Update on the Classification and Treatment of Localized Scleroderma

array:24 ["pii" => "S157821901300173X" "issn" => "15782190" "doi" => "10.1016/j.adengl.2012.10.012" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "747" "copyright" => "Elsevier España, S.L. and AEDV" "copyrightAnyo" => "2011" "documento" => "article" "crossmark" => 0 "subdocumento" => "ssu" "cita" => "Actas Dermosifiliogr. 2013;104:654-66" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 14994 "formatos" => array:3 [ "EPUB" => 47 "HTML" => 11590 "PDF" => 3357 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0001731012004772" "issn" => "00017310" "doi" => "10.1016/j.ad.2012.10.003" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "747" "copyright" => "Elsevier España, S.L. and AEDV" "documento" => "article" "crossmark" => 0 "subdocumento" => "ssu" "cita" => "Actas Dermosifiliogr. 2013;104:654-66" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 44615 "formatos" => array:3 [ "EPUB" => 1 "HTML" => 30863 "PDF" => 13751 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Revisión" "titulo" => "Actualización en la clasificación y el tratamiento de la esclerodermia localizada" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "654" "paginaFinal" => "666" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Update on the Classification and Treatment of Localized Scleroderma" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figura 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 766 "Ancho" => 1024 "Tamanyo" => 114777 ] ] "descripcion" => array:1 [ "es" => "Banda de piel deprimida que se extiende desde la parte baja de la pantorrilla hasta el extremo distal de los últimos dedos del pie junto con la desaparición del tejido graso y atrofia de las estructuras más profundas como consecuencia de una esclerodermia lineal sufrida en la infancia." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Bielsa Marsol" "autores" => array:1 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Bielsa Marsol" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S157821901300173X" "doi" => "10.1016/j.adengl.2012.10.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901300173X?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731012004772?idApp=UINPBA000044" "url" => "/00017310/0000010400000008/v1_201309240051/S0001731012004772/v1_201309240051/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1578219013001741" "issn" => "15782190" "doi" => "10.1016/j.adengl.2013.01.003" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "806" "copyright" => "Elsevier España, S.L. and AEDV" "documento" => "article" "crossmark" => 0 "subdocumento" => "ssu" "cita" => "Actas Dermosifiliogr. 2013;104:667-71" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3889 "formatos" => array:3 [ "EPUB" => 42 "HTML" => 3276 "PDF" => 571 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Controversies in Dermatology" "titulo" => "Is Bone Marrow Biopsy Always Indicated in Patients With Primary Cutaneous Marginal Zone B-Cell Lymphoma?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "667" "paginaFinal" => "671" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Está siempre indicada la biopsia de médula ósea en los pacientes con linfoma primario cutáneo de células B de la zona marginal?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 644 "Ancho" => 950 "Tamanyo" => 95078 ] ] "descripcion" => array:1 [ "en" => "Isolated nodule on the arm of a patient with primary cutaneous marginal zone B-cell lymphoma." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Muniesa, B. Hernández-Machín" "autores" => array:2 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Muniesa" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Hernández-Machín" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731013000598" "doi" => "10.1016/j.ad.2013.01.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731013000598?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013001741?idApp=UINPBA000044" "url" => "/15782190/0000010400000008/v1_201309240048/S1578219013001741/v1_201309240048/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219013001728" "issn" => "15782190" "doi" => "10.1016/j.adengl.2012.01.024" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "633" "copyright" => "Elsevier España, S.L. and AEDV" "documento" => "article" "crossmark" => 0 "subdocumento" => "ssu" "cita" => "Actas Dermosifiliogr. 2013;104:645-53" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6003 "formatos" => array:3 [ "EPUB" => 45 "HTML" => 4871 "PDF" => 1087 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Photodistributed Erythema Multiforme" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "645" "paginaFinal" => "653" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eritema multiforme fotodistribuido" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 664 "Ancho" => 1000 "Tamanyo" => 125224 ] ] "descripcion" => array:1 [ "en" => "Lesions in sun-exposed areas in a patient with photodistributed erythema multiforme. Erythematous, edematous papules, several with a target-like morphology, in the facial region (A) and on the forearms (B)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Rodríguez-Pazos, S. Gómez-Bernal, M.T. Rodríguez-Granados, J. Toribio" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Rodríguez-Pazos" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Gómez-Bernal" ] 2 => array:2 [ "nombre" => "M.T." "apellidos" => "Rodríguez-Granados" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Toribio" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731012002177" "doi" => "10.1016/j.ad.2012.01.021" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731012002177?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013001728?idApp=UINPBA000044" "url" => "/15782190/0000010400000008/v1_201309240048/S1578219013001728/v1_201309240048/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Update on the Classification and Treatment of Localized Scleroderma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "654" "paginaFinal" => "666" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "I. Bielsa Marsol" "autores" => array:1 [ 0 => array:3 [ "nombre" => "I." "apellidos" => "Bielsa Marsol" "email" => array:1 [ 0 => "ibielsa.germanstrias@gencat.cat" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actualización en la clasificación y el tratamiento de la esclerodermia localizada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1696 "Ancho" => 840 "Tamanyo" => 200417 ] ] "descripcion" => array:1 [ "en" => "Generalized morphea. A, Multiple plaques of swollen, indurated, shiny skin. The plaques have become confluent and affect practically all the skin of the trunk and limbs. B, Erosions and scabs on the plaques on the distal areas of the lower limbs. Two biopsies taken from this patient revealed changes consistent with morphea in one and with lichen sclerosus et atrophicus in the other." ] ] ] "textoCompleto" => "IntroductionThe synonymous terms morphea and localized scleroderma refer to a distinctive inflammatory disease that primarily affects the skin and underlying tissues and ultimately leads to sclerosis. Localized scleroderma is differentiated from the systemic form of the disease by the absence of sclerodactily, Raynaud phenomenon, abnormalities of the nail-bed capillaries, or internal organ involvement.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It is a rare disease, with an incidence that varies between 0.34 and 2.7 cases per 100 000 population per year.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> It is more common in white women (female to male ratio between 2.4:1 and 4.2:1)<a class="elsevierStyleCrossRefs" href="#bib0015">3–6</a> and its prevalence is similar in children and adults.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>ClassificationLocalized scleroderma includes a number of conditions that can be distinguished by their clinical manifestations and by the structure of the skin and subcutaneous tissue affected by the fibrosis. However, classification can be difficult because the boundaries between the different types are not always clear, and overlap is common. In 1995, after reviewing the medical literature, Peterson et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> proposed a classification of localized scleroderma that has been adopted with few modifications in the majority of review articles published since that time.<a class="elsevierStyleCrossRefs" href="#bib0040">8–14</a> In their classification, Peterson et al. used the term morphea consistently for all clinical types, describing plaque morphea, generalized morphea, bullous morphea, linear morphea, and deep morphea. They also defined different subtypes within each of these groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In addition, those authors proposed the inclusion of a number of diseases whose relationship with morphea had been suggested previously but which were, and in some cases still are, a source of controversy; for example, they added atrophoderma of Pasini and Pierini and lichen sclerosus et atrophicus to the plaque morphea group, progressive facial hemiatrophy to the linear morphea group, and eosinophilic fasciitis to the deep morphea group. Finally, they introduced the idea that this classification was not restrictive, meaning that the different categories were not mutually exclusive and that different subtypes could often be observed in a single patient.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In 2004, a working group of the Paediatric Rheumatology European Society<a class="elsevierStyleCrossRef" href="#bib0075">15</a> published a new proposal for the classification of juvenile localized scleroderma with the aim, in their opinion, of correcting certain deficiencies in the classification put forward by Peterson et al. They excluded atrophoderma of Pasini and Pierini, lichen sclerosus et atrophicus, and eosinophilic fasciitis, and proposed minor modifications to the organization of the different subtypes. The essence of the previous classification was maintained and the concept of mixed morphea was added to make allowance for patients presenting a combination of 2 or more types of lesion (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In 2006, the same working group published a study that included a large number of children with localized scleroderma and highlighted the need to incorporate the concept of mixed morphea, as up to 15% of the children presented a combination of lesions of different forms of morphea (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0025">5</a> This same approach can be used in adults. In reality, recognition of this subgroup is implicit in the classification by Peterson et al., as they accepted that a single patient can develop different subtypes of morphea simultaneously.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Plaque morphea is the most superficial form, as the fibrotic process is often limited to the dermis, whereas the fibrosis in linear morphea affects not only the dermis but also the adipose tissue, muscle, and in many cases even bone. In deep morphea, the fibrosis affects the deep dermis, adipose tissue and muscle but, in contrast to the linear form, the lesions are more diffuse and do not follow a linear pattern.Although serious systemic repercussions only develop in very rare cases of localized scleroderma, the disease can be a source of considerable morbidity as the lesions often affect the face and limbs and can lead to marked deformity and significant physical disability. In general, the deeper and more extensive the sclerotic process, the greater the likelihood of some associated visceral abnormality. This visceral involvement occurs principally in linear scleroderma, generalized morphea, and deep morphea. The most common systemic complications are joint pain and, when lesions affect the head, neurological and ocular manifestations. Relatives of patients with morphea are also at higher risk of developing autoimmune diseases.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>Clinical variantsPlaque (Circumscribed) MorpheaPlaque morphea, also known as circumscribed morphea, is the most common variant of localized scleroderma in the adult.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4,6</a> The sclerotic changes mainly affect the reticular dermis. This condition presents as clearly circumscribed, oval or round areas of shiny indurated skin in 1 or at most 2 anatomical regions, most frequently the trunk or limbs (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the earliest phases there is a highly characteristic, violaceous halo around the plaque; this represents the most inflammatory phase of morphea. Atrophoderma of Pasini and Pierini is the term used when lesions develop from the outset as slightly depressed plaques of grayish-brown color. These lesions often affect the trunk or the proximal areas of the limbs.<a class="elsevierStyleCrossRefs" href="#bib0045">9,13</a> Most authors agree that the lesions of atrophoderma of Pasini and Pierini, in which the skin is not indurated, constitute a variant of morphea, either an abortive form of the disease<a class="elsevierStyleCrossRefs" href="#bib0045">9,16</a> or an even more superficial variant in which the sclerotic changes affect only the papillary or superficial dermis.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> There is evidence to support the relationship between these lesions and morphea. First, the lesions of atrophoderma of Pasini and Pierini coexist with the typical lesions of plaque morphea in 20% of cases<a class="elsevierStyleCrossRef" href="#bib0080">16</a> and, secondly, microscopy in plaque morphea has shown that sclerosis limited to the most superficial layers of the reticular dermis is observed clinically as thinner plaques in which pigmentation is the predominant feature and the induration is minimal.<a class="elsevierStyleCrossRef" href="#bib0090">18</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Very rarely, blisters or erosions may form over the plaques of morphea, giving rise to the condition known as bullous morphea. Curiously, in the majority of cases reported, the underlying pathological change is of the lichen sclerosus et atrophicus type (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>)<a class="elsevierStyleCrossRef" href="#bib0095">19</a> although, in some cases, the blistering may be attributed to lymphatic obstruction by the sclerotic process itself<a class="elsevierStyleCrossRef" href="#bib0100">20</a> or to an associated autoimmune bullous disease.<a class="elsevierStyleCrossRef" href="#bib0105">21</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The presence of microscopic features of lichen sclerosus et atrophicus in cases of bullous morphea and the rare but well-documented concomitant appearance of typical plaques of morphea and of lichen sclerosus et atrophicus in a single patient<a class="elsevierStyleCrossRefs" href="#bib0110">22–25</a> raise the question of whether lichen sclerosus et atrophicus should be considered a superficial form of plaque morphea. This is a controversial question for which there is as yet no adequate explanation. Although, as noted above, some patients develop lesions of both types, which can be difficult to distinguish clinically and microscopically, some studies have attempted to differentiate them on the basis of light-microscopic and ultrastructural features.<a class="elsevierStyleCrossRefs" href="#bib0120">24,26,27</a>Sclerotic changes affecting a circumscribed area of skin can sometimes extend beyond the dermis to involve the adipose tissue or other underlying tissues, such as the fascia or muscle. In such cases we speak of subcutaneous morphea or solitary morphea profunda<a class="elsevierStyleCrossRefs" href="#bib0140">28–31</a> (the latter term has also been used to refer to more extensive and widespread lesions [see below]). Presentation is often as a single lesion, frequently situated on the upper part of the back, close to the midline. The overlying skin may appear normal or atrophic and may be indurated, but it is almost always depressed and adherent to the deeper tissues (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Blisters have occasionally been reported.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> In general, the condition is asymptomatic and is not associated with visceral alterations. The most evident microscopic findings in this form of morphea are dense sclerosis of the collagen and marked subcutaneous inflammation with the presence of lymphocytes and plasma cells; bone formation in the deep dermis has also occasionally been observed.<a class="elsevierStyleCrossRefs" href="#bib0165">33,34</a> In some cases, solitary morphea profunda or similar lesions have been reported after vaccinations<a class="elsevierStyleCrossRef" href="#bib0175">35</a> or after intramuscular vitamin K injection.<a class="elsevierStyleCrossRefs" href="#bib0180">36,37</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Generalized Morphea, Deep Morphea, and Eosinophilic FasciitisGeneralized morphea is the term used to describe plaques of morphea that affect more than 2 anatomical regions. Generalized morphea has been described more often in women, and physical exercise has been proposed as a possible trigger. Manifestations include slightly inflamed, poorly defined pigmented plaques in some areas, often on the trunk, together with thickened skin adherent to the deeper planes, the fascia, and muscle in other areas, particularly on the limbs (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The onset of sclerosis is usually progressive and relatively rapid over a period of a few months. Acute inflammatory signs, such as edema and erythema, are typically absent. In rare cases, there may be concomitant lesions of lichen sclerosus et atrophicus and blisters may form on the surface of the plaques (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B).<a class="elsevierStyleCrossRefs" href="#bib0100">20,32</a><elsevierMultimedia ident="fig0025"></elsevierMultimedia>An in-depth review of the literature revealed that the terms generalized morphea and deep morphea are used indistinctly to refer to cases with this form of presentation.<a class="elsevierStyleCrossRefs" href="#bib0190">38–46</a> These terms have therefore been used in the literature to refer to the situation in which the sclerosis mainly affects the deep dermis and adipose tissue but there is also extensive involvement of the fascia and superficial muscle. The term generalized morphea alludes to the extensive fibrotic changes of this disease, whereas the term deep morphea indicates that the microscopic changes are seen mainly in the superficial muscle, fascia, adipose tissue, and deepest layers of the dermis.Generalized morphea must be distinguished from systemic scleroderma. Although the digits can be affected in generalized morphea, ulceration, reabsorption of the phalanges, changes in the nail-fold capillaries, and Raynaud phenomenon are uncommon. Moreover, the face is not usually affected, which means that although the sclerotic changes of the skin may be very extensive in generalized morphea, the patient does not usually present the facial changes typical of systemic scleroderma, such as disappearance of the lines of facial expression, thinning of the lips, and radial lines around the mouth. However, flexion contractures of the limbs and joint and muscle manifestations are common.<a class="elsevierStyleCrossRefs" href="#bib0195">39,46</a> Very rarely, there have been reports of alterations of the lungs, esophagus, and even of the kidney and heart.<a class="elsevierStyleCrossRefs" href="#bib0020">4,6,46–48</a> Characteristic laboratory findings include peripheral eosinophilia, which may be marked, elevation of the gammaglobulins, and immunological alterations such as the presence of antinuclear and anti-single-stranded DNA antibodies, hypocomplementemia, and even antiphospholipid antibodies.<a class="elsevierStyleCrossRefs" href="#bib0195">39,46,49,50</a> Antihistone antibodies and elevation of the serum levels of type III procollagen are indicators of severe disease in localized scleroderma, and it is not uncommon to detect these alterations in the widespread, deep forms of morphea.<a class="elsevierStyleCrossRefs" href="#bib0255">51–54</a>The cutaneous and systemic manifestations of generalized morphea overlap to a great extent with another disorder, eosinophilic fasciitis. The inclusion of eosinophilic fasciitis in the deep morphea group of Peterson et al.’s<a class="elsevierStyleCrossRef" href="#bib0035">7</a> classification has been and continues to be a subject of debate in the medical literature. Without going any further, some recent publications from prestigious authors in the dermatology literature consider eosinophilic fasciitis to be a sclerodermiform syndrome.<a class="elsevierStyleCrossRef" href="#bib0275">55</a> Nor is this disorder included in the latest classification proposed by Zulian et al.<a class="elsevierStyleCrossRefs" href="#bib0025">5,15</a> Clinically, the disease is characterized by symmetrical induration of the skin of all 4 limbs. In most patients, the condition begins with an edematous phase that produces a feeling of tightness of the skin, and diffuse areas of pale erythema appear on the limbs. This phase, which is usually of short duration and typically passes unnoticed, is followed by a phase in which the skin, now stiff and indurated, becomes irregular and dimpled, particularly over the medial surfaces of the upper limbs and of the thighs, as a result of the development of sclerotic bands that cross the subcutaneous fat perpendicularly between the deep dermis and the fascia (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). In the final stages, the skin is completely smooth and indurated and is adherent to the deeper planes.<a class="elsevierStyleCrossRefs" href="#bib0280">56–59</a> Lesions typical of plaque morphea are observed on other areas of the body, mainly the trunk, in around 30% of patients diagnosed with eosinophilic fasciitis (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).