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trunk&#44; and limbs&#44; consisted of plaques and nodules with areas of necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Biopsy revealed acanthosis and partial necrosis of the epidermis&#44; which was infiltrated by lymphocytes with an atypical morphology and marked epidermotropism &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Immunohistochemistry was positive for CD3&#44; CD7&#44; CD8&#44; TIA1&#44; and Ki67 &#40;50&#37;&#41; and negative for CD4&#44; CD5&#44; CD56&#44; T-cell receptor &#946;-F1&#44; CD79a&#44; and CD20&#44; and Epstein-Barr virus RNA was not detected&#46; Serology for Human T-Lymphotrophic Virus I&#47;II and <span class="elsevierStyleItalic">Borrelia burgdorferi</span> was negative&#46; The study of tumor spread was negative&#46; Based on the above data&#44; a diagnosis of aggressive primary cutaneous cytotoxic T-cell lymphoma was made&#46; The patient received treatment with various chemotherapy protocols&#8212;cyclophosphamide&#44; 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it was decided to prescribe aprepitant for off-label use&#46; After using aprepitant for 3 consecutive days &#40;125<span class="elsevierStyleHsp" style=""></span>mg on the first day and 80<span class="elsevierStyleHsp" style=""></span>mg on the second and third days&#41;&#8212;there was a marked symptomatic improvement at each 2-weekly evaluation &#40;score of 3&#47;10 on the verbal numerical scale&#41;&#44; and this led to a considerable improvement in the patient&#39;s quality of life until her death 13 months after diagnosis of the lymphoma&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Substance P is a potent inducer of pruritus&#46; It activates the neurokinin-1 receptors present on keratinocytes and mast cells and also on the neurons of the sensory dorsal root ganglion&#46; Aprepitant inhibits the effect of substance P by blocking the neurokinin receptors&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> It acts by blocking signal conduction along peripheral nerve C fibers&#8212;inhibiting the release of nerve growth factor from keratinocytes&#8212;or by blocking signal transmission in the dorsal horn&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In 2009&#44; Duval et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> reported 3 patients with pruritus secondary to S&#233;zary syndrome in whom aprepitant was used at a dose of 80<span class="elsevierStyleHsp" style=""></span>mg&#47;d continuously and led to successful control of the pruritus&#46; Subsequently&#44; Booken et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> published the cases of 5 patients with pruritus secondary to erythrodermic cutaneous T-cell lymphoma who were treated with aprepitant on a 3-day regimen &#40;125<span class="elsevierStyleHsp" style=""></span>mg on day 1 and 80<span class="elsevierStyleHsp" style=""></span>mg on days 2 and<span class="elsevierStyleHsp" style=""></span>3&#41; every 2 weeks&#44; with improvement of the pruritus in 4 cases&#46; Later&#44; Torres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> described 2 patients with pruritus secondary to S&#233;zary syndrome&#59; both responded well to aprepitant at a dose of 80<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; Most recently&#44; Ladizinski et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> were the first to report the efficacy of aprepitant in a patient with nonerythrodermic cutaneous T-cell lymphoma&#59; they administered the drug at a dose of 80<span class="elsevierStyleHsp" style=""></span>mg 3 times a week &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Aprepitant has also been effective in the control of chronic itching in patients with atopic dermatitis or nodular pruritus&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in patients with solid tumors&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and in those with erlotinib-induced pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Aprepitant has a good pharmacological safety profile&#46; It is important to remember that this drug is able to inhibit CYP3A4&#44; and it must not therefore be administered to patients on treatment with pimozide&#44; terfenadine&#44; astemizole&#44; or cisapride&#46; It can also induce elevations of the aminotransferases and must be used with caution in patients with altered liver function&#46; The common side effects of aprepitant include hiccup&#44; fatigue&#44; constipation&#44; headache&#44; and anorexia&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In summary&#44; we have presented the case of a patient in whom aprepitant was used successfully to treat refractory pruritus secondary to cutaneous T-cell lymphoma&#46; This treatment produced a marked improvement in patient&#39;s quality of life&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Borja-Consigliere HA&#44; L&#243;pez-Pesta&#241;a A&#44; Vidal-Mance&#241;ido MJ&#44; Tuneu-Valls A&#46; Tratamiento con aprepitant del prurito refractario secundario a linfoma cut&#225;neo de c&#233;lulas T&#46; Actas Dermosifiliogr&#46; 2014&#59;105&#58;716&#8211;718&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Plaques and tumors on the trunk&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Acanthotic epidermis with an intense pagetoid infiltrate of lymphocytes with an atypical morphology &#40;hematoxylin and eosin&#44; original magnification &#215;<span class="elsevierStyleHsp" style=""></span>20&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; VAS&#44; visual analogue scale&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; of Cases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Aprepitant Regimen&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">VAS &#40;0-10&#41;Pretreatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">VAS &#40;0-10&#41;After Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duval et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80<span class="elsevierStyleHsp" style=""></span>mg&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#44; 8&#44; 9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#44; 3&#44; 2&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
