun-exposed areas&#59; the authors classified the lesions as EM-like PMLE based on the presence of pruritus&#44; the location of lesions in sun-exposed areas only&#44; and the absence of mucosal involvement&#46; However&#44; the patient also had lesions on her face and the dorsum of her hands and PMLE does not usually affect areas subject to chronic sun exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> We therefore believe that this case could possibly be classified as idiopathic PEM&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Pathogenesis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The pathogenesis of EM is not fully understood&#44; but it appears to be a hypersensitivity reaction of the skin to a variety of stimuli&#46; In PEM&#44; UV radiation might contribute to the development of lesions by inducing the release of inflammatory mediators&#44; such as quinines&#44; prostaglandins&#44; and histamine&#44; which would increase vascular permeability&#44; thereby facilitating the passage of skin antigens into the bloodstream and favoring the formation of circulating antibodies in sun-exposed areas&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The source of the antigenic stimulus is not always known&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Short sequences of viral DNA have been detected in keratinocytes in patients with HSV-associated EM&#44; leading to the hypothesis that these sequences might act as antigens and induce the release of interferon &#947;&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In drug-induced PEM&#44; either a photoproduct or the actual drug activated by UV radiation might act as an antigen&#44; triggering the immune response&#44; or as a phototoxic agent&#44; favoring the rupture of cells and the release of nuclear antigens&#44; which would then pass into the bloodstream&#44; facilitated by the increased vascular permeability induced by sun radiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;20</span></a> It has also been speculated that alterations of porphyrin metabolism induced by several drugs might be involved in the development of lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> In PEM secondary to the topical application of drugs&#44; the absorption of the drug through the skin or mucosa could cause systemic contact dermatitis&#44; which might manifest as EM-like lesions&#46; Finally&#44; the location of lesions in sun-exposed areas could be due to the photo Koebner phenomenon&#44; with light acting as a traumatic stimulus&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In such cases&#44; once the acute episode has been treated and the offending drug withdrawn&#44; the patient does not generally experience further episodes&#46; Recurrence following exposure to other antigens and sunlight has been reported in just 2 cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;21</span></a> In 1 of these&#44; Rodr&#237;guez-Pazos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> described a patient who developed 2 consecutive episodes of PEM related to 2 different antigens&#58; paroxetine and HSV reactivation&#46; In the other case&#44; Shiohara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> described a patient who experienced PEM in association with afloqualone and exposure to <span class="elsevierStyleItalic">Rhus verniciflua</span>&#44; to which he had been previously sensitized&#46; It has been postulated that following the initial episodes of PEM&#44; the skin might retain traces of photoactive substances&#44; but not in sufficient quantities to cause the development of lesions&#46; The presence of additional&#44; nonspecific&#44; antigenic stimuli&#44; such as HSV reactivation or contact dermatitis due to <span class="elsevierStyleItalic">R verniciflua</span> might then have an add-on effect and trigger the development of skin photosensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">It has also been suggested that PMLE might be an immune response to as yet unknown endogenous or photoinduced antigens&#44; and that associated cases of EM or PEM could be triggered by the same antigenic stimulus&#46; Another theory is that the sun exposure that triggers PMLE could cause subclinical HSV reactivation and the subsequent development of EM&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> However&#44; in all the cases described to date&#44; PEM and EM occurred after PMLE&#46; Furthermore&#44; although 1 of the patients had a history of recurrent herpes labialis&#44; he had had no episodes in the preceding year that might explain the EM lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Subclinical reactivation of HSV has also been implicated in the etiology of several cases of idiopathic PEM&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and HSV DNA has been detected by polymerase chain reaction in 40&#37; of recurrent&#44; apparently idiopathic EM&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Some of the cases responded to prophylactic antiviral treatment&#44; strongly suggesting that they were triggered by subclinical HSV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical Manifestations</span><p id="par0095" class="elsevierStylePara elsevierViewall">The skin lesions that characterize PEM are identical to those seen in EM&#46; They start out as erythematous macules and then develop into erythematous&#44; edematous papules&#46; They can grow and acquire a characteristic target-like appearance&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;32</span></a> These target lesions may be few in number&#44; and may not even be apparent in the first few days after the onset of the rash&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> As these lesions are a key diagnostic clue&#44; a thorough skin examination is essential&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In PEM&#44; the lesions are limited to sun-exposed areas&#46; They typically affect the face&#44; the neckline&#44; the back of the arms and the forearms&#44; but they can occur on any part of the body that has been exposed to the sun &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Certain physical findings can help to classify the condition as photodistributed&#58; <span class="elsevierStyleItalic">a</span>&#41; sparing of areas not exposed to the sun&#44; such as under the chin or behind the ears&#44; the nasolabial triangle&#44; and the upper