<a class="elsevierStyleCrossRefs" href="#bib0295">59–62</a> In general, these lesions are not synchronous with the fasciitis and can appear before or after the inflammation of the fascia. The presence of alterations in the peripheral blood, such as eosinophilia, hypergammaglobulinemia, and elevation of the erythrocyte sedimentation rate, is characteristic. However, their absence does not rule out the diagnosis as these changes are usually transient.<a class="elsevierStyleCrossRef" href="#bib0295">59</a> Similarly, although the presence of inflammation of the fascia with an infiltrate rich in eosinophils is a characteristic microscopic finding, this feature is not essential for making the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0315">63</a> Finally, the most common extracutaneous manifestations are synovitis or tenosynovitis, arthritis, contractures, and carpal tunnel syndrome. Although visceral complications affecting the lung, esophagus, or heart have been described, they are rare. The hematological abnormalities described can be pronounced and, in addition to the eosinophilia, these patients can develop megacaryocytic aplasia,<a class="elsevierStyleCrossRef" href="#bib0320">64</a> aplastic anemia,<a class="elsevierStyleCrossRefs" href="#bib0325">65–67</a> thrombocytopenia, hemolytic anemia,<a class="elsevierStyleCrossRef" href="#bib0340">68</a> and myeloproliferative or lymphoproliferative disorders.<a class="elsevierStyleCrossRefs" href="#bib0345">69,70</a><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia>Most of the literature describing the clinical and microscopic characteristics of eosinophilic fasciitis has been published by rheumatologists, the specialists who mainly use this term. However, their descriptions include many of the cutaneous and extracutaneous features of the disease described as generalized or deep morphea in the dermatological literature. It would appear likely that all these terms (generalized morphea, deep morphea, and eosinophilic fasciitis) in actual fact refer to the same clinical entity. However, the existence of typical or “pure” cases of each disorder probably justifies the continued use of the existing terminology.Linear MorpheaLinear morphea or linear scleroderma is often observed in childhood or youth and is probably the most common variant of morphea in these age groups, affecting between 40% and 70% of the children studied.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6,48</a> Presentation is typically with a single unilateral lesion having a linear distribution, most commonly on the limbs, face, or scalp (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>). These linear lesions often follow the Blaschko lines, and genetic mosaicism has therefore been proposed as a factor that could produce this linear distribution of the sclerosis.<a class="elsevierStyleCrossRef" href="#bib0355">71</a> The lesions are often deep and can interfere with limb growth, giving rise to deformity due to atrophy of the underlying muscle and bone, as well as joint contractures. Clinically the lesions appear as poorly defined bands of depressed skin with alterations of pigmentation.<elsevierMultimedia ident="fig0040"></elsevierMultimedia>When the lesions are located on the scalp, they produce linear plaques of alopecia that are frequently atrophic and slightly depressed, and the indurated skin is smooth, shiny, and ivory-colored, though in some cases the plaques may be pigmented. The unilateral nature of these lesions, their preference for the parietal region, and their tendency to deform the bone, giving rise to depressed lesions, has led to such descriptive names as linear scleroderma en coup de sabre. Lesions can sometimes extend onto or exclusively affect the cheek, nose, or upper lip. At these sites, there is often only a mild linear pigmentation on the skin surface, but deeper involvement can produce deformities and asymmetry of facial structures and alterations of dental implantation.When the sclerotic disorder affects a whole side of the face, it is called progressive facial hemiatrophy or Parry-Romberg syndrome. There has been a great deal of discussion about the relationship of progressive facial hemiatrophy with localized scleroderma, but the coexistence of progressive facial hemiatrophy with lesions of linear scleroderma en coup de sabre or even with plaque morphea confirms that it is a variant of linear scleroderma.<a class="elsevierStyleCrossRefs" href="#bib0360">72–74</a> The disease particularly affects adipose tissue, sometimes muscle and bone, and there is evident atrophy of the fat and muscle and facial deformities. Skin changes are almost completely absent. This atrophy favors the appearance of ocular disturbances such as endophthalmos, paralysis of the ocular muscles, ptosis, or Horner syndrome, as well as deformities of the jaw that can result in malocclusion, incorrect dental implantation, dental root atrophy, or delayed tooth eruption.<a class="elsevierStyleCrossRef" href="#bib0370">74</a>Linear morphea, especially when the lesions are located on the head (coup de sabre and progressive facial hemiatrophy), is commonly associated with neurological complications (in almost 20% of cases),<a class="elsevierStyleCrossRefs" href="#bib0025">5,73,74</a> and ophthalmological complications (15%).<a class="elsevierStyleCrossRef" href="#bib0375">75</a> The most significant neurological disorders are epilepsy, migraine, neuralgia and/or paresthesia of various cranial nerves, and alterations of the electroencephalogram and certain imaging studies. The predominant ophthalmological abnormality is sclerosis of the adnexal structures, followed by inflammation of the anterior segment and anterior uveitis; these latter 2 complications are often asymptomatic and unilateral.<a class="elsevierStyleCrossRef" href="#bib0375">75</a> There is also a higher risk of other extracutaneous complications, particularly neurological disorders, when ocular lesions are present.<a class="elsevierStyleCrossRef" href="#bib0375">75</a>Pansclerotic Morphea of ChildhoodThis is a very rare and highly aggressive and mutilating variant of deep morphea.<a class="elsevierStyleCrossRef" href="#bib0380">76</a> It typically affects children, although onset in adult life has been reported.<a class="elsevierStyleCrossRef" href="#bib0385">77</a> Presentation is similar to that of generalized morphea, but there is more marked and more extensive involvement not only of all the layers of the skin and subcutaneous cellular tissue but also of deeper structures such as muscle, tendons, and bone. The sclerotic plaques typically form on the extensor surfaces of the limbs and on the trunk and progress to affect all of the skin, including the face, neck, and scalp. The tips of the fingers and toes are not affected and there is no Raynaud phenomenon.<a class="elsevierStyleCrossRefs" href="#bib0380">76–78</a> The intense sclerotic changes in the skin and underlying tissues lead to pronounced joint contractures, deformity, very painful ulceration, and calcifications. Squamous cell carcinoma has occasionally be reported on long-standing pansclerotic plaques.<a class="elsevierStyleCrossRefs" href="#bib0395">79,80</a> The systemic complications and the laboratory test abnormalities observed in this disease are identical to those reported in other related disorders (eosinophilia, hypergammaglobulinemia, elevation of the erythrocyte sedimentation rate, positive antinuclear antibodies, abnormal lung function tests, esophageal disturbances, etc.).TreatmentAs no truly effective global treatment yet exists for localized scleroderma, management must be based on the extent and the severity of the disease, and focus primarily on the risk of deformities and movement limitation.<a class="elsevierStyleCrossRef" href="#bib0405">81</a> Treatment of these complications is difficult, and a preventive approach is therefore essential. The decision on when to start systemic therapy is hampered by the difficulty of determining clinically if the lesions are active and are going to progress or if the disease is stable and whether the damage already present will respond to treatment. It can also be difficult to qualify and evaluate any improvement in the lesions, whether in the natural course of the disease or after starting treatment. Numerous devices of differing degrees of complexity (cutometer, durometer, and ultrasound, thermographic, and computerized imaging systems, etc.) have been used to objectively measure the clinical course of morphea, but none of these approaches is universally accepted. Nor is any validated system available to score the level of activity of the disease or the damage caused. The recently published LoSCAT (Localized Scleroderma Cutaneous Assessment Tool) is a promising measurement tool as it appears to be able to differentiate between activity and damage, it is sensitive to changes, and it does not require complex equipment.<a class="elsevierStyleCrossRef" href="#bib0410">82</a> Using the LoSCAT, the physician can quantify damage to the skin and extracutaneous tissues in a patient with localized scleroderma by evaluating a series of symptoms and clinical signs of activity (skin hardening, erythema) and damage (atrophy and alterations of pigmentation) together with the results of a number of laboratory parameters. An effective assessment tool is obviously essential if we are to conduct the multicenter studies and meta-analyses necessary for the study of rare diseases such as morphea.The current lack of effective assessment tools explains why there are still no randomized double-blind studies to demonstrate the actual efficacy of most of the drugs proposed for the treatment of morphea. Randomized, placebo-controlled studies have shown that neither intralesional interferon<a class="elsevierStyleCrossRef" href="#bib0415">83</a> nor oral calcitriol<a class="elsevierStyleCrossRef" href="#bib0420">84</a> are effective systemic treatments for morphea.The drugs most widely accepted as useful in the treatment of this disease are methotrexate and systemic glucocorticoids, almost always administered in combination. Their efficacy is supported by the results of a number of prospective<a class="elsevierStyleCrossRefs" href="#bib0425">85–87</a> and retrospective<a class="elsevierStyleCrossRefs" href="#bib0440">88–91</a> studies, but none were randomized, double-blind, or placebo controlled. Those studies included adults and children and the methotrexate dosages varied between 0.3 and 0.4mg/kg per week in children and between 15 and 25mg per week in adults. Glucocorticoids are usually administered as high-dose intravenous boluses of methylprednisolone, sometimes followed by a tapering regimen of oral prednisone. It is generally agreed that the administration of high-dose boluses of glucocorticoids achieves the desired anti-inflammatory and immunomodulator effect with a lower risk of the side effects than can develop with long-term administration of these drugs. Adults are usually administered 1g/d of methylprednisolone on 3 consecutive days per month for a maximum of 6 months, whereas the dose in children is of 30mg/kg/d of methylprednisolone (maximum dose, 500mg/d) as intravenous boluses on 3 consecutive days, repeated each week or each month.<a class="elsevierStyleCrossRefs" href="#bib0430">86,87</a> Improvement, based on the clinical impression of the physician prescribing the treatment, was observed in more than 80% of cases in the majority of those studies. When the Modified Skin Score (which has not been validated) and ultrasound measurements of the sclerosed skin were used to assess the response to treatment, only 2 of the prospective studies conducted in adults showed a significant improvement.<a class="elsevierStyleCrossRefs" href="#bib0425">85,86</a> The retrospective and uncontrolled design of those studies does not allow us to determine whether the results in the patients treated with methotrexate and glucocorticoids were similar to those of patients treated with methotrexate alone. Monotherapy with oral glucocorticoids at dosages between 0.5 and 1mg/kg/d has been shown to be effective in some studies, but there is probably a higher risk of relapse after stopping treatment.<a class="elsevierStyleCrossRef" href="#bib0460">92</a>The various forms of UV therapy constitute another approach that must be included among the therapies available for the treatment of morphea. These include broadband UV-A therapy with or without psoralen (bath, cream, or oral), UV-A1, and narrowband UV-B. The mechanism underlying the beneficial effects of phototherapy in morphea is unknown. The majority of studies of phototherapy in morphea have used UV-A1. This form of UV radiation can induce apoptosis of Langerhans cells and T lymphocytes, reduce collagen synthesis, increase collagenase secretion, and alter the local concentrations of cytokines such as interleukin 6, transforming growth factor β, and interferon γ, which also affect collagen and glycosaminoglycan production, fibroblast growth, and the concentration of metalloproteinases in the matrix.<a class="elsevierStyleCrossRefs" href="#bib0465">93,94</a>UV-A1 is the phototherapy with the most experience and the greatest efficacy. Since Kerscher et al.<a class="elsevierStyleCrossRef" href="#bib0475">95</a> first used UV-A1 to treat morphea in 1995, its efficacy has been evaluated in prospective studies in more than 100 patients.<a class="elsevierStyleCrossRefs" href="#bib0480">96–102</a> Improvement has been reported in 90% of patients, based on clinical examination, a skin scoring system, ultrasound, biopsy, cutometer, or a combination of these systems. In the opinion of some authors, UV-A1 therapy is particularly beneficial in the final, fibrotic phase of morphea. However, it is not very useful in patients with particularly aggressive forms of the disease characterized by involvement of the subcutaneous tissue and muscle and rapid progression.<a class="elsevierStyleCrossRefs" href="#bib0405">81,86,103</a> The main obstacles to the routine use of UV-A1 are the need for specific equipment not available in most phototherapy centers and prolonged exposure (between 30 and 60minutes, 3 times a week). In addition, the most effective treatment regimens have not yet been clearly defined. High doses of UV-A1 (130J/cm2 per session with a total dose of 3900J/cm2) are probably more effective than intermediate doses (70J/cm2 per session with a total dose of 2100J/cm2) or low doses (20J/cm2 per session with a total dose of 600J/cm2), although most patients to date have received low doses.<a class="elsevierStyleCrossRef" href="#bib0410">82</a> Finally, it has not been demonstrated that this type of phototherapy is as effective in patients with darker skin phototypes (phototype IV or higher), as most of the studies have been performed in countries in which the majority of the population has fair skin (phototypes l to III). Wang et al.<a class="elsevierStyleCrossRef" href="#bib0520">104</a> showed experimentally that the administration of high doses of UV-A1 produced a greater reduction of type 1 and type 3 collagen and a greater increase in the matrix metalloproteinases in patients with lighter skin phototypes. Moreover, the reduction in the production of type 1 and type 3 collagen was greater in patients treated with a single high dose of UV-A1 than in those who had received 3 sessions of high doses of UV-A1 before any assessment was made. These findings suggest that UV-A1 should be administered as pulses (a single high dose with an interval of several weeks before the following session) or else as low-dose therapy in order to prevent tanning and thus increase efficacy.There is much less experience with other forms of phototherapy, in particular with broadband UV-A with or without psoralens, although some prospective studies have reported clinical improvement (with or without ultrasound or biopsy assessment) in around 80% of treated patients.<a class="elsevierStyleCrossRefs" href="#bib0525">105–107</a> The authors of some of those studies suggested that treatment with topical psoralen, whether by baths or cream, plus UV-A could be particularly useful in the earliest inflammatory phase of morphea.<a class="elsevierStyleCrossRef" href="#bib0405">81</a> Experience with the use of narrowband UV-B is even more limited. The efficacy of this option has only been reported in isolated cases and we await its evaluation in controlled studies or larger case series.<a class="elsevierStyleCrossRef" href="#bib0540">108</a>The use of other immunosuppressants for the treatment of morphea has been proposed based on their application in systemic scleroderma, though benefits have only been reported in isolated cases. This is the case with D-penicillamine, not advisable because of its poor safety profile, ciclosporin, used in 2 children with linear morphea,<a class="elsevierStyleCrossRef" href="#bib0545">109</a> and extracorporeal photophoresis, sometimes combined with mycophenolate mofetil.<a class="elsevierStyleCrossRefs" href="#bib0550">110,111</a> Mycophenolate mofetil, an immunosuppressant that is usually well tolerated, was found to be effective in children with morphea that had not responded to treatment with a combination of glucocorticoids and metotrexate.<a class="elsevierStyleCrossRef" href="#bib0560">112</a> That retrospective study included 10 children with various severe forms of localized scleroderma (pansclerotic morphea, generalized morphea, and linear morphea), and a clinical improvement was achieved in all patients, thus permitting the dose of glucocorticoids and methotrexate to be reduced or withdrawn. In a recent prospective study conducted in patients with diffuse systemic scleroderma, mycophenolate mofetil was shown to soften the skin.<a class="elsevierStyleCrossRef" href="#bib0565">113</a> The good safety profile of this drug makes it a useful treatment option when the other, more traditional approaches described above proved ineffective.Significant improvement has also been reported in cases of generalized morphea after treatment with infliximab, an anti-tumor necrosis factor agent,<a class="elsevierStyleCrossRef" href="#bib0570">114</a> and imatinib, a tyrosine kinase inhibitor.<a class="elsevierStyleCrossRef" href="#bib0575">115</a>Topical therapy, for which several options exist, should only be used in the most superficial and limited forms of morphea, such as plaque morphea. Topical corticosteroids, particularly high potency corticosteroids, have traditionally been recommended on morphea plaques, particularly during the early, most inflammatory phase. However, no studies have demonstrated the actual efficacy of this treatment.<a class="elsevierStyleCrossRef" href="#bib0410">82</a> A single randomized, double-blind, placebo-controlled pilot study conducted in 10 patients with plaque morphea found tacrolimus to be effective.<a class="elsevierStyleCrossRef" href="#bib0580">116</a> In a prospective study of 12 patients, the application of imiquimod 3 times a week was shown to be effective in reducing the erythema and induration of the plaques of morphea.<a class="elsevierStyleCrossRef" href="#bib0585">117</a> Subsequently, imiquimod was shown to improve the plaques of morphea in 2 cases after its application 5 times a week for 16 weeks.<a class="elsevierStyleCrossRef" href="#bib0590">118</a> Calcipotriol in combination with betamethasone has also been shown to be effective in a prospective study of 6 patients with plaque morphea.<a class="elsevierStyleCrossRef" href="#bib0595">119</a> Finally, photodynamic therapy has been found to be totally ineffective in the treatment of morphea.<a class="elsevierStyleCrossRef" href="#bib0600">120</a>To summarize, in <a class="elsevierStyleCrossRef" href="#fig0045">Figure 9</a> we propose a treatment algorithm for localized scleroderma based on our own experience, that of other authors, and the most recent reviews on this topic.<a class="elsevierStyleCrossRef" href="#bib0410">82</a><elsevierMultimedia ident="fig0045"></elsevierMultimedia>Physiotherapy is an option worth considering in patients in whom morphea has led to joint contractures and limitations of limb movement, although once again the true usefulness of such therapy has not been demonstrated by any studies. However, it does not appear to exacerbate the disease and may therefore be prescribed.<a class="elsevierStyleCrossRef" href="#bib0410">82</a>Whatever the therapeutic regimen used, all types of morphea tend to progress and recur, particularly when onset occurs during childhood.<a class="elsevierStyleCrossRef" href="#bib0605">121</a> It is therefore not surprising that, throughout their lives, these patients may require various periods of treatment to cope with new outbreaks of disease activity.Ethical DisclosuresProtection of human and animal subjectsThe author declares that no experiments were performed on humans or animals for this investigation.Confidentiality of dataThe author declares that she has followed her hospital's protocol on the publication of data concerning patients and that all patients included in the study have received sufficient information and have given their written informed consent to participate in the study.Right to privacy and informed consentThe author obtained informed consent from the patients and/or subjects referred to in this article. This document is held by the corresponding author.Conflicts of InterestThe author declares that she has no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres276224" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec258200" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres276225" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec258199" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Classification" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Clinical variants" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Plaque (Circumscribed) Morphea" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Generalized Morphea, Deep Morphea, and Eosinophilic Fasciitis" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Linear Morphea" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Pansclerotic Morphea of Childhood" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Treatment" ] 8 => array:3 [ "identificador" => "sec0045" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-09-26" "fechaAceptado" => "2012-10-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec258200" "palabras" => array:6 [ 0 => "Morphea en coup de sabre" 1 => "Progressive facial hemiatrophy" 2 => "Eosinophilic fasciitis" 3 => "Deep morphea" 4 => "Atrophoderma of Pasini and Pierini" 5 => "Lichen sclerosus et atrophicus" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec258199" "palabras" => array:6 [ 0 => "Morfea en coup de sabre" 1 => "Hemiatrofia facial progresiva" 2 => "Fascitis eosinofílica" 3 => "Morfea profunda" 4 => "Atrofodermia de Pasini y Pierini" 5 => "Liquen escleroso y atrófico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Morphea or localized scleroderma is a distinctive inflammatory disease that leads to sclerosis of the skin and subcutaneous tissues. It comprises a number of subtypes differentiated according to their clinical presentation and the structure of the skin and underlying tissues involved in the fibrotic process. However, classification is difficult because the boundaries between the different types of morphea are blurred and different entities frequently overlap. The main subtypes are plaque morphea, linear scleroderma, generalized morphea, and pansclerotic morphea. With certain exceptions, the disorder does not have serious systemic repercussions, but it can cause considerable morbidity. In the case of lesions affecting the head, neurological and ocular complications may occur. There is no really effective and universal treatment so it is important to make a correct assessment of the extent and severity of the disease before deciding on a treatment approach." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La morfea o esclerodermia localizada es una enfermedad inflamatoria distintiva que conduce a la esclerosis de la piel y los tejidos subyacentes. Incluye una serie de entidades que pueden distinguirse en base a las manifestaciones clínicas y la estructura de la piel y los tejidos subyacentes involucrados en el proceso fibroso. Sin embargo, la clasificación de estos procesos resulta difícil desde el momento en que los límites entre ellos no siempre son claros y es frecuente el solapamiento. En esencia, se distingue entre la morfea en placas, la esclerodermia lineal, la morfea generalizada y la panesclerótica. Si bien no tiene, salvo excepciones, una repercusión sistémica grave, sí que puede ser causa de una gran morbilidad. Si las lesiones asientan en el polo cefálico, pueden acompañarse de complicaciones neurológicas y oculares. No existe un tratamiento realmente eficaz y universal por lo que es importante realizar una evaluación correcta de la extensión y la gravedad de la enfermedad antes de tomar una decisión terapéutica." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Bielsa Marsol I. Actualización en la clasificación y el tratamiento de la esclerodermia localizada. Actas Dermosifiliogr.2013;104:654–66." ] ] "multimedia" => array:11 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 763 "Ancho" => 1024 "Tamanyo" => 107048 ] ] "descripcion" => array:1 [ "en" => "A case of mixed morphea. A linear lesion affecting most of the upper limb is associated with lesions of plaque morphea on the abdomen." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1144 "Ancho" => 1575 "Tamanyo" => 204462 ] ] "descripcion" => array:1 [ "en" => "Different presentations of plaque morphea. A, A violaceous plaque characteristic of an early inflammatory lesion. B, Hyperpigmented plaques with minimal induration of the skin in the later phases. C, Indurated, ivory-colored plaque. D, Multiple, poorly defined, hyperpigmented plaques on the trunk." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 768 "Ancho" => 1024 "Tamanyo" => 117247 ] ] "descripcion" => array:1 [ "en" => "Multiple plaques in a single patient. Some are of a uniform ivory-white color, with clinical and microscopic features of morphea, and others show a mottled appearance with clinical and microscopic features of lichen sclerosus et atrophicus. Blisters and scabs are visible on some of the plaques." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1123 "Ancho" => 840 "Tamanyo" => 116894 ] ] "descripcion" => array:1 [ "en" => "Single plaque of depressed skin with no other superficial changes. This is typical of circumscribed deep plaque morphea, subcutaneous morphea, or solitary deep morphea." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1696 "Ancho" => 840 "Tamanyo" => 200417 ] ] "descripcion" => array:1 [ "en" => "Generalized morphea. A, Multiple plaques of swollen, indurated, shiny skin. The plaques have become confluent and affect practically all the skin of the trunk and limbs. B, Erosions and scabs on the plaques on the distal areas of the lower limbs. Two biopsies taken from this patient revealed changes consistent with morphea in one and with lichen sclerosus et atrophicus in the other." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 762 "Ancho" => 1024 "Tamanyo" => 92310 ] ] "descripcion" => array:1 [ "en" => "The skin of the medial aspect of the arms has an irregular, dimpled surface as a result of the deep sclerosis typical of eosinophilic fasciitis." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1064 "Ancho" => 788 "Tamanyo" => 85515 ] ] "descripcion" => array:1 [ "en" => "Plaques of morphea on the trunk of a patient with eosinophilic fasciitis." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 766 "Ancho" => 1024 "Tamanyo" => 114777 ] ] "descripcion" => array:1 [ "en" => "Band of depressed skin that extends from the inferior region of the calf to the tips of the lateral toes, associated with disappearance of the adipose tissue and atrophy of deeper structures caused by linear scleroderma during the patient's childhood." ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 4253 "Ancho" => 2670 "Tamanyo" => 616972 ] ] "descripcion" => array:1 [ "en" => "Therapeutic algorithm for localized scleroderma.<a class="elsevierStyleCrossRefs" href="#bib0405">81,82</a> aAs available." ] ] 9 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Source: Peterson et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>" "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=""><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">Plaque morphea \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">Plaque morphea \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">Guttate morphea \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">Atrophoderma of Pasini and Pierini \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">Keloid morphea (nodular morphea) \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">(Lichen sclerosus et atrophicus) \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"> \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">Generalized morphea \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">Bullous morphea \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"> \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">Linear morphea \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">Linear morphea (linear scleroderma) \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">Morphea en coup de sabre \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">Progressive facial hemiatrophy \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"> \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">Deep morphea \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">Morphea profunda \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">Subcutaneous morphea \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">Eosinophilic fasciitis \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">Pansclerotic morphea of childhood \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab397366.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of Morphea or Localized Scleroderma." ] ] 10 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Source: Consensus Conference, Padua (Italy), 2004.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>" "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=""><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">Circumscribed morphea \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">a) Superficial \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">b) Deep \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"> \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">Linear scleroderma \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">a) Trunk/limbs \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">b) Head \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"> \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">Generalized morphea \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">Pansclerotic morphea \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">Mixed morphea \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab397365.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of Morphea or Localized Scleroderma." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:121 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on morphea. Part I. Epidemiology, clinical presentation, and pathogenesis" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2010.05.045" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2011" "volumen" => "64" "paginaInicial" => "217" "paginaFinal" => "228" "link" => array:1 [ …1] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An epidemiological study of scleroderma in the West Midlands" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Rheumatol" "fecha" => "1988" "volumen" => "27" "paginaInicial" => "286" "paginaFinal" => "290" "link" => array:1 [ …1] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epidemiology of morphea (localized scleroderma) in Olmsted County 1960-1993" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Rheumatol" "fecha" => "1997" "volumen" => "24" "paginaInicial" => "73" "paginaFinal" => "80" "link" => array:1 [ …1] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Localized scleroderma in adults and children. Clinical and laboratory investigations on 239 cases" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur J Dermatol" "fecha" => "2003" "volumen" => "13" "paginaInicial" => "171" "paginaFinal" => "176" "link" => array:1 [ …1] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Juvenile localized scleroderma: clinical and epidemiological features in 750 children. An international study" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rheumatology (Oxford)" "fecha" => "2006" "volumen" => "45" "paginaInicial" => "614" "paginaFinal" => "620" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distinct autoimmune syndromes in morphea: a review of 245 adult and pediatric cases" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archdermatol.2009.79" "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2009" "volumen" => "145" "paginaInicial" => "545" "paginaFinal" => "550" "link" => array:1 [ …1] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classification of morphea (localized scleroderma)" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "May Clin Proc" "fecha" => "1995" "volumen" => "70" "paginaInicial" => "1068" "paginaFinal" => "1076" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classification and epidemiology of scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Semin Cutan Med Surg" "fecha" => "1998" "volumen" => "17" "paginaInicial" => "22" "paginaFinal" => "26" "link" => array:1 [ …1] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Localized scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Semin Cutan Med Surg" "fecha" => "1998" "volumen" => "17" "paginaInicial" => "27" "paginaFinal" => "33" "link" => array:1 [ …1] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morphées: classification et pris en charge" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Dermatol Venereol" "fecha" => "1998" "volumen" => "125" "paginaInicial" => "283" "paginaFinal" => "290" "link" => array:1 [ …1] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morphea and localized scleroderma in children" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Semin Cut Med Surg" "fecha" => "1999" "volumen" => "18" "paginaInicial" => "210" "paginaFinal" => "225" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Localized and systemic scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/sder.2001.23093" "Revista" => array:6 [ "tituloSerie" => "Semin Cutan Med Surg" "fecha" => "2001" "volumen" => "20" "paginaInicial" => "27" "paginaFinal" => "37" "link" => array:1 [ …1] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic and localized scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clindermatol.2006.07.004" "Revista" => array:6 [ "tituloSerie" => "Clin Dermatol" "fecha" => "2006" "volumen" => "24" "paginaInicial" => "374" "paginaFinal" => "392" "link" => array:1 [ …1] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep morphea" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.sder.2007.02.005" "Revista" => array:6 [ "tituloSerie" => "Semin Cutan Med Surg" "fecha" => "2007" "volumen" => "26" "paginaInicial" => "90" "paginaFinal" => "95" "link" => array:1 [ …1] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Localized scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.bor.0000245727.40630.c3" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Rheumatol" "fecha" => "2006" "volumen" => "18" "paginaInicial" => "606" "paginaFinal" => "613" "link" => array:1 [ …1] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atrophoderma Pasini-Pierini is a primary atrophic abortive morphea" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatology" "fecha" => "1995" "volumen" => "190" "paginaInicial" => "203" "paginaFinal" => "206" "link" => array:1 [ …1] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is superficial morphea synonymous with atrophoderma Pasini-Pierini" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2003.11.088" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2004" "volumen" => "50" "paginaInicial" => "979" "paginaFinal" => "980" "link" => array:1 [ …1] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morphea limited to the superficial reticular dermis: an underrecognized histologic phenomenon" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "1999" "volumen" => "21" "paginaInicial" => "315" "paginaFinal" => "319" "link" => array:1 [ …1] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bullous morphea: a distinct entity" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "1994" "volumen" => "16" "paginaInicial" => "414" "paginaFinal" => "417" "link" => array:1 [ …1] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bullous morphea: clinical pathologic and immunopathologic evaluation of 13 cases" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1994" "volumen" => "30" "paginaInicial" => "937" "paginaFinal" => "943" "link" => array:1 [ …1] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bullous lesions in scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2002" "volumen" => "41" "paginaInicial" => "335" "paginaFinal" => "339" "link" => array:1 [ …1] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coexistence of generalized morphea with histological changes in lichen sclerosus et atrophicus" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Dermatol" "fecha" => "1998" "volumen" => "25" "paginaInicial" => "409" "paginaFinal" => "411" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morphea and lichen sclerosus et atrophicus" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1980" "volumen" => "3" "paginaInicial" => "271" "paginaFinal" => "279" "link" => array:1 [ …1] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lichen sclerosus et atrophicus, morphea and coexistence of both diseases: histological studies using lectins" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1991" "volumen" => "127" "paginaInicial" => "1352" "paginaFinal" => "1356" "link" => array:1 [ …1] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genital lichen sclerosus associated with morphea or systemic sclerosis: clinical and HLA characteristics" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2000" "volumen" => "143" "paginaInicial" => "598" "paginaFinal" => "603" "link" => array:1 [ …1] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lichen sclerosus et atrophicus is not related to morphea" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "1984" "volumen" => "6" "paginaInicial" => "323" "paginaFinal" => "335" "link" => array:1 [ …1] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alterations of basement membrane zone and cutaneous microvasculature in morphea and extragenital lichen sclerosus" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "2005" "volumen" => "27" "paginaInicial" => "489" "paginaFinal" => "496" "link" => array:1 [ …1] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Solitary morphea profunda" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "1989" "volumen" => "120" "paginaInicial" => "431" "paginaFinal" => "440" "link" => array:1 [ …1] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Solitary morphea profunda in a 5-year-old girl: case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Dermatol" "fecha" => "1991" "volumen" => "8" "paginaInicial" => "292" "paginaFinal" => "295" "link" => array:1 [ …1] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Solitary fibrosing paraspinal plaque: solitary morphea profunda" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "1993" "volumen" => "128" "paginaInicial" => "99" "paginaFinal" => "101" "link" => array:1 [ …1] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0155" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does solitary morphea profunda progress" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2004" "volumen" => "29" "paginaInicial" => "25" "paginaFinal" => "27" "link" => array:1 [ …1] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0160" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bullous morphea profunda" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "1986" "volumen" => "8" "paginaInicial" => "144" "paginaFinal" => "147" "link" => array:1 [ …1] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0165" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perforating plate-like osteoma cutis in a man with solitary morphea profunda" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "1996" "volumen" => "134" "paginaInicial" => "949" "paginaFinal" => "952" "link" => array:1 [ …1] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0170" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoma cutis in a lesion of solitary morphea profunda" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2003" "volumen" => "28" "paginaInicial" => "673" "paginaFinal" => "674" "link" => array:1 [ …1] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0175" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep morphea after vaccination in two young children" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1525-1470.2006.00289.x" "Revista" => array:6 [ "tituloSerie" => "Pediatr Dermatol" "fecha" => "2006" "volumen" => "23" "paginaInicial" => "484" "paginaFinal" => "487" "link" => array:1 [ …1] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0180" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morphea-like reaction from vitamin K1" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "1995" "volumen" => "34" "paginaInicial" => "201" "paginaFinal" => "202" "link" => array:1 [ …1] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0185" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scleroderma-like patch on the thigh in infants after vitamin K injection at birth: six observations" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Dermatol Venereol" "fecha" => "1996" "volumen" => "123" "paginaInicial" => "634" "paginaFinal" => "638" "link" => array:1 [ …1] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Generalized morphea I. Histology of the dermis and subcutaneous tissue" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1972" "volumen" => "106" "paginaInicial" => "509" "paginaFinal" => "514" "link" => array:1 [ …1] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subcutaneous morphea: a clinical study of sixteen cases" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "1979" "volumen" => "100" "paginaInicial" => "371" "paginaFinal" => "380" "link" => array:1 [ …1] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0200" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morphea profunda. A new concept and a histopathologic study of 23 cases" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "1981" "volumen" => "3" "paginaInicial" => "251" "paginaFinal" => "260" "link" => array:1 [ …1] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0205" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morphea profunda" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Int J Dermatol" "fecha" => "1991" "volumen" => "30" "paginaInicial" => "873" "paginaFinal" => "875" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0210" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scleroderma profunda. Clinicopathological studies" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Adv Exp Med Biol" "fecha" => "1999" "volumen" => "455" "paginaInicial" => "105" "paginaFinal" => "109" "link" => array:1 [ …1] ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0215" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Concurrent development of dermatomyositis and morphea profunda" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2002" "volumen" => "27" "paginaInicial" => "324" "paginaFinal" => "327" "link" => array:1 [ …1] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0220" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morphea, fasciitis and scleroderma with eosinophilia: a broad spectrum of disease [abstract]" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "1976" "volumen" => "19" "paginaInicial" => "792" "paginaFinal" => "793" ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0225" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Generalized morphea with peripheral eosinophilia: fasciitis and myositis" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "1980" "volumen" => "19" "paginaInicial" => "149" "paginaFinal" => "153" "link" => array:1 [ …1] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0230" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Generalized morphea: systemic aspects of a cutaneous disease. Description of 12 cases and review of the