eyelids&#59; <span class="elsevierStyleItalic">b</span>&#41; a clear division between exposed areas &#40;with lesions&#41; and unexposed areas &#40;without lesions&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#59; and <span class="elsevierStyleItalic">c</span>&#41;&#44; typical absence of lesions on the palms of the hands and the mucous membranes&#46; Nevertheless&#44; in cases of idiopathic PEM&#44; there have been reports of isolated lesions in covered areas &#40;trunk and scrotum&#41; and on the palms of the hands&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;25</span></a> Albeit rarely&#44; some patients also develop fever&#44; joint pain&#44; and headache<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> or lesions affecting the oral and&#47;or genital mucosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;23&#44;25</span></a> Onycholysis has been described in cases of paclitaxel-induced PEM&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Patients with PEM can experience single or recurrent episodes that can occur at any time of the year&#44; although they are more common in the sunnier months&#46; Patients typically report previous sun exposure or the practice of outdoor activities&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis</span><p id="par0105" class="elsevierStylePara elsevierViewall">When EM is suspected&#44; the first step is to establish whether or not it is photodistributed and the second step is to identify the cause&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The diagnosis of EM is based on clinical history and physical examination and is greatly facilitated when the characteristic target lesions are detected&#46; Laboratory tests do not generally reveal any distinctive alterations&#46; Histology findings are characteristic but nonspecific and are particularly useful for excluding other diagnoses&#46; Histologic features vary according to the type and site of the lesion biopsied and to the age of the lesion&#46; A predominantly mononuclear inflammatory infiltrate is seen in early erythematous macules or papules&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;33</span></a> In lesions of longer duration and in the central area of target lesions&#44; hydropic degeneration of the basal layer and necrosis of keratinocytes are observed&#46; There may also be subepidermal blisters with keratinocytic necrosis in the adjacent area&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;33</span></a> The presence of a predominantly neutrophilic infiltrate or of leukocytoclastic vasculitis suggests a diagnosis other than EM&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Once a diagnosis of EM has been established&#44; the next step is to examine the lesions to determine whether or not they follow a photodistributed pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Clinical history&#44; physical examination&#44; and laboratory tests are useful for ruling out other photodermatoses&#46; The following factors should all be considered&#58; age at onset of the lesions&#44; possible exposure to photosensitizing agents&#44; exposure to light sources&#44; time between exposure to the sun and development of the lesions&#44; time since onset of the lesions&#44; and a personal or family history of photodermatosis&#46; The laboratory workup should include testing for antinuclear antibodies &#40;ANAs&#41; and anti-SSA &#40;Ro&#41; and anti-SSB &#40;La&#41; antibodies and measurement of plasma porphyrins&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The last step in the diagnostic workup is the identification of precipitating factors&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">A diagnosis of drug-induced PEM must be confirmed by photobiologic testing&#44; with at least 2 phototests performed at different times&#46; Ideally&#44; the first test should be conducted during the first visit &#40;when the patient is still taking the suspect drug&#41; and the second test after the drug has been withdrawn&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Diagnosis is confirmed when response to UV radiation is altered in the first test and normal in the second one&#46; It is easy to suspect PEM in patients who are taking just 1 recently introduced drug&#46; In patients on several drugs that were prescribed simultaneously&#44; however&#44; it may be more difficult to identify the offending agent&#46; In such cases&#44; it is important to perform a sequential investigation until the drug responsible for the PEM is identified&#46; The wavelength involved will vary according to the drug and it is therefore important to investigate response to both UV-B and UV-A radiation&#46; The phototests should be performed on a part of the body that is usually covered by clothing&#44; such as the buttocks or the lower back&#46; If the patient has lesions at the time of testing&#44; it is not necessary to wait for these to clear&#46; The time it takes for phototest results to normalize after withdrawal of the drug responsible for PEM varies&#44; and may be as long as a year&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It is therefore important to repeat the tests regularly until the UV response is completely normal&#59; at this point&#44; it will be possible to establish a definitive diagnosis of systemic photosensitivity and at the same time exclude persistent light reactivity or chronic actinic dermatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;36</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Photopatch testing with a standard series of photoallergens and the suspect drug allows the dermatologist to exclude other diagnoses and determine whether or not the condition is immune mediated&#46; The tests should be performed between 6 weeks and 6 months after resolution of the skin lesions&#44; and at least a month after withdrawal of systemic corticosteroids or oral antihistamines&#46; Phototest results must be normal before the photopatch tests are performed to prevent erythema from developing in the irradiated area&#46; Photopatch testing can be performed using either the commercial drug or the pure substance&#46; As a general rule&#44; the commercial form of the drug can be applied directly or added to petrolatum or water at a concentration of 30&#37;&#46; Pure substances must be diluted at 10&#37; in petrolatum&#44; and if possible&#44; also at 10&#37; in water or alcohol&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;38</span></a> Each drug must be patch tested in triplicate&#46; The 3 sets of patches are removed after 48<span class="elsevierStyleHsp" style=""></span>hours&#46; One of the sets is irradiated with 5<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> of UV-A&#44; while the other is irradiated with a sub-MED dose of UV-B &#40;dose just below the dose that produces erythema&#44; equivalent to 80&#37; of the minimal erythemal dose&#44; or MED&#41;&#46; The third set serves as the control&#46; It is important to perform the patch tests in controls&#44; as a negative result will add credibility to a positive result in a patient&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Photoprovocation can be useful for confirming diagnosis in both drug-induced and idiopathic cases&#46; Based on data in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;17</span></a> some authors have postulated that it might only be possible to reproduce lesions during the initial eruption&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However&#44; there has been a report of lesions being provoked 4 weeks after the acute episode&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Photoprovocation involves the performance of phototesting following the administration of the test drug at therapeutic doses over a period of 3 to 5 days&#46; An alternative is phototesting performed 1&#44; 3&#44; and 5<span class="elsevierStyleHsp" style=""></span>hours after the administration of a single dose of the suspect drug&#46; The expected result would be a qualitative and&#47;or quantitative pathologic response to the UV radiation&#46; Informed consent must be obtained from the patient in all cases&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In our review of the literature&#44; the diagnosis of drug-induced PEM was confirmed by photobiologic testing in 7 patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Three patients showed a decrease in UV-B-MED and&#47;or a qualitatively pathologic response to UV-A while the patient was taking the drug and normalization of results after its discontinuation&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> In another case&#44; the patient had already stopped treatment with the offending drug at the time of his visit&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The phototest was therefore performed a posteriori&#44; 3<span class="elsevierStyleHsp" style=""></span>hours after the administration of a single dose of the drug&#46; The result was a decrease in UV-B-MED&#46; The time between discontinuation of the drug and normalization of the UV response varied among the patients&#46; In 1 patient&#44; the UV-B-MED returned to normal within 6 weeks&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> whereas in another&#44; it took 12 weeks&#46; In the third patient&#44; UV-B-MED had normalized by week 8&#44; but normal results were not seen on repeated UV-A-MED tests until month 9&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Two of the 7 patients had a normal UV-B and UV-A response&#44; but diagnosis was confirmed following the reproduction of EM lesions in the irradiated area&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;17</span></a> Photopatch tests with the suspect drug yielded positive results in 4 patients&#58; 2 had a positive reaction in the area irradiated with a sub-MED dose of UV-B&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;21</span></a> 1 had a positive reaction in the area irradiated with UV-A&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and 1 had a positive reaction in the areas irradiated with UV-B and UV-A&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">HSV-induced PEM is diagnosed on the basis of a compatible clinical history and the exclusion of other possible causes of PEM&#46; The skin eruption is usually preceded by HSV lesions and sun exposure&#46; Elevated anti-HSV IgG titers are usually the only abnormal finding on blood tests&#46; Photobiologic tests have been negative in all cases in which these tests were performed&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with PEM secondary to PMLE have a history consistent with PMLE that will probably have been present for several years&#46; Laboratory and photobiologic test results are normal&#46; A photobiologic study was reported for just 1 of the cases described in the literature&#59; it was performed 2 months after the skin eruption and the patient showed a normal response to both UV-A and UV-B&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Idiopathic PEM is diagnosed after all other known causes have been ruled out&#46; Photoprovocation can reproduce lesions in some cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;26</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment</span><p id="par0160" class="elsevierStylePara elsevierViewall">The goal of treatment in EM is to reduce the duration of the skin lesions&#44; alleviate symptoms&#44; and prevent recurrence&#46; To achieve this&#44; it is necessary to eliminate the causative agent and treat the symptoms with antihistamines and topical and&#47;or systemic corticosteroids&#46; Sun protection measures are also important in the case of PEM&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In drug-induced PEM&#44; avoidance of sun exposure and withdrawal of the offending drug tend to be sufficient to achieve resolution of lesions&#46; Topical or systemic corticosteroids can also be used&#46; There has also been a report of a successful outcome with dapsone and oral corticosteroids in 1 patient&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> A risk-benefit assessment should be performed before withdrawing the drug definitively&#44; because&#44; as was shown by Cohen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> treatment may be maintained if sun protection measures are taken&#46; Patients do not generally experience recurrent episodes once treatment has been stopped&#46; There have been just 2 reports of lesions returning following exposure to other antigens and sunlight&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;21</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In HSV-induced PEM&#44; symptomatic treatment with topical corticosteroids and antihistamines achieves resolution of lesions within days&#46; Prophylactic treatment with acyclovir can prevent HSV reactivation and new episodes