literature" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "1985" "volumen" => "85" "paginaInicial" => "171" "paginaFinal" => "174" "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0235" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Internal involvement in localized scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Medicine" "fecha" => "1994" "volumen" => "73" "paginaInicial" => "241" "paginaFinal" => "245" "link" => array:1 [ …1] ] ] ] ] ] ] 47 => array:3 [ "identificador" => "bib0240" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric morphea (localized scleroderma): Review of 136 patients" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2008.05.005" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2008" "volumen" => "59" "paginaInicial" => "385" "paginaFinal" => "396" "link" => array:1 [ …1] ] ] ] ] ] ] 48 => array:3 [ "identificador" => "bib0245" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antinuclear and anti-single-stranded DNA antibodies in morphea and generalized morphea" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1987" "volumen" => "123" "paginaInicial" => "350" "paginaFinal" => "353" "link" => array:1 [ …1] ] ] ] ] ] ] 49 => array:3 [ "identificador" => "bib0250" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anti-phosphatidylserine-prothrombin complex antibodies in patients with localized scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2006" "volumen" => "24" "paginaInicial" => "19" "paginaFinal" => "24" "link" => array:1 [ …1] ] ] ] ] ] ] 50 => array:3 [ "identificador" => "bib0255" "etiqueta" => "51" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antigen specificity of antihistone antibodies in localized scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1994" "volumen" => "130" "paginaInicial" => "1273" "paginaFinal" => "1277" "link" => array:1 [ …1] ] ] ] ] ] ] 51 => array:3 [ "identificador" => "bib0260" "etiqueta" => "52" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics associated with antihistone antibodies in patients with localized scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1994" "volumen" => "31" "paginaInicial" => "567" "paginaFinal" => "571" "link" => array:1 [ …1] ] ] ] ] ] ] 52 => array:3 [ "identificador" => "bib0265" "etiqueta" => "53" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antihistone antibodies in scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatology" "fecha" => "1995" "volumen" => "191" "paginaInicial" => "16" "paginaFinal" => "18" "link" => array:1 [ …1] ] ] ] ] ] ] 53 => array:3 [ "identificador" => "bib0270" "etiqueta" => "54" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Serum concentration of procollagen type I carboxyterminal propeptide in localized scleroderma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1994" "volumen" => "130" "paginaInicial" => "1269" "paginaFinal" => "1272" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 54 => array:3 [ "identificador" => "bib0275" "etiqueta" => "55" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic sclerosis (scleroderma) and related disorders" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Dermatology" "paginaInicial" => "585" "paginaFinal" => "596" "serieFecha" => "2008" ] ] ] ] ] ] 55 => array:3 [ "identificador" => "bib0280" "etiqueta" => "56" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diffuse fasciitis with hypergammaglobulinemia and eosinophilia: A new syndrome? [abstract]" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Rheumatol" "fecha" => "1974" "volumen" => "1" "numero" => "Suppl 1" "paginaInicial" => "46" ] ] ] ] ] ] 56 => array:3 [ "identificador" => "bib0285" "etiqueta" => "57" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic fasciitis: report of six cases of a newly recognized scleroderma-like syndrome" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "1975" "volumen" => "18" "paginaInicial" => "525" "link" => array:1 [ …1] ] ] ] ] ] ] 57 => array:3 [ "identificador" => "bib0290" "etiqueta" => "58" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic fasciitis: report of 15 cases" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "May Clin Proc" "fecha" => "1981" "volumen" => "56" "paginaInicial" => "27" "paginaFinal" => "34" ] ] ] ] ] ] 58 => array:3 [ "identificador" => "bib0295" "etiqueta" => "59" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic fasciitis: clinical spectrum and therapeutic response in 52 cases" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Semin Arthritis Rheum" "fecha" => "1988" "volumen" => "17" "paginaInicial" => "221" "paginaFinal" => "231" "link" => array:1 [ …1] ] ] ] ] ] ] 59 => array:3 [ "identificador" => "bib0300" "etiqueta" => "60" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The fasciitis-morphea complex in children" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "AJDC" "fecha" => "1992" "volumen" => "146" "paginaInicial" => "733" "paginaFinal" => "736" "link" => array:1 [ …1] ] ] ] ] ] ] 60 => array:3 [ "identificador" => "bib0305" "etiqueta" => "61" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association of eosinophilic fasciitis, multiple morphea and antiphospholipid antibody" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatology" "fecha" => "1994" "volumen" => "189" "paginaInicial" => "304" "paginaFinal" => "307" "link" => array:1 [ …1] ] ] ] ] ] ] 61 => array:3 [ "identificador" => "bib0310" "etiqueta" => "62" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic fasciitis/generalized morphea overlap" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatology Online Journal" …5 ] ] ] ] ] ] 62 => array:3 [ "identificador" => "bib0315" "etiqueta" => "63" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic fasciitis. A pathological study of twenty cases" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 63 => array:3 [ "identificador" => "bib0320" "etiqueta" => "64" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic fasciitis with megakaryocyte aplasia" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 64 => array:3 [ "identificador" => "bib0325" "etiqueta" => "65" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antibody-mediated aplastic anemia and diffuse fasciitis" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM197903293001307" "Revista" => array:6 [ …6] ] ] ] ] ] 65 => array:3 [ "identificador" => "bib0330" "etiqueta" => "66" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic fasciitis and aplastic anemia" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 66 => array:3 [ "identificador" => "bib0335" "etiqueta" => "67" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful treatment with antithymocyte globulin and cyclosporin A of a severe aplastic anemia associated with an eosinophilic fasciitis" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 67 => array:3 [ "identificador" => "bib0340" "etiqueta" => "68" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoimmune haemolytic anemia associated with eosinophilic fasciitis" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 68 => array:3 [ "identificador" => "bib0345" "etiqueta" => "69" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic fasciitis associated with low-grade T-cell lymphoma" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 69 => array:3 [ "identificador" => "bib0350" "etiqueta" => "70" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lymph-node-based malignant lymphoma and reactive lymphadenopathy in eosinophilic fasciitis" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 70 => array:3 [ "identificador" => "bib0355" "etiqueta" => "71" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Linear morphea follows Blaschko's lines" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2008.08647.x" "Revista" => array:6 [ …6] ] ] ] ] ] 71 => array:3 [ "identificador" => "bib0360" "etiqueta" => "72" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scleroderma en coup de sabre and progressive facial hemiatrophy. It is possible to differentiate them?" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 72 => array:3 [ "identificador" => "bib0365" "etiqueta" => "73" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Progressive facial hemiatrophy: central nervous system involvement and relationship with scleroderma en coup de sabre" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 73 => array:3 [ "identificador" => "bib0370" "etiqueta" => "74" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "En coup de sabre morphea and Parry-Romberg syndrome: a retrospective review of 54 patients" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 74 => array:3 [ "identificador" => "bib0375" "etiqueta" => "75" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ocular involvement in children with localized scleroderma: a multi-centre study" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bjo.2007.116038" "Revista" => array:7 [ …7] ] ] ] ] ] 75 => array:3 [ "identificador" => "bib0380" "etiqueta" => "76" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disabling pansclerotic morphea of children" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ …7] ] ] ] ] ] 76 => array:3 [ "identificador" => "bib0385" "etiqueta" => "77" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disabling pansclerotic morphea: clinical presentation in two adults" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2004.10.881" "Revista" => array:6 [ …6] ] ] ] ] ] 77 => array:3 [ "identificador" => "bib0390" "etiqueta" => "78" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incapacitating pansclerotic morphea in childhood" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 78 => array:3 [ "identificador" => "bib0395" "etiqueta" => "79" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Squamous cell carcinoma arising in a patient with long-standing pansclerotic morphea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 79 => array:3 [ "identificador" => "bib0400" "etiqueta" => "80" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Squamous cell carcinoma in pansclerotic morphea of childhood" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ …7] ] ] ] ] ] 80 => array:3 [ "identificador" => "bib0405" "etiqueta" => "81" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of localized scleroderma depends on the clinical subtype" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2007.07866.x" "Revista" => array:6 [ …6] ] ] ] ] ] 81 => array:3 [ "identificador" => "bib0410" "etiqueta" => "82" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on morphea: part II. Outcome measures and treatment" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2010.05.046" "Revista" => array:6 [ …6] ] ] ] ] ] 82 => array:3 [ "identificador" => "bib0415" "etiqueta" => "83" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Double-blind, placebo-controlled study of intralesional interferon gamma for the treatment of localized scleroderma" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 83 => array:3 [ "identificador" => "bib0420" "etiqueta" => "84" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Double-blind, placebo-controlled study of oral calcitriol for the treatment of localized and systemic sclerosis" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 84 => array:3 [ "identificador" => "bib0425" "etiqueta" => "85" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low-dose methotrexate in the treatment of widespread morphea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 85 => array:3 [ "identificador" => "bib0430" "etiqueta" => "86" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulsed high-dose corticosteroids combined with low-dose methotrexate in severe localized scleroderma" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.141.7.847" "Revista" => array:6 [ …6] ] ] ] ] ] 86 => array:3 [ "identificador" => "bib0435" "etiqueta" => "87" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Methotrexate and corticosteroids therapy for pediatric localized scleroderma" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 87 => array:3 [ "identificador" => "bib0440" "etiqueta" => "88" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of methotrexate and corticosteroids for the treatment of localized scleroderma (morphea) in children" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2006.07497.x" "Revista" => array:6 [ …6] ] ] ] ] ] 88 => array:3 [ "identificador" => "bib0445" "etiqueta" => "89" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of pediatric localized scleroderma with methotrexate" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 89 => array:3 [ "identificador" => "bib0450" "etiqueta" => "90" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Juvenile localized scleroderma: a retrospective review of response to systemic treatment" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11845-008-0217-0" "Revista" => array:6 [ …6] ] ] ] ] ] 90 => array:3 [ "identificador" => "bib0455" "etiqueta" => "91" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effectiveness, side-effects and period of remission after treatment with methotrexate in localized scleroderma and related sclerotic skin diseases: an inception cohort study" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2008.09017.x" "Revista" => array:6 [ …6] ] ] ] ] ] 91 => array:3 [ "identificador" => "bib0460" "etiqueta" => "92" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of severe forms of localized scleroderma with oral corticosteroids: follow-up study on 17 patients" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 92 => array:3 [ "identificador" => "bib0465" "etiqueta" => "93" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultraviolet A1 (340-400 nm) phototherapy for scleroderma in systemic sclerosis" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/mjd.2000.105165" "Revista" => array:6 [ …6] ] ] ] ] ] 93 => array:3 [ "identificador" => "bib0470" "etiqueta" => "94" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Suggested mechanisms of action of UVA phototherapy in morphea: a molecular study" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-0781.2004.00080.x" "Revista" => array:6 [ …6] ] ] ] ] ] 94 => array:3 [ "identificador" => "bib0475" "etiqueta" => "95" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of localized scleroderma by UVA1 phototherapy" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 95 => array:3 [ "identificador" => "bib0480" "etiqueta" => "96" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High-dose UVA1 radiation therapy for localized scleroderma" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ …7] ] ] ] ] ] 96 => array:3 [ "identificador" => "bib0485" "etiqueta" => "97" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low-dose UVA phototherapy for treatment of localized scleroderma" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 97 => array:3 [ "identificador" => "bib0490" "etiqueta" => "98" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of low dose ultraviolet A-1 phototherapy on morphea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 98 => array:3 [ "identificador" => "bib0495" "etiqueta" => "99" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of medium-dose UVA1 phototherapy in localized scleroderma with the cutometer and fast Fourier transform method" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "73093" "Revista" => array:6 [ …6] ] ] ] ] ] 99 => array:3 [ "identificador" => "bib0500" "etiqueta" => "100" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Medium-dose is more effective than low-dose ultraviolet A1 phototherapy for localized scleroderma as shown by 20-MHz ultrasound assessment" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2008.12.013" "Revista" => array:6 [ …6] ] ] ] ] ] 100 => array:3 [ "identificador" => "bib0505" "etiqueta" => "101" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful ultraviolet A1 phototherapy in the treatment of localized scleroderma: a retrospective and prospective study" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2009.09438.x" "Revista" => array:6 [ …6] ] ] ] ] ] 101 => array:3 [ "identificador" => "bib0510" "etiqueta" => "102" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combined treatment with calcipotriol ointment and low-dose ultraviolet A1 phototherapy in childhood morphea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 102 => array:3 [ "identificador" => "bib0515" "etiqueta" => "103" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "UV-A1 phototherapy for sclerotic skin diseases: implications for optimizing patient selection and management" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.144.7.912" "Revista" => array:6 [ …6] ] ] ] ] ] 103 => array:3 [ "identificador" => "bib0520" "etiqueta" => "104" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of increased pigmentation on the antifibrotic response of human skin to UV-A1 phototheraphy" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.144.7.851" "Revista" => array:6 [ …6] ] ] ] ] ] 104 => array:3 [ "identificador" => "bib0525" "etiqueta" => "105" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PUVA bath photochemotherapy for localized scleroderma. Evaluation of 17 consecutive patients" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 105 => array:3 [ "identificador" => "bib0530" "etiqueta" => "106" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Different low doses of broad-band UVA in the treatment of morphea and systemic sclerosis" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-0781.2004.00081.x" "Revista" => array:6 [ …6] ] ] ] ] ] 106 => array:3 [ "identificador" => "bib0535" "etiqueta" => "107" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Photochemotherapy for localized morphea: effect on clinical and molecular markers" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.2008.02890.x" "Revista" => array:7 [ …7] ] ] ] ] ] 107 => array:3 [ "identificador" => "bib0540" "etiqueta" => "108" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A randomized controlled study of low-dose UVA1, medium-dose UVA1, and narrowband UVB phototherapy in the treatment of localized scleroderma" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2005.11.1063" "Revista" => array:6 [ …6] ] ] ] ] ] 108 => array:3 [ "identificador" => "bib0545" "etiqueta" => "109" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rapid response to cyclosporine and maintenance with methotrexate in linear scleroderma in a young girl" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1525-1470.2008.00847.x" "Revista" => array:7 [ …7] ] ] ] ] ] 109 => array:3 [ "identificador" => "bib0550" "etiqueta" => "110" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extracorporeal photochemotherapy for generalized deep morphea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archdermatol.2008.547" "Revista" => array:6 [ …6] ] ] ] ] ] 110 => array:3 [ "identificador" => "bib0555" "etiqueta" => "111" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful therapy of a patient with therapy recalcitrant generalized bullous scleroderma by extracorporeal photopheresis and mycophenolate mofetil" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1468-3083.2007.02403.x" "Revista" => array:6 [ …6] ] ] ] ] ] 111 => array:3 [ "identificador" => "bib0560" "etiqueta" => "112" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful treatment of severe or methotrexate-resistant juvenile localized scleroderma with mycophenolate mofetil" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 112 => array:3 [ "identificador" => "bib0565" "etiqueta" => "113" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A prospective open-label study of mycophenolate mofetil for the treatment of diffuse systemic sclerosis" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 113 => array:3 [ "identificador" => "bib0570" "etiqueta" => "114" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of recalcitrant generalized morphea with infliximab" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archdermatol.2010.120" "Revista" => array:6 [ …6] ] ] ] ] ] 114 => array:3 [ "identificador" => "bib0575" "etiqueta" => "115" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Imatinib treatment of generalized localized scleroderma (morphea)" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ …5] ] ] ] ] ] 115 => array:3 [ "identificador" => "bib0580" "etiqueta" => "116" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy of topical tacrolimus 0.1% in active plaque morphea: randomized, double-blind, emollient-controlled pilot study" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ …6] ] ] ] ] ] 116 => array:3 [ "identificador" => "bib0585" "etiqueta" => "117" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "First case series on the use of imiquimod for morphoea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2005.06776.x" "Revista" => array:7 [ …7] ] ] ] ] ] 117 => array:3 [ "identificador" => "bib0590" "etiqueta" => "118" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Localized morphea treated with imiquimod 5% and dermoscopic assessment of effectiveness" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/09546630802132668" "Revista" => array:7 [ …7] ] ] ] ] ] 118 => array:3 [ "identificador" => "bib0595" "etiqueta" => "119" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "First case series on the use of calcipotriol-betamethasone dipropionate for morphoea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2007.07971.x" "Revista" => array:6 [ …6] ] ] ] ] ] 119 => array:3 [ "identificador" => "bib0600" "etiqueta" => "120" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Photodynamic therapy for the treatment of morphoea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.2008.02873.x" "Revista" => array:6 [ …6] ] ] ] ] ] 120 => array:3 [ "identificador" => "bib0605" "etiqueta" => "121" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An evaluation of long-term outcomes in adults with pediatric-onset morphea" "autores" => array:1 [ …1] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archdermatol.2010.239" "Revista" => array:6 [ …6] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010400000008/v1_201309240048/S157821901300173X/v1_201309240048/en/main.assets" "Apartado" => array:4 [ "identificador" => "6177" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Reviews" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010400000008/v1_201309240048/S157821901300173X/v1_201309240048/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901300173X?idApp=UINPBA000044"]

Estadísticas

Review

Update on the Classification and Treatment of Localized Scleroderma

Actualización en la clasificación y el tratamiento de la esclerodermia localizada

I. Bielsa Marsol

Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Barcelona, Spain

Leído

33375

Veces
se ha leído el artículo

8631

Total PDF

24744

Total HTML

Compartir estadísticas

 array:24 [
  "pii" => "S157821901300173X"
  "issn" => "15782190"
  "doi" => "10.1016/j.adengl.2012.10.012"
  "estado" => "S300"
  "fechaPublicacion" => "2013-10-01"
  "aid" => "747"
  "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and AEDV"
  "copyrightAnyo" => "2011"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "ssu"
  "cita" => "Actas Dermosifiliogr. 2013;104:654-66"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 14994
    "formatos" => array:3 [
      "EPUB" => 47
      "HTML" => 11590
      "PDF" => 3357
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0001731012004772"
      "issn" => "00017310"
      "doi" => "10.1016/j.ad.2012.10.003"
      "estado" => "S300"
      "fechaPublicacion" => "2013-10-01"
      "aid" => "747"
      "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and AEDV"
      "documento" => "article"
      "crossmark" => 0
      "subdocumento" => "ssu"
      "cita" => "Actas Dermosifiliogr. 2013;104:654-66"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 44615
        "formatos" => array:3 [
          "EPUB" => 1
          "HTML" => 30863
          "PDF" => 13751
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Revisi&#243;n</span>"
        "titulo" => "Actualizaci&#243;n en la clasificaci&#243;n y el tratamiento de la esclerodermia localizada"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "654"
            "paginaFinal" => "666"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Update on the Classification and Treatment of Localized Scleroderma"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0040"
            "etiqueta" => "Figura 8"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr8.jpeg"
                "Alto" => 766
                "Ancho" => 1024
                "Tamanyo" => 114777
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Banda de piel deprimida que se extiende desde la parte baja de la pantorrilla hasta el extremo distal de los &#250;ltimos dedos del pie junto con la desaparici&#243;n del tejido graso y atrofia de las estructuras m&#225;s profundas como consecuencia de una esclerodermia lineal sufrida en la infancia&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "I&#46; Bielsa Marsol"
            "autores" => array:1 [
              0 => array:2 [
                "nombre" => "I&#46;"
                "apellidos" => "Bielsa Marsol"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S157821901300173X"
          "doi" => "10.1016/j.adengl.2012.10.012"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901300173X?idApp=UINPBA000044"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731012004772?idApp=UINPBA000044"
      "url" => "/00017310/0000010400000008/v1_201309240051/S0001731012004772/v1_201309240051/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S1578219013001741"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2013.01.003"
    "estado" => "S300"
    "fechaPublicacion" => "2013-10-01"
    "aid" => "806"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and AEDV"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "ssu"
    "cita" => "Actas Dermosifiliogr. 2013;104:667-71"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3889
      "formatos" => array:3 [
        "EPUB" => 42
        "HTML" => 3276
        "PDF" => 571
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Controversies in Dermatology</span>"
      "titulo" => "Is Bone Marrow Biopsy Always Indicated in Patients With Primary Cutaneous Marginal Zone B-Cell Lymphoma&#63;"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "667"
          "paginaFinal" => "671"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "&#191;Est&#225; siempre indicada la biopsia de m&#233;dula &#243;sea en los pacientes con linfoma primario cut&#225;neo de c&#233;lulas B de la zona marginal&#63;"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 644
              "Ancho" => 950
              "Tamanyo" => 95078
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Isolated nodule on the arm of a patient with primary cutaneous marginal zone B-cell lymphoma&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "C&#46; Muniesa, B&#46; Hern&#225;ndez-Mach&#237;n"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Muniesa"
            ]
            1 => array:2 [
              "nombre" => "B&#46;"
              "apellidos" => "Hern&#225;ndez-Mach&#237;n"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731013000598"
        "doi" => "10.1016/j.ad.2013.01.004"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731013000598?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013001741?idApp=UINPBA000044"
    "url" => "/15782190/0000010400000008/v1_201309240048/S1578219013001741/v1_201309240048/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S1578219013001728"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2012.01.024"
    "estado" => "S300"
    "fechaPublicacion" => "2013-10-01"
    "aid" => "633"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and AEDV"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "ssu"
    "cita" => "Actas Dermosifiliogr. 2013;104:645-53"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 6003
      "formatos" => array:3 [
        "EPUB" => 45
        "HTML" => 4871
        "PDF" => 1087
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
      "titulo" => "Photodistributed Erythema Multiforme"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "645"
          "paginaFinal" => "653"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Eritema multiforme fotodistribuido"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 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>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "L&#46; Rodr&#237;guez-Pazos, S&#46; G&#243;mez-Bernal, M&#46;T&#46; Rodr&#237;guez-Granados, J&#46; Toribio"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "L&#46;"
              "apellidos" => "Rodr&#237;guez-Pazos"
            ]
            1 => array:2 [
              "nombre" => "S&#46;"
              "apellidos" => "G&#243;mez-Bernal"
            ]
            2 => array:2 [
              "nombre" => "M&#46;T&#46;"
              "apellidos" => "Rodr&#237;guez-Granados"
            ]
            3 => array:2 [
              "nombre" => "J&#46;"
              "apellidos" => "Toribio"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731012002177"
        "doi" => "10.1016/j.ad.2012.01.021"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731012002177?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013001728?idApp=UINPBA000044"
    "url" => "/15782190/0000010400000008/v1_201309240048/S1578219013001728/v1_201309240048/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
    "titulo" => "Update on the Classification and Treatment of Localized Scleroderma"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "654"
        "paginaFinal" => "666"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "I&#46; Bielsa Marsol"
        "autores" => array:1 [
          0 => array:3 [
            "nombre" => "I&#46;"
            "apellidos" => "Bielsa Marsol"
            "email" => array:1 [
              0 => "ibielsa&#46;germanstrias&#64;gencat&#46;cat"
            ]
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Servicio de Dermatolog&#237;a&#44; Hospital Universitari Germans Trias i Pujol&#44; Universidad Aut&#243;noma de Barcelona&#44; Barcelona&#44; Spain"
            "identificador" => "aff0005"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Actualizaci&#243;n en la clasificaci&#243;n y el tratamiento de la esclerodermia localizada"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1696
            "Ancho" => 840
            "Tamanyo" => 200417
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Generalized morphea&#46; A&#44; Multiple plaques of swollen&#44; indurated&#44; shiny skin&#46; The plaques have become confluent and affect practically all the skin of the trunk and limbs&#46; B&#44; Erosions and scabs on the plaques on the distal areas of the lower limbs&#46; Two biopsies taken from this patient revealed changes consistent with morphea in one and with lichen sclerosus et atrophicus in the other&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The synonymous terms <span class="elsevierStyleItalic">morphea</span> and <span class="elsevierStyleItalic">localized scleroderma</span> refer to a distinctive inflammatory disease that primarily affects the skin and underlying tissues and ultimately leads to sclerosis&#46; Localized scleroderma is differentiated from the systemic form of the disease by the absence of sclerodactily&#44; Raynaud phenomenon&#44; abnormalities of the nail-bed capillaries&#44; or internal organ involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is a rare disease&#44; with an incidence that varies between 0&#46;34 and 2&#46;7 cases per 100 000 population per year&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> It is more common in white women &#40;female to male ratio between 2&#46;4&#58;1 and 4&#46;2&#58;1&#41;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> and its prevalence is similar in children and adults&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Classification</span><p id="par0010" class="elsevierStylePara elsevierViewall">Localized scleroderma includes a number of conditions that can be distinguished by their clinical manifestations and by the structure of the skin and subcutaneous tissue affected by the fibrosis&#46; However&#44; classification can be difficult because the boundaries between the different types are not always clear&#44; and overlap is common&#46; In 1995&#44; after reviewing the medical literature&#44; Peterson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> proposed a classification of localized scleroderma that has been adopted with few modifications in the majority of review articles published since that time&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;14</span></a> In their classification&#44; Peterson et al&#46; used the term <span class="elsevierStyleItalic">morphea</span> consistently for all clinical types&#44; describing plaque morphea&#44; generalized morphea&#44; bullous morphea&#44; linear morphea&#44; and deep morphea&#46; They also defined different subtypes within each of these groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In addition&#44; those authors proposed the inclusion of a number of diseases whose relationship with morphea had been suggested previously but which were&#44; and in some cases still are&#44; a source of controversy&#59; for example&#44; they added atrophoderma of Pasini and Pierini and lichen sclerosus et atrophicus to the plaque morphea group&#44; progressive facial hemiatrophy to the linear morphea group&#44; and eosinophilic fasciitis to the deep morphea group&#46; Finally&#44; they introduced the idea that this classification was not restrictive&#44; meaning that the different categories were not mutually exclusive and that different subtypes could often be observed in a single patient&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In 2004&#44; a working group of the Paediatric Rheumatology European Society<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> published a new proposal for the classification of juvenile localized scleroderma with the aim&#44; in their opinion&#44; of correcting certain deficiencies in the classification put forward by Peterson et al&#46; They excluded atrophoderma of Pasini and Pierini&#44; lichen sclerosus et atrophicus&#44; and eosinophilic fasciitis&#44; and proposed minor modifications to the organization of the different subtypes&#46; The essence of the previous classification was maintained and the concept of mixed morphea was added to make allowance for patients presenting a combination of 2 or more types of lesion &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In 2006&#44; the same working group published a study that included a large number of children with localized scleroderma and highlighted the need to incorporate the concept of mixed morphea&#44; as up to 15&#37; of the children presented a combination of lesions of different forms of morphea &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This same approach can be used in adults&#46; In reality&#44; recognition of this subgroup is implicit in the classification by Peterson et al&#46;&#44; as they accepted that a single patient can develop different subtypes of morphea simultaneously&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Plaque morphea is the most superficial form&#44; as the fibrotic process is often limited to the dermis&#44; whereas the fibrosis in linear morphea affects not only the dermis but also the adipose tissue&#44; muscle&#44; and in many cases even bone&#46; In deep morphea&#44; the fibrosis affects the deep dermis&#44; adipose tissue and muscle but&#44; in contrast to the linear form&#44; the lesions are more diffuse and do not follow a linear pattern&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although serious systemic repercussions only develop in very rare cases of localized scleroderma&#44; the disease can be a source of considerable morbidity as the lesions often affect the face and limbs and can lead to marked deformity and significant physical disability&#46; In general&#44; the deeper and more extensive the sclerotic process&#44; the greater the likelihood of some associated visceral abnormality&#46; This visceral involvement occurs principally in linear scleroderma&#44; generalized morphea&#44; and deep morphea&#46; The most common systemic complications are joint pain and&#44; when lesions affect the head&#44; neurological and ocular manifestations&#46; Relatives of patients with morphea are also at higher risk of developing autoimmune diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical variants</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Plaque &#40;Circumscribed&#41; Morphea</span><p id="par0030" class="elsevierStylePara elsevierViewall">Plaque morphea&#44; also known as circumscribed morphea&#44; is the most common variant of localized scleroderma in the adult&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;6</span></a> The sclerotic changes mainly affect the reticular dermis&#46; This condition presents as clearly circumscribed&#44; oval or round areas of shiny indurated skin in 1 or at most 2 anatomical regions&#44; most frequently the trunk or limbs &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In the earliest phases there is a highly characteristic&#44; violaceous halo around the plaque&#59; this represents the most inflammatory phase of morphea&#46; <span class="elsevierStyleItalic">Atrophoderma of Pasini and Pierini</span> is the term used when lesions develop from the outset as slightly depressed plaques of grayish-brown color&#46; These lesions often affect the trunk or the proximal areas of the limbs&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;13</span></a> Most authors agree that the lesions of atrophoderma of Pasini and Pierini&#44; in which the skin is not indurated&#44; constitute a variant of morphea&#44; either an abortive form of the disease<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;16</span></a> or an even more superficial variant in which the sclerotic changes affect only the papillary or superficial dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> There is evidence to support the relationship between these lesions and morphea&#46; First&#44; the lesions of atrophoderma of Pasini and Pierini coexist with the typical lesions of plaque morphea in 20&#37; of cases<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and&#44; secondly&#44; microscopy in plaque morphea has shown that sclerosis limited to the most superficial layers of the reticular dermis is observed clinically as thinner plaques in which pigmentation is the predominant feature and the induration is minimal&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Very rarely&#44; blisters or erosions may form over the plaques of morphea&#44; giving rise to the condition known as bullous morphea&#46; Curiously&#44; in the majority of cases reported&#44; the underlying pathological change is of the lichen sclerosus et atrophicus type &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> although&#44; in some cases&#44; the blistering may be attributed to lymphatic obstruction by the sclerotic process itself<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> or to an associated autoimmune bullous disease&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The presence of microscopic features of lichen sclerosus et atrophicus in cases of bullous morphea and the rare but well-documented concomitant appearance of typical plaques of morphea and of lichen sclerosus et atrophicus in a single patient<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;25</span></a> raise the question of whether lichen sclerosus et atrophicus should be considered a superficial form of plaque morphea&#46; This is a controversial question for which there is as yet no adequate explanation&#46; Although&#44; as noted above&#44; some patients develop lesions of both types&#44; which can be difficult to distinguish clinically and microscopically&#44; some studies have attempted to differentiate them on the basis of light-microscopic and ultrastructural features&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;26&#44;27</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Sclerotic changes affecting a circumscribed area of skin can sometimes extend beyond the dermis to involve the adipose tissue or other underlying tissues&#44; such as the fascia or muscle&#46; In such cases we speak of subcutaneous morphea or solitary morphea profunda<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#8211;31</span></a> &#40;the latter term has also been used to refer to more extensive and widespread lesions &#91;see below&#93;&#41;&#46; Presentation is often as a single lesion&#44; frequently situated on the upper part of the back&#44; close to the midline&#46; The overlying skin may appear normal or atrophic and may be indurated&#44; but it is almost always depressed and adherent to the deeper tissues &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Blisters have occasionally been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> In general&#44; the condition is asymptomatic and is not associated with visceral alterations&#46; The most evident microscopic findings in this form of morphea are dense sclerosis of the collagen and marked subcutaneous inflammation with the presence of lymphocytes and plasma cells&#59; bone formation in the deep dermis has also occasionally been observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a> In some cases&#44; solitary morphea profunda or similar lesions have been reported after vaccinations<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> or after intramuscular vitamin K injection&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Generalized Morphea&#44; Deep Morphea&#44; and Eosinophilic Fasciitis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Generalized morphea is the term used to describe plaques of morphea that affect more than 2 anatomical regions&#46; Generalized morphea has been described more often in women&#44; and physical exercise has been proposed as a possible trigger&#46; Manifestations include slightly inflamed&#44; poorly defined pigmented plaques in some areas&#44; often on the trunk&#44; together with thickened skin adherent to the deeper planes&#44; the fascia&#44; and muscle in other areas&#44; particularly on the limbs &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The onset of sclerosis is usually progressive and relatively rapid over a period of a few months&#46; Acute inflammatory signs&#44; such as edema and erythema&#44; are typically absent&#46; In rare cases&#44; there may be concomitant lesions of lichen sclerosus et atrophicus and blisters may form on the surface of the plaques &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;32</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">An in-depth review of the literature revealed that the terms <span class="elsevierStyleItalic">generalized morphea</span> and <span class="elsevierStyleItalic">deep morphea</span> are used indistinctly to refer to cases with this form of presentation&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#8211;46</span></a> These terms have therefore been used in the literature to refer to the situation in which the sclerosis mainly affects the deep dermis and adipose tissue but there is also extensive involvement of the fascia and superficial muscle&#46; The term <span class="elsevierStyleItalic">generalized morphea</span> alludes to the extensive fibrotic changes of this disease&#44; whereas the term <span class="elsevierStyleItalic">deep morphea</span> indicates that the microscopic changes are seen mainly in the superficial muscle&#44; fascia&#44; adipose tissue&#44; and deepest layers of the dermis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Generalized morphea must be distinguished from systemic scleroderma&#46; Although the digits can be affected in generalized morphea&#44; ulceration&#44; reabsorption of the phalanges&#44; changes in the nail-fold capillaries&#44; and Raynaud phenomenon are uncommon&#46; Moreover&#44; the face is not usually affected&#44; which means that although the sclerotic changes of the skin may be very extensive in generalized morphea&#44; the patient does not usually present the facial changes typical of systemic scleroderma&#44; such as disappearance of the lines of facial expression&#44; thinning of the lips&#44; and radial lines around the mouth&#46; However&#44; flexion contractures of the limbs and joint and muscle manifestations are common&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;46</span></a> Very rarely&#44; there have been reports of alterations of the lungs&#44; esophagus&#44; and even of the kidney and heart&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;46&#8211;48</span></a> Characteristic laboratory findings include peripheral eosinophilia&#44; which may be marked&#44; elevation of the gammaglobulins&#44; and immunological alterations such as the presence of antinuclear and anti-single-stranded DNA antibodies&#44; hypocomplementemia&#44; and even antiphospholipid antibodies&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;46&#44;49&#44;50</span></a> Antihistone antibodies and elevation of the serum levels of type III procollagen are indicators of severe disease in localized scleroderma&#44; and it is not uncommon to detect these alterations in the widespread&#44; deep forms of morphea&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#8211;54</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The cutaneous and systemic manifestations of generalized morphea overlap to a great extent with another disorder&#44; eosinophilic fasciitis&#46; The inclusion of eosinophilic fasciitis in the deep morphea group of Peterson et al&#46;&#8217;s<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> classification has been and continues to be a subject of debate in the medical literature&#46; Without going any further&#44; some recent publications from prestigious authors in the dermatology literature consider eosinophilic fasciitis to be a sclerodermiform syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Nor is this disorder included in the latest classification proposed by Zulian et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;15</span></a> Clinically&#44; the disease is characterized by symmetrical induration of the skin of all 4 limbs&#46; In most patients&#44; the condition begins with an edematous phase that produces a feeling of tightness of the skin&#44; and diffuse areas of pale erythema appear on the limbs&#46; This phase&#44; which is usually of short duration and typically passes unnoticed&#44; is followed by a phase in which the skin&#44; now stiff and indurated&#44; becomes irregular and dimpled&#44; particularly over the medial surfaces of the upper limbs and of the thighs&#44; as a result of the development of sclerotic bands that cross the subcutaneous fat perpendicularly between the deep dermis and the fascia &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; In the final stages&#44; the skin is completely smooth and indurated and is adherent to the deeper planes&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#8211;59</span></a> Lesions typical of plaque morphea are observed on other areas of the body&#44; mainly the trunk&#44; in around 30&#37; of patients diagnosed with eosinophilic fasciitis &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59&#8211;62</span></a> In general&#44; these lesions are not synchronous with the fasciitis and can appear before or after the inflammation of the fascia&#46; The presence of alterations in the peripheral blood&#44; such as eosinophilia&#44; hypergammaglobulinemia&#44; and elevation of the erythrocyte sedimentation rate&#44; is characteristic&#46; However&#44; their absence does not rule out the diagnosis as these changes are usually transient&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Similarly&#44; although the presence of inflammation of the fascia with an infiltrate rich in eosinophils is a characteristic microscopic finding&#44; this feature is not essential for making the diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> Finally&#44; the most common extracutaneous manifestations are synovitis or tenosynovitis&#44; arthritis&#44; contractures&#44; and carpal tunnel syndrome&#46; Although visceral complications affecting the lung&#44; esophagus&#44; or heart have been described&#44; they are rare&#46; The hematological abnormalities described can be pronounced and&#44; in addition to the eosinophilia&#44; these patients can develop megacaryocytic aplasia&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> aplastic anemia&#44;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">65&#8211;67</span></a> thrombocytopenia&#44; hemolytic anemia&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> and myeloproliferative or lymphoproliferative disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#44;70</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Most of the literature describing the clinical and microscopic characteristics of eosinophilic fasciitis has been published by rheumatologists&#44; the specialists who mainly use this term&#46; However&#44; their descriptions include many of the cutaneous and extracutaneous features of the disease described as generalized or deep morphea in the dermatological literature&#46; It would appear likely that all these terms &#40;<span class="elsevierStyleItalic">generalized morphea</span>&#44; <span class="elsevierStyleItalic">deep morphea</span>&#44; and <span class="elsevierStyleItalic">eosinophilic fasciitis</span>&#41; in actual fact refer to the same clinical entity&#46; However&#44; the existence of typical or &#8220;pure&#8221; cases of each disorder probably justifies the continued use of the existing terminology&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Linear Morphea</span><p id="par0075" class="elsevierStylePara elsevierViewall">Linear morphea or linear scleroderma is often observed in childhood or youth and is probably the most common variant of morphea in these age groups&#44; affecting between 40&#37; and 70&#37; of the children studied&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;48</span></a> Presentation is typically with a single unilateral lesion having a linear distribution&#44; most commonly on the limbs&#44; face&#44; or scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; These linear lesions often follow the Blaschko lines&#44; and genetic mosaicism has therefore been proposed as a factor that could produce this linear distribution of the sclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> The lesions are often deep and can interfere with limb growth&#44; giving rise to deformity due to atrophy of the underlying muscle and bone&#44; as well as joint contractures&#46; Clinically the lesions appear as poorly defined bands of depressed skin with alterations of pigmentation&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">When the lesions are located on the scalp&#44; they produce linear plaques of alopecia that are frequently atrophic and slightly depressed&#44; and the indurated skin is smooth&#44; shiny&#44; and ivory-colored&#44; though in some cases the plaques may be pigmented&#46; The unilateral nature of these lesions&#44; their preference for the parietal region&#44; and their tendency to deform the bone&#44; giving rise to depressed lesions&#44; has led to such descriptive names as linear scleroderma <span class="elsevierStyleItalic">en coup de sabre</span>&#46; Lesions can sometimes extend onto or exclusively affect the cheek&#44; nose&#44; or upper lip&#46; At these sites&#44; there is often only a mild linear pigmentation on the skin surface&#44; but deeper involvement can produce deformities and asymmetry of facial structures and alterations of dental implantation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">When the sclerotic disorder affects a whole side of the face&#44; it is called progressive facial hemiatrophy or Parry-Romberg syndrome&#46; There has been a great deal of discussion about the relationship of progressive facial hemiatrophy with localized scleroderma&#44; but the coexistence of progressive facial hemiatrophy with lesions of linear scleroderma en coup de sabre or even with plaque morphea confirms that it is a variant of linear scleroderma&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72&#8211;74</span></a> The disease particularly affects adipose tissue&#44; sometimes muscle and bone&#44; and there is evident atrophy of the fat and muscle and facial deformities&#46; Skin changes are almost completely absent&#46; This atrophy favors the appearance of ocular disturbances such as endophthalmos&#44; paralysis of the ocular muscles&#44; ptosis&#44; or Horner syndrome&#44; as well as deformities of the jaw that can result in malocclusion&#44; incorrect dental implantation&#44; dental root atrophy&#44; or delayed tooth eruption&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Linear morphea&#44; especially when the lesions are located on the head &#40;coup de sabre and progressive facial hemiatrophy&#41;&#44; is commonly associated with neurological complications &#40;in almost 20&#37; of cases&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;73&#44;74</span></a> and ophthalmological complications &#40;15&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> The most significant neurological disorders are epilepsy&#44; migraine&#44; neuralgia and&#47;or paresthesia of various cranial nerves&#44; and alterations of the electroencephalogram and certain imaging studies&#46; The predominant ophthalmological abnormality is sclerosis of the adnexal structures&#44; followed by inflammation of the anterior segment and anterior uveitis&#59; these latter 2 complications are often asymptomatic and unilateral&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> There is also a higher risk of other extracutaneous complications&#44; particularly neurological disorders&#44; when ocular lesions are present&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pansclerotic Morphea of Childhood</span><p id="par0095" class="elsevierStylePara elsevierViewall">This is a very rare and highly aggressive and mutilating variant of deep morphea&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> It typically affects children&#44; although onset in adult life has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> Presentation is similar to that of generalized morphea&#44; but there is more marked and more extensive involvement not only of all the layers of the skin and subcutaneous cellular tissue but also of deeper structures such as muscle&#44; tendons&#44; and bone&#46; The sclerotic plaques typically form on the extensor surfaces of the limbs and on the trunk and progress to affect all of the skin&#44; including the face&#44; neck&#44; and scalp&#46; The tips of the fingers and toes are not affected and there is no Raynaud phenomenon&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">76&#8211;78</span></a> The intense sclerotic changes in the skin and underlying tissues lead to pronounced joint contractures&#44; deformity&#44; very painful ulceration&#44; and calcifications&#46; Squamous cell carcinoma has occasionally be reported on long-standing pansclerotic plaques&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79&#44;80</span></a> The systemic complications and the laboratory test abnormalities observed in this disease are identical to those reported in other related disorders &#40;eosinophilia&#44; hypergammaglobulinemia&#44; elevation of the erythrocyte sedimentation rate&#44; positive antinuclear antibodies&#44; abnormal lung function tests&#44; esophageal disturbances&#44; etc&#46;&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><p id="par0100" class="elsevierStylePara elsevierViewall">As no truly effective global treatment yet exists for localized scleroderma&#44; management must