of PEM&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">As in drug-induced PEM&#44; avoidance of sun exposure and the administration of antihistamines and oral and topical corticosteroids lead to the resolution of lesions&#46; Short cycles of corticosteroids can be prescribed on detection of the first signs of PMLE&#44; as these will interrupt the eruption within a matter of hours and prevent PEM from developing&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Suppression of PMLE with prophylactic psoralen plus UV-A therapy also prevents the development of PEM&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Idiopathic cases are logically more complicated to manage as the cause is not known&#46; Patients tend to respond to oral corticosteroids&#44; but lesions recur very soon after cessation of treatment&#46; The prophylactic administration of hydroxychloroquine<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;25</span></a> and long-term oral corticosteroids administered at low doses on alternate days in association with physical sun protection measures has been successful&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Sulfapyridine and dapsone have not produced good results&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Likewise&#44; prophylactic narrow-band UV-B radiation<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and topical sunscreens used with or without oral antihistamines do not appear to be useful&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Differential Diagnosis</span><p id="par0185" class="elsevierStylePara elsevierViewall">The differential diagnosis for PEM should include other photoaggravated dermatoses&#44; certain idiopathic photodermatoses&#44; and skin disorders that present with annular maculopapular lesions&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">EM-like PMLE&#46; PMLE is a common idiopathic photodermatosis characterized by pruritic lesions in the form of erythematous papules&#44; papulovesicles&#44; vesicles&#44; or plaques that develop in sun-covered areas hours or days after exposure to sunlight&#46; Patients tend to report the development of lesions following exposure to the sun at the beginning of the summer&#46; The episodes typically recur over successive years and the appearance of lesions is usually followed by what is known as the <span class="elsevierStyleItalic">hardening phenomenon</span>&#46; Diagnosis is generally straightforward and is based on a compatible clinical history&#46; Histology can help in doubtful cases&#46; As already mentioned&#44; PEM can be triggered by PMLE&#46; Furthermore&#44; it can sometimes be difficult to distinguish between the 2 entities&#46; PMLE has many morphologic variants&#44; some of which mimic EM&#46; Furthermore&#44; EM-like PLE and EM may be indistinguishable histologically&#46; In such cases&#44; investigation of viral DNA in skin biopsy specimens may be of use&#44; as results are positive in between 32&#37; and 72&#37; of cases of EM and negative in PMLE&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The absence of mucosal involvement in PMLE<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> can also be a useful pointer&#46; Finally&#44; phototesting is negative in PMLE but not in drug-induced PEM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Juvenile spring eruption&#46; This is a localized form of MPLE that tends to affect children aged between 5 and 12 years&#46; It starts as erythematous papules that are located on the ears and can develop into vesicles or blisters&#46; The detection of mucosal involvement and a history of HSV reactivation can help to establish a diagnosis of PEM rather than juvenile spring eruption&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Subacute cutaneous lupus erythematosus&#46; This is a subtype of lupus erythematosus with distinctive clinical&#44; histologic&#44; and immunologic features&#46; The most noteworthy of these are photosensitivity and the presence of anti-Ro &#40;SSA&#41; and anti-La &#40;SSB&#41; antibodies&#46; Patients develop psoriasiform or annular lesions typically located in sun-exposed areas such as the neckline&#44; the shoulders&#44; the lateral aspect of the arms&#44; and the dorsum of the hands&#44; with sparing of the face&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> Small annular lesions can mimic the characteristic target lesions of EM&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Subacute cutaneous lupus erythematosus can also be triggered by photosensitizing drugs&#44; some of which have also been implicated in PEM&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;40</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Rowell syndrome&#46; Patients with lupus erythematosus can develop lesions that are not only similar in appearance to those seen in EM but also follow an identical clinical course&#46; Rowell syndrome was first described in patients with discoid lupus erythematosus&#44; but it has also been seen in association with subacute cutaneous lupus erythematosus and systemic lupus erythematosus&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;43</span></a> Several authors do not consider Rowell syndrome to be a separate entity but rather a morphologic variant of subacute cutaneous lupus erythematosus with target lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;43</span></a> The presence of ANAs&#44; anti-LA &#40;SSB&#41; or anti-Ro &#40;SSA&#41; antibodies&#44; rheumatoid factor&#44; and perniotic lesions are typical findings in Rowell syndrome41 and can be useful in the differential diagnosis&#46;</p></li></ul></p><p id="par0210" class="elsevierStylePara elsevierViewall">Other diseases with target lesions that should be included in the differential diagnosis are acute hemorrhagic edema of infancy&#44; EM-like contact dermatitis&#44; paraneoplastic pemphigus&#44; IgA pemphigus&#44; pruritic urticarial papules and plaques of pregnancy&#44; syphilis&#44; fixed drug eruption&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> ecthyma gangrenosum&#44; erythema chronicum migrans&#44; and granuloma annulare&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#8211;49</span></a> In their very early stages and depending on their distribution&#44; urticarial lesions&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> urticarial vasculitis&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and rosacea may also resemble PEM lesions&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall">PEM is an uncommon&#44; probably underdiagnosed&#44; skin condition that can affect both sexes and patients of all ages&#46; It has been associated with drugs&#44; HSV reactivation&#44; and PMLE&#46; Diagnosis is based on clinical history&#44; physical findings&#44; histopathology&#44; and photobiologic tests&#46; The condition runs a self-limiting&#44; benign course but can recur over successive several years if the cause is not eliminated&#46; Treatment is symptomatic&#44; with avoidance of triggers and the use of sun protection measures&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of Interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Drug-Induced PEM"