be based on the extent and the severity of the disease&#44; and focus primarily on the risk of deformities and movement limitation&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> Treatment of these complications is difficult&#44; and a preventive approach is therefore essential&#46; The decision on when to start systemic therapy is hampered by the difficulty of determining clinically if the lesions are active and are going to progress or if the disease is stable and whether the damage already present will respond to treatment&#46; It can also be difficult to qualify and evaluate any improvement in the lesions&#44; whether in the natural course of the disease or after starting treatment&#46; Numerous devices of differing degrees of complexity &#40;cutometer&#44; durometer&#44; and ultrasound&#44; thermographic&#44; and computerized imaging systems&#44; etc&#46;&#41; have been used to objectively measure the clinical course of morphea&#44; but none of these approaches is universally accepted&#46; Nor is any validated system available to score the level of activity of the disease or the damage caused&#46; The recently published LoSCAT &#40;Localized Scleroderma Cutaneous Assessment Tool&#41; is a promising measurement tool as it appears to be able to differentiate between activity and damage&#44; it is sensitive to changes&#44; and it does not require complex equipment&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> Using the LoSCAT&#44; the physician can quantify damage to the skin and extracutaneous tissues in a patient with localized scleroderma by evaluating a series of symptoms and clinical signs of activity &#40;skin hardening&#44; erythema&#41; and damage &#40;atrophy and alterations of pigmentation&#41; together with the results of a number of laboratory parameters&#46; An effective assessment tool is obviously essential if we are to conduct the multicenter studies and meta-analyses necessary for the study of rare diseases such as morphea&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The current lack of effective assessment tools explains why there are still no randomized double-blind studies to demonstrate the actual efficacy of most of the drugs proposed for the treatment of morphea&#46; Randomized&#44; placebo-controlled studies have shown that neither intralesional interferon<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> nor oral calcitriol<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> are effective systemic treatments for morphea&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The drugs most widely accepted as useful in the treatment of this disease are methotrexate and systemic glucocorticoids&#44; almost always administered in combination&#46; Their efficacy is supported by the results of a number of prospective<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">85&#8211;87</span></a> and retrospective<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">88&#8211;91</span></a> studies&#44; but none were randomized&#44; double-blind&#44; or placebo controlled&#46; Those studies included adults and children and the methotrexate dosages varied between 0&#46;3 and 0&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;kg per week in children and between 15 and 25<span class="elsevierStyleHsp" style=""></span>mg per week in adults&#46; Glucocorticoids are usually administered as high-dose intravenous boluses of methylprednisolone&#44; sometimes followed by a tapering regimen of oral prednisone&#46; It is generally agreed that the administration of high-dose boluses of glucocorticoids achieves the desired anti-inflammatory and immunomodulator effect with a lower risk of the side effects than can develop with long-term administration of these drugs&#46; Adults are usually administered 1<span class="elsevierStyleHsp" style=""></span>g&#47;d of methylprednisolone on 3 consecutive days per month for a maximum of 6 months&#44; whereas the dose in children is of 30<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d of methylprednisolone &#40;maximum dose&#44; 500<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; as intravenous boluses on 3 consecutive days&#44; repeated each week or each month&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">86&#44;87</span></a> Improvement&#44; based on the clinical impression of the physician prescribing the treatment&#44; was observed in more than 80&#37; of cases in the majority of those studies&#46; When the Modified Skin Score &#40;which has not been validated&#41; and ultrasound measurements of the sclerosed skin were used to assess the response to treatment&#44; only 2 of the prospective studies conducted in adults showed a significant improvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">85&#44;86</span></a> The retrospective and uncontrolled design of those studies does not allow us to determine whether the results in the patients treated with methotrexate and glucocorticoids were similar to those of patients treated with methotrexate alone&#46; Monotherapy with oral glucocorticoids at dosages between 0&#46;5 and 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d has been shown to be effective in some studies&#44; but there is probably a higher risk of relapse after stopping treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The various forms of UV therapy constitute another approach that must be included among the therapies available for the treatment of morphea&#46; These include broadband UV-A therapy with or without psoralen &#40;bath&#44; cream&#44; or oral&#41;&#44; UV-A1&#44; and narrowband UV-B&#46; The mechanism underlying the beneficial effects of phototherapy in morphea is unknown&#46; The majority of studies of phototherapy in morphea have used UV-A1&#46; This form of UV radiation can induce apoptosis of Langerhans cells and T lymphocytes&#44; reduce collagen synthesis&#44; increase collagenase secretion&#44; and alter the local concentrations of cytokines such as interleukin 6&#44; transforming growth factor &#946;&#44; and interferon &#947;&#44; which also affect collagen and glycosaminoglycan production&#44; fibroblast growth&#44; and the concentration of metalloproteinases in the matrix&#46;<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93&#44;94</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">UV-A1 is the phototherapy with the most experience and the greatest efficacy&#46; Since Kerscher et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> first used UV-A1 to treat morphea in 1995&#44; its efficacy has been evaluated in prospective studies in more than 100 patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">96&#8211;102</span></a> Improvement has been reported in 90&#37; of patients&#44; based on clinical examination&#44; a skin scoring system&#44; ultrasound&#44; biopsy&#44; cutometer&#44; or a combination of these systems&#46; In the opinion of some authors&#44; UV-A1 therapy is particularly beneficial in the final&#44; fibrotic phase of morphea&#46; However&#44; it is not very useful in patients with particularly aggressive forms of the disease characterized by involvement of the subcutaneous tissue and muscle and rapid progression&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">81&#44;86&#44;103</span></a> The main obstacles to the routine use of UV-A1 are the need for specific equipment not available in most phototherapy centers and prolonged exposure &#40;between 30 and 60<span class="elsevierStyleHsp" style=""></span>minutes&#44; 3 times a week&#41;&#46; In addition&#44; the most effective treatment regimens have not yet been clearly defined&#46; High doses of UV-A1 &#40;130<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> per session with a total dose of 3900<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#41; are probably more effective than intermediate doses &#40;70<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> per session with a total dose of 2100<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#41; or low doses &#40;20<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span> per session with a total dose of 600<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#44; although most patients to date have received low doses&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> Finally&#44; it has not been demonstrated that this type of phototherapy is as effective in patients with darker skin phototypes &#40;phototype IV or higher&#41;&#44; as most of the studies have been performed in countries in which the majority of the population has fair skin &#40;phototypes l to III&#41;&#46; Wang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> showed experimentally that the administration of high doses of UV-A1 produced a greater reduction of type 1 and type 3 collagen and a greater increase in the matrix metalloproteinases in patients with lighter skin phototypes&#46; Moreover&#44; the reduction in the production of type 1 and type 3 collagen was greater in patients treated with a single high dose of UV-A1 than in those who had received 3 sessions of high doses of UV-A1 before any assessment was made&#46; These findings suggest that UV-A1 should be administered as pulses &#40;a single high dose with an interval of several weeks before the following session&#41; or else as low-dose therapy in order to prevent tanning and thus increase efficacy&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">There is much less experience with other forms of phototherapy&#44; in particular with broadband UV-A with or without psoralens&#44; although some prospective studies have reported clinical improvement &#40;with or without ultrasound or biopsy assessment&#41; in around 80&#37; of treated patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">105&#8211;107</span></a> The authors of some of those studies suggested that treatment with topical psoralen&#44; whether by baths or cream&#44; plus UV-A could be particularly useful in the earliest inflammatory phase of morphea&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> Experience with the use of narrowband UV-B is even more limited&#46; The efficacy of this option has only been reported in isolated cases and we await its evaluation in controlled studies or larger case series&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">108</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The use of other immunosuppressants for the treatment of morphea has been proposed based on their application in systemic scleroderma&#44; though benefits have only been reported in isolated cases&#46; This is the case with D-penicillamine&#44; not advisable because of its poor safety profile&#44; ciclosporin&#44; used in 2 children with linear morphea&#44;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">109</span></a> and extracorporeal photophoresis&#44; sometimes combined with mycophenolate mofetil&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">110&#44;111</span></a> Mycophenolate mofetil&#44; an immunosuppressant that is usually well tolerated&#44; was found to be effective in children with morphea that had not responded to treatment with a combination of glucocorticoids and metotrexate&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">112</span></a> That retrospective study included 10 children with various severe forms of localized scleroderma &#40;pansclerotic morphea&#44; generalized morphea&#44; and linear morphea&#41;&#44; and a clinical improvement was achieved in all patients&#44; thus permitting the dose of glucocorticoids and methotrexate to be reduced or withdrawn&#46; In a recent prospective study conducted in patients with diffuse systemic scleroderma&#44; mycophenolate mofetil was shown to soften the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">113</span></a> The good safety profile of this drug makes it a useful treatment option when the other&#44; more traditional approaches described above proved ineffective&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Significant improvement has also been reported in cases of generalized morphea after treatment with infliximab&#44; an anti-tumor necrosis factor agent&#44;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">114</span></a> and imatinib&#44; a tyrosine kinase inhibitor&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">115</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Topical therapy&#44; for which several options exist&#44; should only be used in the most superficial and limited forms of morphea&#44; such as plaque morphea&#46; Topical corticosteroids&#44; particularly high potency corticosteroids&#44; have traditionally been recommended on morphea plaques&#44; particularly during the early&#44; most inflammatory phase&#46; However&#44; no studies have demonstrated the actual efficacy of this treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> A single randomized&#44; double-blind&#44; placebo-controlled pilot study conducted in 10 patients with plaque morphea found tacrolimus to be effective&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">116</span></a> In a prospective study of 12 patients&#44; the application of imiquimod 3 times a week was shown to be effective in reducing the erythema and induration of the plaques of morphea&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">117</span></a> Subsequently&#44; imiquimod was shown to improve the plaques of morphea in 2 cases after its application 5 times a week for 16 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">118</span></a> Calcipotriol in combination with betamethasone has also been shown to be effective in a prospective study of 6 patients with plaque morphea&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">119</span></a> Finally&#44; photodynamic therapy has been found to be totally ineffective in the treatment of morphea&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">120</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">To summarize&#44; in <a class="elsevierStyleCrossRef" href="#fig0045">Figure 9</a> we propose a treatment algorithm for localized scleroderma based on our own experience&#44; that of other authors&#44; and the most recent reviews on this topic&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a></p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Physiotherapy is an option worth considering in patients in whom morphea has led to joint contractures and limitations of limb movement&#44; although once again the true usefulness of such therapy has not been demonstrated by any studies&#46; However&#44; it does not appear to exacerbate the disease and may therefore be prescribed&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Whatever the therapeutic regimen used&#44; all types of morphea tend to progress and recur&#44; particularly when onset occurs during childhood&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a> It is therefore not surprising that&#44; throughout their lives&#44; these patients may require various periods of treatment to cope with new outbreaks of disease activity&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ethical Disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Protection of human and animal subjects</span><p id="par0160" class="elsevierStylePara elsevierViewall">The author declares that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Confidentiality of data</span><p id="par0165" class="elsevierStylePara elsevierViewall">The author declares that she has followed her hospital&#39;s protocol on the publication of data concerning patients and that all patients included in the study have received sufficient information and have given their written informed consent to participate in the study&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Right to privacy and informed consent</span><p id="par0170" class="elsevierStylePara elsevierViewall">The author obtained informed consent from the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The author declares that she has no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:2 [
          "identificador" => "xres276224"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec258200"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres276225"
          "titulo" => "Resumen"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec258199"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Classification"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Clinical variants"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Plaque &#40;Circumscribed&#41; Morphea"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Generalized Morphea&#44; Deep Morphea&#44; and Eosinophilic Fasciitis"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Linear Morphea"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Pansclerotic Morphea of Childhood"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Treatment"
        ]
        8 => array:3 [
          "identificador" => "sec0045"
          "titulo" => "Ethical Disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Conflicts of Interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-09-26"
    "fechaAceptado" => "2012-10-07"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec258200"
          "palabras" => array:6 [
            0 => "Morphea en coup de sabre"
            1 => "Progressive facial hemiatrophy"
            2 => "Eosinophilic fasciitis"
            3 => "Deep morphea"
            4 => "Atrophoderma of Pasini and Pierini"
            5 => "Lichen sclerosus et atrophicus"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec258199"
          "palabras" => array:6 [
            0 => "Morfea en <span class="elsevierStyleItalic">coup de sabre</span>"
            1 => "Hemiatrofia facial progresiva"
            2 => "Fascitis eosinof&#237;lica"
            3 => "Morfea profunda"
            4 => "Atrofodermia de Pasini y Pierini"
            5 => "Liquen escleroso y atr&#243;fico"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Morphea or localized scleroderma is a distinctive inflammatory disease that leads to sclerosis of the skin and subcutaneous tissues&#46; It comprises a number of subtypes differentiated according to their clinical presentation and the structure of the skin and underlying tissues involved in the fibrotic process&#46; However&#44; classification is difficult because the boundaries between the different types of morphea are blurred and different entities frequently overlap&#46; The main subtypes are plaque morphea&#44; linear scleroderma&#44; generalized morphea&#44; and pansclerotic morphea&#46; With certain exceptions&#44; the disorder does not have serious systemic repercussions&#44; but it can cause considerable morbidity&#46; In the case of lesions affecting the head&#44; neurological and ocular complications may occur&#46; There is no really effective and universal treatment so it is important to make a correct assessment of the extent and severity of the disease before deciding on a treatment approach&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La morfea o esclerodermia localizada es una enfermedad inflamatoria distintiva que conduce a la esclerosis de la piel y los tejidos subyacentes&#46; Incluye una serie de entidades que pueden distinguirse en base a las manifestaciones cl&#237;nicas y la estructura de la piel y los tejidos subyacentes involucrados en el proceso fibroso&#46; Sin embargo&#44; la clasificaci&#243;n de estos procesos resulta dif&#237;cil desde el momento en que los l&#237;mites entre ellos no siempre son claros y es frecuente el solapamiento&#46; En esencia&#44; se distingue entre la morfea en placas&#44; la esclerodermia lineal&#44; la morfea generalizada y la panescler&#243;tica&#46; Si bien no tiene&#44; salvo excepciones&#44; una repercusi&#243;n sist&#233;mica grave&#44; s&#237; que puede ser causa de una gran morbilidad&#46; Si las lesiones asientan en el polo cef&#225;lico&#44; pueden acompa&#241;arse de complicaciones neurol&#243;gicas y oculares&#46; No existe un tratamiento realmente eficaz y universal por lo que es importante realizar una evaluaci&#243;n correcta de la extensi&#243;n y la gravedad de la enfermedad antes de tomar una decisi&#243;n terap&#233;utica&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bielsa Marsol I&#46; Actualizaci&#243;n en la clasificaci&#243;n y el tratamiento de la esclerodermia localizada&#46; Actas Dermosifiliogr&#46;2013&#59;104&#58;654&#8211;66&#46;</p>"
      ]
    ]
    "multimedia" => array:11 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 763
            "Ancho" => 1024
            "Tamanyo" => 107048
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A case of mixed morphea&#46; A linear lesion affecting most of the upper limb is associated with lesions of plaque morphea on the abdomen&#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" => 1144
            "Ancho" => 1575
            "Tamanyo" => 204462
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Different presentations of plaque morphea&#46; A&#44; A violaceous plaque characteristic of an early inflammatory lesion&#46; B&#44; Hyperpigmented plaques with minimal induration of the skin in the later phases&#46; C&#44; Indurated&#44; ivory-colored plaque&#46; D&#44; Multiple&#44; poorly defined&#44; hyperpigmented plaques on the trunk&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 768
            "Ancho" => 1024
            "Tamanyo" => 117247
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Multiple plaques in a single patient&#46; Some are of a uniform ivory-white color&#44; with clinical and microscopic features of morphea&#44; and others show a mottled appearance with clinical and microscopic features of lichen sclerosus et atrophicus&#46; Blisters and scabs are visible on some of the plaques&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1123
            "Ancho" => 840
            "Tamanyo" => 116894
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Single plaque of depressed skin with no other superficial changes&#46; This is typical of circumscribed deep plaque morphea&#44; subcutaneous morphea&#44; or solitary deep morphea&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1696
            "Ancho" => 840
            "Tamanyo" => 200417
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Generalized morphea&#46; A&#44; Multiple plaques of swollen&#44; indurated&#44; shiny skin&#46; The plaques have become confluent and affect practically all the skin of the trunk and limbs&#46; B&#44; Erosions and scabs on the plaques on the distal areas of the lower limbs&#46; Two biopsies taken from this patient revealed changes consistent with morphea in one and with lichen sclerosus et atrophicus in the other&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 762
            "Ancho" => 1024
            "Tamanyo" => 92310
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The skin of the medial aspect of the arms has an irregular&#44; dimpled surface as a result of the deep sclerosis typical of eosinophilic fasciitis&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1064
            "Ancho" => 788
            "Tamanyo" => 85515
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Plaques of morphea on the trunk of a patient with eosinophilic fasciitis&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 766
            "Ancho" => 1024
            "Tamanyo" => 114777
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Band of depressed skin that extends from the inferior region of the calf to the tips of the lateral toes&#44; associated with disappearance of the adipose tissue and atrophy of deeper structures caused by linear scleroderma during the patient&#39;s childhood&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "fig0045"
        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 4253
            "Ancho" => 2670
            "Tamanyo" => 616972
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Therapeutic algorithm for localized scleroderma&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">81&#44;82</span></a></p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span>As available&#46;</p>"
        ]
      ]
      9 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Peterson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></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=""><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"><span class="elsevierStyleItalic">Plaque morphea</span>&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"><span class="elsevierStyleHsp" style=""></span>Plaque morphea&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"><span class="elsevierStyleHsp" style=""></span>Guttate morphea&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"><span class="elsevierStyleHsp" style=""></span>Atrophoderma of Pasini and Pierini&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"><span class="elsevierStyleHsp" style=""></span>Keloid morphea &#40;nodular morphea&#41;&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"><span class="elsevierStyleHsp" style=""></span>&#40;Lichen sclerosus et atrophicus&#41;&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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&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"><span class="elsevierStyleItalic">Generalized morphea</span>&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"><span class="elsevierStyleItalic">Bullous morphea</span>&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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&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"><span class="elsevierStyleItalic">Linear morphea</span>&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"><span class="elsevierStyleHsp" style=""></span>Linear morphea &#40;linear scleroderma&#41;&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"><span class="elsevierStyleHsp" style=""></span>Morphea en coup de sabre&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"><span class="elsevierStyleHsp" style=""></span>Progressive facial hemiatrophy&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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&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"><span class="elsevierStyleItalic">Deep morphea</span>&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"><span class="elsevierStyleHsp" style=""></span>Morphea profunda&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"><span class="elsevierStyleHsp" style=""></span>Subcutaneous morphea&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"><span class="elsevierStyleHsp" style=""></span>Eosinophilic fasciitis&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"><span class="elsevierStyleHsp" style=""></span>Pansclerotic morphea of childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab397366.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Classification of Morphea or Localized Scleroderma&#46;</p>"
        ]
      ]
      10 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Consensus Conference&#44; Padua &#40;Italy&#41;&#44; 2004&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></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=""><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"><span class="elsevierStyleItalic">Circumscribed morphea</span>&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"><span class="elsevierStyleHsp" style=""></span>a&#41; Superficial&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"><span class="elsevierStyleHsp" style=""></span>b&#41; Deep&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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&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"><span class="elsevierStyleItalic">Linear scleroderma</span>&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"><span class="elsevierStyleHsp" style=""></span>a&#41; Trunk&#47;limbs&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"><span class="elsevierStyleHsp" style=""></span>b&#41; Head&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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&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"><span class="elsevierStyleItalic">Generalized morphea</span>&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"><span class="elsevierStyleItalic">Pansclerotic morphea</span>&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"><span class="elsevierStyleItalic">Mixed morphea</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab397365.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Classification of Morphea or Localized Scleroderma&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:121 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Update on morphea&#46; Part I&#46; Epidemiology&#44; clinical presentation&#44; and pathogenesis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2010.05.045"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2011"
                        "volumen" => "64"
                        "paginaInicial" => "217"
                        "paginaFinal" => "228"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An epidemiological study of scleroderma in the West Midlands"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Rheumatol"
                        "fecha" => "1988"
                        "volumen" => "27"
                        "paginaInicial" => "286"
                        "paginaFinal" => "290"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The epidemiology of morphea &#40;localized scleroderma&#41; in Olmsted County 1960-1993"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "1997"
                        "volumen" => "24"
                        "paginaInicial" => "73"
                        "paginaFinal" => "80"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Localized scleroderma in adults and children&#46; Clinical and laboratory investigations on 239 cases"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Dermatol"
                        "fecha" => "2003"
                        "volumen" => "13"
                        "paginaInicial" => "171"
                        "paginaFinal" => "176"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Juvenile localized scleroderma&#58; clinical and epidemiological features in 750 children&#46; An international study"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rheumatology &#40;Oxford&#41;"
                        "fecha" => "2006"
                        "volumen" => "45"
                        "paginaInicial" => "614"
                        "paginaFinal" => "620"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Distinct autoimmune syndromes in morphea&#58; a review of 245 adult and pediatric cases"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archdermatol.2009.79"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "2009"
                        "volumen" => "145"
                        "paginaInicial" => "545"
                        "paginaFinal" => "550"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification of morphea &#40;localized scleroderma&#41;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "May Clin Proc"
                        "fecha" => "1995"
                        "volumen" => "70"
                        "paginaInicial" => "1068"
                        "paginaFinal" => "1076"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification and epidemiology of scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Cutan Med Surg"
                        "fecha" => "1998"
                        "volumen" => "17"
                        "paginaInicial" => "22"
                        "paginaFinal" => "26"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Localized scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Cutan Med Surg"
                        "fecha" => "1998"
                        "volumen" => "17"
                        "paginaInicial" => "27"
                        "paginaFinal" => "33"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morph&#233;es&#58; classification et pris en charge"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Dermatol Venereol"
                        "fecha" => "1998"
                        "volumen" => "125"
                        "paginaInicial" => "283"
                        "paginaFinal" => "290"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morphea and localized scleroderma in children"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Semin Cut Med Surg"
                        "fecha" => "1999"
                        "volumen" => "18"
                        "paginaInicial" => "210"
                        "paginaFinal" => "225"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Localized and systemic scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/sder.2001.23093"
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Cutan Med Surg"
                        "fecha" => "2001"
                        "volumen" => "20"
                        "paginaInicial" => "27"
                        "paginaFinal" => "37"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systemic and localized scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.clindermatol.2006.07.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Dermatol"
                        "fecha" => "2006"
                        "volumen" => "24"
                        "paginaInicial" => "374"
                        "paginaFinal" => "392"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Deep morphea"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.sder.2007.02.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Cutan Med Surg"
                        "fecha" => "2007"
                        "volumen" => "26"
                        "paginaInicial" => "90"
                        "paginaFinal" => "95"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Localized scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.bor.0000245727.40630.c3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Rheumatol"
                        "fecha" => "2006"
                        "volumen" => "18"
                        "paginaInicial" => "606"
                        "paginaFinal" => "613"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Atrophoderma Pasini-Pierini is a primary atrophic abortive morphea"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatology"
                        "fecha" => "1995"
                        "volumen" => "190"
                        "paginaInicial" => "203"
                        "paginaFinal" => "206"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is superficial morphea synonymous with atrophoderma Pasini-Pierini"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2003.11.088"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2004"
                        "volumen" => "50"
                        "paginaInicial" => "979"
                        "paginaFinal" => "980"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morphea limited to the superficial reticular dermis&#58; an underrecognized histologic phenomenon"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol"
                        "fecha" => "1999"
                        "volumen" => "21"
                        "paginaInicial" => "315"
                        "paginaFinal" => "319"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bullous morphea&#58; a distinct entity"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol"
                        "fecha" => "1994"
                        "volumen" => "16"
                        "paginaInicial" => "414"
                        "paginaFinal" => "417"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bullous morphea&#58; clinical pathologic and immunopathologic evaluation of 13 cases"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "1994"
                        "volumen" => "30"
                        "paginaInicial" => "937"
                        "paginaFinal" => "943"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bullous lesions in scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol"
                        "fecha" => "2002"
                        "volumen" => "41"
                        "paginaInicial" => "335"
                        "paginaFinal" => "339"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Coexistence of generalized morphea with histological changes in lichen sclerosus et atrophicus"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Dermatol"
                        "fecha" => "1998"
                        "volumen" => "25"
                        "paginaInicial" => "409"
                        "paginaFinal" => "411"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morphea and lichen sclerosus et atrophicus"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "1980"
                        "volumen" => "3"
                        "paginaInicial" => "271"
                        "paginaFinal" => "279"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lichen sclerosus et atrophicus&#44; morphea and coexistence of both diseases&#58; histological studies using lectins"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1991"
                        "volumen" => "127"
                        "paginaInicial" => "1352"
                        "paginaFinal" => "1356"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Genital lichen sclerosus associated with morphea or systemic sclerosis&#58; clinical and HLA characteristics"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2000"
                        "volumen" => "143"
                        "paginaInicial" => "598"
                        "paginaFinal" => "603"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lichen sclerosus et atrophicus is not related to morphea"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol"
                        "fecha" => "1984"
                        "volumen" => "6"
                        "paginaInicial" => "323"
                        "paginaFinal" => "335"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Alterations of basement membrane zone and cutaneous microvasculature in morphea and extragenital lichen sclerosus"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol"
                        "fecha" => "2005"
                        "volumen" => "27"
                        "paginaInicial" => "489"
                        "paginaFinal" => "496"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Solitary morphea profunda"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "1989"
                        "volumen" => "120"
                        "paginaInicial" => "431"
                        "paginaFinal" => "440"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Solitary morphea profunda in a 5-year-old girl&#58; case report and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Dermatol"
                        "fecha" => "1991"
                        "volumen" => "8"
                        "paginaInicial" => "292"
                        "paginaFinal" => "295"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Solitary fibrosing paraspinal plaque&#58; solitary morphea profunda"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "1993"
                        "volumen" => "128"
                        "paginaInicial" => "99"
                        "paginaFinal" => "101"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Does solitary morphea profunda progress"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Dermatol"
                        "fecha" => "2004"
                        "volumen" => "29"
                        "paginaInicial" => "25"
                        "paginaFinal" => "27"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bullous morphea profunda"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol"
                        "fecha" => "1986"
                        "volumen" => "8"
                        "paginaInicial" => "144"
                        "paginaFinal" => "147"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perforating plate-like osteoma cutis in a man with solitary morphea profunda"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "1996"
                        "volumen" => "134"
                        "paginaInicial" => "949"
                        "paginaFinal" => "952"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoma cutis in a lesion of solitary morphea profunda"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Dermatol"
                        "fecha" => "2003"
                        "volumen" => "28"
                        "paginaInicial" => "673"
                        "paginaFinal" => "674"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Deep morphea after vaccination in two young children"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1525-1470.2006.00289.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Dermatol"
                        "fecha" => "2006"
                        "volumen" => "23"
                        "paginaInicial" => "484"
                        "paginaFinal" => "487"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morphea-like reaction from vitamin K1"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol"
                        "fecha" => "1995"
                        "volumen" => "34"
                        "paginaInicial" => "201"
                        "paginaFinal" => "202"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scleroderma-like patch on the thigh in infants after vitamin K injection at birth&#58; six observations"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Dermatol Venereol"
                        "fecha" => "1996"
                        "volumen" => "123"
                        "paginaInicial" => "634"
                        "paginaFinal" => "638"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Generalized morphea I&#46; Histology of the dermis and subcutaneous tissue"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1972"
                        "volumen" => "106"
                        "paginaInicial" => "509"
                        "paginaFinal" => "514"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subcutaneous morphea&#58; a clinical study of sixteen cases"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "1979"
                        "volumen" => "100"
                        "paginaInicial" => "371"
                        "paginaFinal" => "380"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morphea profunda&#46; A new concept and a histopathologic study of 23 cases"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol"
                        "fecha" => "1981"
                        "volumen" => "3"
                        "paginaInicial" => "251"
                        "paginaFinal" => "260"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morphea profunda"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Int J Dermatol"
                        "fecha" => "1991"
                        "volumen" => "30"
                        "paginaInicial" => "873"
                        "paginaFinal" => "875"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scleroderma profunda&#46; Clinicopathological studies"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Adv Exp Med Biol"
                        "fecha" => "1999"
                        "volumen" => "455"
                        "paginaInicial" => "105"
                        "paginaFinal" => "109"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Concurrent development of dermatomyositis and morphea profunda"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Dermatol"
                        "fecha" => "2002"
                        "volumen" => "27"
                        "paginaInicial" => "324"
                        "paginaFinal" => "327"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morphea&#44; fasciitis and scleroderma with eosinophilia&#58; a broad spectrum of disease &#91;abstract&#93;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1976"
                        "volumen" => "19"
                        "paginaInicial" => "792"
                        "paginaFinal" => "793"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Generalized morphea with peripheral eosinophilia&#58; fasciitis and myositis"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol"
                        "fecha" => "1980"
                        "volumen" => "19"
                        "paginaInicial" => "149"
                        "paginaFinal" => "153"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Generalized morphea&#58; systemic aspects of a cutaneous disease&#46; Description of 12 cases and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "1985"
                        "volumen" => "85"
                        "paginaInicial" => "171"
                        "paginaFinal" => "174"
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Internal involvement in localized scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Medicine"
                        "fecha" => "1994"
                        "volumen" => "73"
                        "paginaInicial" => "241"
                        "paginaFinal" => "245"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric morphea &#40;localized scleroderma&#41;&#58; Review of 136 patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2008.05.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2008"
                        "volumen" => "59"
                        "paginaInicial" => "385"
                        "paginaFinal" => "396"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antinuclear and anti-single-stranded DNA antibodies in morphea and generalized morphea"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1987"
                        "volumen" => "123"
                        "paginaInicial" => "350"
                        "paginaFinal" => "353"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anti-phosphatidylserine-prothrombin complex antibodies in patients with localized scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Dermatol"
                        "fecha" => "2006"
                        "volumen" => "24"
                        "paginaInicial" => "19"
                        "paginaFinal" => "24"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antigen specificity of antihistone antibodies in localized scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1994"
                        "volumen" => "130"
                        "paginaInicial" => "1273"
                        "paginaFinal" => "1277"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical characteristics associated with antihistone antibodies in patients with localized scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "1994"
                        "volumen" => "31"
                        "paginaInicial" => "567"
                        "paginaFinal" => "571"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antihistone antibodies in scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatology"
                        "fecha" => "1995"
                        "volumen" => "191"
                        "paginaInicial" => "16"
                        "paginaFinal" => "18"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Serum concentration of procollagen type I carboxyterminal propeptide in localized scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1994"
                        "volumen" => "130"
                        "paginaInicial" => "1269"
                        "paginaFinal" => "1272"
                        "link" => array:1 [ …1]
                        "itemHostRev" => array:3 [ …3]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systemic sclerosis &#40;scleroderma&#41; and related disorders"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Dermatology"
                        "paginaInicial" => "585"
                        "paginaFinal" => "596"
                        "serieFecha" => "2008"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diffuse fasciitis with hypergammaglobulinemia and eosinophilia&#58; A new syndrome&#63; &#91;abstract&#93;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "1974"
                        "volumen" => "1"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "46"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic fasciitis&#58; report of six cases of a newly recognized scleroderma-like syndrome"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1975"
                        "volumen" => "18"
                        "paginaInicial" => "525"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic fasciitis&#58; report of 15 cases"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "May Clin Proc"
                        "fecha" => "1981"
                        "volumen" => "56"
                        "paginaInicial" => "27"
                        "paginaFinal" => "34"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic fasciitis&#58; clinical spectrum and therapeutic response in 52 cases"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Arthritis Rheum"
                        "fecha" => "1988"
                        "volumen" => "17"
                        "paginaInicial" => "221"
                        "paginaFinal" => "231"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The fasciitis-morphea complex in children"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "AJDC"
                        "fecha" => "1992"
                        "volumen" => "146"
                        "paginaInicial" => "733"
                        "paginaFinal" => "736"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of eosinophilic fasciitis&#44; multiple morphea and antiphospholipid antibody"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatology"
                        "fecha" => "1994"
                        "volumen" => "189"
                        "paginaInicial" => "304"
                        "paginaFinal" => "307"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic fasciitis&#47;generalized morphea overlap"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatology Online Journal"
                         …5
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic fasciitis&#46; A pathological study of twenty cases"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic fasciitis with megakaryocyte aplasia"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antibody-mediated aplastic anemia and diffuse fasciitis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM197903293001307"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic fasciitis and aplastic anemia"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Successful treatment with antithymocyte globulin and cyclosporin A of a severe aplastic anemia associated with an eosinophilic fasciitis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Autoimmune haemolytic anemia associated with eosinophilic fasciitis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic fasciitis associated with low-grade T-cell lymphoma"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lymph-node-based malignant lymphoma and reactive lymphadenopathy in eosinophilic fasciitis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Linear morphea follows Blaschko&#39;s lines"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2008.08647.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Scleroderma en coup de sabre and progressive facial hemiatrophy&#46; It is possible to differentiate them&#63;"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Progressive facial hemiatrophy&#58; central nervous system involvement and relationship with scleroderma en coup de sabre"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "En coup de sabre morphea and Parry-Romberg syndrome&#58; a retrospective review of 54 patients"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ocular involvement in children with localized scleroderma&#58; a multi-centre study"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bjo.2007.116038"
                      "Revista" => array:7 [ …7]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0380"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disabling pansclerotic morphea of children"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [ …7]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0385"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disabling pansclerotic morphea&#58; clinical presentation in two adults"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2004.10.881"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0390"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incapacitating pansclerotic morphea in childhood"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0395"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Squamous cell carcinoma arising in a patient with long-standing pansclerotic morphea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0400"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Squamous cell carcinoma in pansclerotic morphea of childhood"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [ …7]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of localized scleroderma depends on the clinical subtype"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2007.07866.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Update on morphea&#58; part II&#46; Outcome measures and treatment"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2010.05.046"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib0415"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Double-blind&#44; placebo-controlled study of intralesional interferon gamma for the treatment of localized scleroderma"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib0420"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Double-blind&#44; placebo-controlled study of oral calcitriol for the treatment of localized and systemic sclerosis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib0425"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Low-dose methotrexate in the treatment of widespread morphea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib0430"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulsed high-dose corticosteroids combined with low-dose methotrexate in severe localized scleroderma"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archderm.141.7.847"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            86 => array:3 [
              "identificador" => "bib0435"
              "etiqueta" => "87"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Methotrexate and corticosteroids therapy for pediatric localized scleroderma"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            87 => array:3 [
              "identificador" => "bib0440"
              "etiqueta" => "88"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation of methotrexate and corticosteroids for the treatment of localized scleroderma &#40;morphea&#41; in children"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2006.07497.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            88 => array:3 [
              "identificador" => "bib0445"
              "etiqueta" => "89"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of pediatric localized scleroderma with methotrexate"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            89 => array:3 [
              "identificador" => "bib0450"
              "etiqueta" => "90"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Juvenile localized scleroderma&#58; a retrospective review of response to systemic treatment"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11845-008-0217-0"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            90 => array:3 [
              "identificador" => "bib0455"
              "etiqueta" => "91"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness&#44; side-effects and period of remission after treatment with methotrexate in localized scleroderma and related sclerotic skin diseases&#58; an inception cohort study"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2008.09017.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            91 => array:3 [
              "identificador" => "bib0460"
              "etiqueta" => "92"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of severe forms of localized scleroderma with oral corticosteroids&#58; follow-up study on 17 patients"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            92 => array:3 [
              "identificador" => "bib0465"
              "etiqueta" => "93"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultraviolet A1 &#40;340-400 nm&#41; phototherapy for scleroderma in systemic sclerosis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1067/mjd.2000.105165"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            93 => array:3 [
              "identificador" => "bib0470"
              "etiqueta" => "94"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Suggested mechanisms of action of UVA phototherapy in morphea&#58; a molecular study"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1600-0781.2004.00080.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            94 => array:3 [
              "identificador" => "bib0475"
              "etiqueta" => "95"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of localized scleroderma by UVA1 phototherapy"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            95 => array:3 [
              "identificador" => "bib0480"
              "etiqueta" => "96"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "High-dose UVA1 radiation therapy for localized scleroderma"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [ …7]
                    ]
                  ]
                ]
              ]
            ]
            96 => array:3 [
              "identificador" => "bib0485"
              "etiqueta" => "97"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Low-dose UVA phototherapy for treatment of localized scleroderma"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            97 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "98"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of low dose ultraviolet A-1 phototherapy on morphea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            98 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "99"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation of medium-dose UVA1 phototherapy in localized scleroderma with the cutometer and fast Fourier transform method"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "73093"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            99 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "100"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medium-dose is more effective than low-dose ultraviolet A1 phototherapy for localized scleroderma as shown by 20-MHz ultrasound assessment"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2008.12.013"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            100 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "101"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Successful ultraviolet A1 phototherapy in the treatment of localized scleroderma&#58; a retrospective and prospective study"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2009.09438.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            101 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "102"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Combined treatment with calcipotriol ointment and low-dose ultraviolet A1 phototherapy in childhood morphea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            102 => array:3 [
              "identificador" => "bib0515"
              "etiqueta" => "103"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "UV-A1 phototherapy for sclerotic skin diseases&#58; implications for optimizing patient selection and management"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archderm.144.7.912"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            103 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "104"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of increased pigmentation on the antifibrotic response of human skin to UV-A1 phototheraphy"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archderm.144.7.851"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            104 => array:3 [
              "identificador" => "bib0525"
              "etiqueta" => "105"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "PUVA bath photochemotherapy for localized scleroderma&#46; Evaluation of 17 consecutive patients"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            105 => array:3 [
              "identificador" => "bib0530"
              "etiqueta" => "106"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Different low doses of broad-band UVA in the treatment of morphea and systemic sclerosis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1600-0781.2004.00081.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            106 => array:3 [
              "identificador" => "bib0535"
              "etiqueta" => "107"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Photochemotherapy for localized morphea&#58; effect on clinical and molecular markers"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2230.2008.02890.x"
                      "Revista" => array:7 [ …7]
                    ]
                  ]
                ]
              ]
            ]
            107 => array:3 [
              "identificador" => "bib0540"
              "etiqueta" => "108"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized controlled study of low-dose UVA1&#44; medium-dose UVA1&#44; and narrowband UVB phototherapy in the treatment of localized scleroderma"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2005.11.1063"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            108 => array:3 [
              "identificador" => "bib0545"
              "etiqueta" => "109"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rapid response to cyclosporine and maintenance with methotrexate in linear scleroderma in a young girl"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1525-1470.2008.00847.x"
                      "Revista" => array:7 [ …7]
                    ]
                  ]
                ]
              ]
            ]
            109 => array:3 [
              "identificador" => "bib0550"
              "etiqueta" => "110"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Extracorporeal photochemotherapy for generalized deep morphea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archdermatol.2008.547"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            110 => array:3 [
              "identificador" => "bib0555"
              "etiqueta" => "111"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Successful therapy of a patient with therapy recalcitrant generalized bullous scleroderma by extracorporeal photopheresis and mycophenolate mofetil"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1468-3083.2007.02403.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            111 => array:3 [
              "identificador" => "bib0560"
              "etiqueta" => "112"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Successful treatment of severe or methotrexate-resistant juvenile localized scleroderma with mycophenolate mofetil"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            112 => array:3 [
              "identificador" => "bib0565"
              "etiqueta" => "113"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A prospective open-label study of mycophenolate mofetil for the treatment of diffuse systemic sclerosis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            113 => array:3 [
              "identificador" => "bib0570"
              "etiqueta" => "114"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of recalcitrant generalized morphea with infliximab"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archdermatol.2010.120"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            114 => array:3 [
              "identificador" => "bib0575"
              "etiqueta" => "115"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Imatinib treatment of generalized localized scleroderma &#40;morphea&#41;"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            115 => array:3 [
              "identificador" => "bib0580"
              "etiqueta" => "116"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of topical tacrolimus 0&#46;1&#37; in active plaque morphea&#58; randomized&#44; double-blind&#44; emollient-controlled pilot study"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            116 => array:3 [
              "identificador" => "bib0585"
              "etiqueta" => "117"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "First case series on the use of imiquimod for morphoea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2005.06776.x"
                      "Revista" => array:7 [ …7]
                    ]
                  ]
                ]
              ]
            ]
            117 => array:3 [
              "identificador" => "bib0590"
              "etiqueta" => "118"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Localized morphea treated with imiquimod 5&#37; and dermoscopic assessment of effectiveness"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1080/09546630802132668"
                      "Revista" => array:7 [ …7]
                    ]
                  ]
                ]
              ]
            ]
            118 => array:3 [
              "identificador" => "bib0595"
              "etiqueta" => "119"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "First case series on the use of calcipotriol-betamethasone dipropionate for morphoea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2007.07971.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            119 => array:3 [
              "identificador" => "bib0600"
              "etiqueta" => "120"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Photodynamic therapy for the treatment of morphoea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2230.2008.02873.x"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            120 => array:3 [
              "identificador" => "bib0605"
              "etiqueta" => "121"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An evaluation of long-term outcomes in adults with pediatric-onset morphea"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archdermatol.2010.239"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15782190/0000010400000008/v1_201309240048/S157821901300173X/v1_201309240048/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "6177"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Reviews"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010400000008/v1_201309240048/S157821901300173X/v1_201309240048/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901300173X?idApp=UINPBA000044"
]