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              "titulo" => "Polymorphous Light Eruption"
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              "titulo" => "Idiopathic PEM"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Erythema multiforme"
            1 => "Photosensitivity"
            2 => "Herpes simplex virus"
            3 => "Drugs"
            4 => "Adverse drug reaction"
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            0 => "Eritema multiforme"
            1 => "Fotosensibilidad"
            2 => "Virus herpes simple"
            3 => "F&#225;rmacos"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although the existence of photodistributed erythema multiforme has been recognized for years&#44; few cases have been described to date&#46; It is an uncommon&#44; and probably underdiagnosed&#44; skin disorder that can affect individuals of both sexes and all ages&#46; It has been associated with drugs&#44; reactivation of herpes simplex virus infection&#44; and polymorphous light eruption&#46; A diagnosis is made on the basis of history&#44; physical examination&#44; histology&#44; and phototesting&#46; The condition runs a benign&#44; self-limiting course but patients may experience outbreaks for several years if the causative agent is not eliminated&#46; It is treated symptomatically and patients are advised to avoid triggers and excessive sun exposure&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A pesar de que la fotodistribuci&#243;n del eritema multiforme se conoce desde hace muchos a&#241;os&#44; pocos casos de eritema multiforme fotodistribuido &#40;EMF&#41; han sido descritos hasta la fecha&#46; El EMF es una dermatosis infrecuente&#44; y probablemente infradiagnosticada&#44; que puede afectar a sujetos de ambos sexos y de todas las edades&#46; Se ha relacionado con f&#225;rmacos&#44; reactivaciones del virus herpes simple y erupci&#243;n polimorfa lum&#237;nica&#46; Su diagn&#243;stico se basa en la anamnesis&#44; la exploraci&#243;n f&#237;sica&#44; la histopatolog&#237;a y el estudio fotobiol&#243;gico&#46; Su curso es benigno y autolimitado&#44; pero pueden aparecer brotes durante varios a&#241;os si no se suprime el agente causal&#46; Se trata de forma sintom&#225;tica&#44; evitando los desencadenantes y adoptando medidas de fotoprotecci&#243;n&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Pazos L&#44; et al&#46; Eritema multiforme fotodistribuido&#46; Actas Dermosifiliogr&#46; 2013&#59;104&#58;645&#8211;53&#46;</p>"
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 664
            "Ancho" => 1000
            "Tamanyo" => 125224
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lesions in sun-exposed areas in a patient with photodistributed erythema multiforme&#46; Erythematous&#44; edematous papules&#44; several with a target-like morphology&#44; in the facial region &#40;A&#41; and on the forearms &#40;B&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 712
            "Ancho" => 950
            "Tamanyo" => 103699
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Photodistributed erythema multiforme after a herpes simplex virus infection and sun exposure&#46; Note the clear division between the sun-exposed and covered areas&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; F&#44; female&#59; IV&#44; intravenous&#59; M&#44; male&#59; MED&#44; minimal erythemal dose&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Study&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">Drug&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">Time on Drug&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">Lesion Site&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&#47;Mucosal Symptoms&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 Course&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">Photobiologic Study&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">Photopatch Testing&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">Leroy et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> 1985&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phenylbutazone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diagnosis based on clinical features and exclusion &#40;no photobiologic study or testing with the causative drug&#41;&#46; Photobiologic study with other drugs being taken by the patient &#40;normal results&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&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">Leroy et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> 1987&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Triclocarban &#40;topical&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Application site and sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;oral mucosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative phototest results with drug but reproduction of lesions in area irradiated with UV-B&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;<span class="elsevierStyleHsp" style=""></span>UV-B&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">Shiohara et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> 1990&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Afloqualone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug not performed&#46; Photoprovocation after single dose of drug led to a decrease in UV-B-MED and reproduction of lesions following sun exposure&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&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">Kurumaji&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 1998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bufexamac &#40;topical&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Application site and sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative phototest with drug but reproduction of lesions in area irradiated with UV-B&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;<span class="elsevierStyleHsp" style=""></span>UV-A&#47;UV-B&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">Cohen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> 2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paclitaxel &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&#59; onycholysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical diagnosis &#40;photobiologic study not performed&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not done&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">Cohen&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paclitaxel &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&#59; onycholysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical diagnosis &#40;photobiologic study not performed&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not done&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">Rodr&#237;guez-Pazos et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> 2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" 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">Simvastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 12 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug led to a decrease in UV-B-MED and abnormal UV-A response&#46; Normalization of UV-B MED and UV-A response at 2 mo and 9 mo&#44; respectively&#44; after withdrawal of the drug&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&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">Rodr&#237;guez-Pazos et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> 2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pravastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug led to a decrease in UV-B-MED&#44; with normalization 3 mo after withdrawal of the drug&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&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">Rodr&#237;guez-Pazos et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> 2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paroxetine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug led to a decrease in UV-B-MED&#44; with normalization 6 wk after withdrawal of the drug&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;<span class="elsevierStyleHsp" style=""></span>UV-B&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">Guti&#233;rrez-Gonz&#225;lez et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> 2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Naproxen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Phototest with drug not performed&#46; Negative photoprovocation test after 2 doses of the drug&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;<span class="elsevierStyleHsp" style=""></span>UV-A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab397363.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cases of Drug-Induced Photodistributed Erythema Multiforme in the Literature&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; F&#44; female&#59; HSV&#44; herpes simplex virus&#59; M&#44; male&#59; PMLE&#44; polymorphous light eruption&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Study&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">Etiology&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">Lesion Site&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&#47;Mucosal Symptoms&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 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">Huff &#38; Weston&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> 1980&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" 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">Sun exposed areas &#40;at site of previous burn&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#47;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">Single episode&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">Wolf et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> 1994&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 7 y&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">Wolf et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> 1994&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 2 y&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">P&#233;rez-Carmona et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 5 y&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">Borges da Costa et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> 2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary to PMLE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" 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">Two consecutive eruptions&#58; the first in sun-exposed areas and the second in areas covered by bathing suit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Single episode&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">Fitzpatrick et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> 1983&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&#59; occasional lesions in covered areas &#40;palms and scrotum&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#47;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">Recurrent episodes over 5 y&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">Calzavara Pint&#243;n et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> 2003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&#59; isolated lesions on palms and covered areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recurrent episodes over 10 y&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">Tamagawa-Mineoka et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> 2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sun-exposed areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&#47;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">Recurrent episodes over 1 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab397364.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cases of Photodistributed Erythema Multiforme Not Related To Drugs in the Literature&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
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ISSN: 15782190
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