Información del artículo

ISSN: 15782190
Idioma original: Inglés

DOI:10.1016/j.adengl.2012.10.012

Datos actualizados diariamente

año/Mes	Html	Pdf	Total

2024 Noviembre	31	23	54
2024 Octubre	257	124	381
2024 Septiembre	249	92	341
2024 Agosto	309	121	430
2024 Julio	327	109	436
2024 Junio	287	128	415
2024 Mayo	287	111	398
2024 Abril	270	111	381
2024 Marzo	308	105	413
2024 Febrero	315	89	404
2024 Enero	314	96	410
2023 Diciembre	394	76	470
2023 Noviembre	414	114	528
2023 Octubre	343	111	454
2023 Septiembre	341	90	431
2023 Agosto	248	59	307
2023 Julio	256	130	386
2023 Junio	213	56	269
2023 Mayo	233	83	316
2023 Abril	304	94	398
2023 Marzo	303	102	405
2023 Febrero	194	100	294
2023 Enero	206	81	287
2022 Diciembre	149	70	219
2022 Noviembre	98	47	145
2022 Octubre	86	72	158
2022 Septiembre	120	66	186
2022 Agosto	82	52	134
2022 Julio	76	71	147
2022 Junio	102	63	165
2022 Mayo	297	126	423
2022 Abril	279	120	399
2022 Marzo	325	148	473
2022 Febrero	250	86	336
2022 Enero	261	116	377
2021 Diciembre	182	95	277
2021 Noviembre	170	124	294
2021 Octubre	174	135	309
2021 Septiembre	143	92	235
2021 Agosto	171	94	265
2021 Julio	144	90	234
2021 Junio	181	79	260
2021 Mayo	173	127	300
2021 Abril	719	216	935
2021 Marzo	319	112	431
2021 Febrero	250	85	335
2021 Enero	310	58	368
2020 Diciembre	167	58	225
2020 Noviembre	147	73	220
2020 Octubre	174	60	234
2020 Septiembre	150	55	205
2020 Agosto	153	84	237
2020 Julio	202	61	263
2020 Junio	139	104	243
2020 Mayo	162	95	257
2020 Abril	309	89	398
2020 Marzo	83	40	123
2020 Febrero	6	7	13
2020 Enero	4	11	15
2019 Diciembre	8	14	22
2019 Noviembre	4	11	15
2019 Octubre	0	10	10
2019 Septiembre	8	31	39
2019 Agosto	4	22	26
2019 Julio	3	39	42
2019 Junio	5	30	35
2019 Mayo	3	70	73
2019 Abril	0	28	28
2019 Marzo	2	11	13
2019 Febrero	0	4	4
2019 Enero	4	8	12
2018 Diciembre	0	4	4
2018 Noviembre	3	3	6
2018 Octubre	6	1	7
2018 Septiembre	4	0	4
2018 Abril	0	24	24
2018 Marzo	9	16	25
2018 Febrero	143	58	201
2018 Enero	155	52	207
2017 Diciembre	145	49	194
2017 Noviembre	169	39	208
2017 Octubre	182	64	246
2017 Septiembre	139	73	212
2017 Agosto	116	70	186
2017 Julio	171	78	249
2017 Junio	146	81	227
2017 Mayo	147	74	221
2017 Abril	286	70	356
2017 Marzo	257	104	361
2017 Febrero	390	74	464
2017 Enero	324	67	391
2016 Diciembre	388	61	449
2016 Noviembre	421	72	493
2016 Octubre	454	100	554
2016 Septiembre	536	108	644
2016 Agosto	551	96	647
2016 Julio	310	90	400
2016 Junio	8	97	105
2016 Mayo	6	82	88
2016 Abril	13	21	34
2016 Marzo	9	29	38
2016 Febrero	10	34	44
2016 Enero	9	31	40
2015 Diciembre	16	27	43
2015 Noviembre	4	44	48
2015 Octubre	8	43	51
2015 Septiembre	2	47	49
2015 Agosto	9	38	47
2015 Julio	475	3	478
2015 Junio	336	53	389
2015 Mayo	458	82	540
2015 Abril	425	61	486
2015 Marzo	490	40	530
2015 Febrero	385	36	421
2015 Enero	378	55	433
2014 Diciembre	258	52	310
2014 Noviembre	250	64	314
2014 Octubre	322	66	388
2014 Septiembre	261	52	313
2014 Agosto	257	55	312
2014 Julio	290	43	333
2014 Junio	251	36	287
2014 Mayo	244	42	286
2014 Abril	234	27	261
2014 Marzo	159	39	198
2014 Febrero	170	44	214
2014 Enero	175	34	209
2013 Diciembre	78	32	110
2013 Noviembre	32	53	85
2013 Octubre	62	66	128
2013 Septiembre	7	11	18

Mostrar todo

Indexada en:

Síguenos:

Estadísticas

Indexada en:

Síguenos:

Estadísticas

Suscríbase a la newsletter