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                  \t\t\t\t">Booken et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">125<span class="elsevierStyleHsp" style=""></span>mg&#44; 80<span class="elsevierStyleHsp" style=""></span>mg&#44; and 80<span class="elsevierStyleHsp" style=""></span>mg on 3 consecutive days every 2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4&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
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                  \t\t\t\t">Torres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">80<span class="elsevierStyleHsp" style=""></span>mg&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8&#44; 9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#44; 3&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
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                  \t\t\t\t">Ladizinski et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">80<span class="elsevierStyleHsp" style=""></span>mg&#47;d 3 times a week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Published Cases of the Use of Aprepitant to Treat Pruritus Secondary to Cutaneous Lymphoma&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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                          "etal" => true
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "S&#46; St&#228;nder"
                            1 => "D&#46; Siepmann"
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Duval"
                            1 => "L&#46; Dubertret"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Oral aprepitant in the therapy of refractory pruritus in erythrodermic cutaneous T-cell lymphoma"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "N&#46; Booken"
                            1 => "M&#46; Heck"
                            2 => "J&#46;P&#46; Nicolay"
                            3 => "C&#46;D&#46; Klemke"
                            4 => "S&#46; Goerdt"
                            5 => "J&#46; Utikal"
                          ]
                        ]
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CASE AND RESEARCH LETTER
Aprepitant in the Treatment of Refractory Pruritus Secondary to Cutaneous T-Cell Lymphoma
Tratamiento con aprepitant del prurito refractario secundario a linfoma cutáneo de células T
H.A. Borja-Consiglierea,
Autor para correspondencia
, A. López-Pestañaa, M.J. Vidal-Manceñidob, A. Tuneu-Vallsa
a Sección de Dermatología, Hospital Universitario Donostia, San Sebastián, Spain
b Departamento de Hematología, Hospital Universitario Donostia, San Sebastián, Spain
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            "entidad" => "Departamento de Hematolog&#237;a&#44; Hospital Universitario Donostia&#44; San Sebasti&#225;n&#44; Spain"
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      "es" => array:1 [
        "titulo" => "Tratamiento con aprepitant del prurito refractario secundario a linfoma cut&#225;neo de c&#233;lulas T"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Acanthotic epidermis with an intense pagetoid infiltrate of lymphocytes with an atypical morphology &#40;hematoxylin and eosin&#44; original magnification &#215;<span class="elsevierStyleHsp" style=""></span>20&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with cutaneous T-cell lymphoma frequently develop intense pruritus&#44; which can often be refractory to anticancer and symptomatic treatments and can affect quality of life to a significant degree&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Aprepitant&#44; an antiemetic that is a substance P antagonist&#44; has been used successfully to manage refractory pruritus&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 61-year-old woman who was a smoker with a history of chronic obstructive pulmonary disease and who required home oxygen&#46; In August 2011 she was seen for a 5-month history of skin lesions that she described as very itchy&#46; The lesions&#44; which were present on the head&#44; trunk&#44; and limbs&#44; consisted of plaques and nodules with areas of necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Biopsy revealed acanthosis and partial necrosis of the epidermis&#44; which was infiltrated by lymphocytes with an atypical morphology and marked epidermotropism &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Immunohistochemistry was positive for CD3&#44; CD7&#44; CD8&#44; TIA1&#44; and Ki67 &#40;50&#37;&#41; and negative for CD4&#44; CD5&#44; CD56&#44; T-cell receptor &#946;-F1&#44; CD79a&#44; and CD20&#44; and Epstein-Barr virus RNA was not detected&#46; Serology for Human T-Lymphotrophic Virus I&#47;II and <span class="elsevierStyleItalic">Borrelia burgdorferi</span> was negative&#46; The study of tumor spread was negative&#46; Based on the above data&#44; a diagnosis of aggressive primary cutaneous cytotoxic T-cell lymphoma was made&#46; The patient received treatment with various chemotherapy protocols&#8212;cyclophosphamide&#44; adriamycin&#44; vincristine&#44; and prednisone &#40;CHOP&#41;&#59; bexarotene&#59; gemcitabine plus oxaliplati&#59; alemtuzumab&#59; and cyclophosphamide&#44; unpegylated liposomal adriamycin&#44; vincristine&#44; and prednisone &#40;COMP&#41;&#8212;without achieving control of disease progression or of the associated pruritus&#46; She was administered symptomatic treatment for the pruritus with 0&#46;1&#37; triamcinolone acetonide cream once a day plus cetirizine 10<span class="elsevierStyleHsp" style=""></span>mg in the morning and dexchlorpheniramine 2<span class="elsevierStyleHsp" style=""></span>mg at night&#44; with no improvement&#46; This treatment was subsequently changed to 0&#46;05&#37; clobetasol cream once a day&#44; plus bilastine 20<span class="elsevierStyleHsp" style=""></span>mg in the morning and dexchlorpheniramine 4<span class="elsevierStyleHsp" style=""></span>mg at night&#46; Due to persistence of the pruritus &#40;score of 10&#47;10 on a verbal numerical scale&#41;&#44; it was decided to prescribe aprepitant for off-label use&#46; After using aprepitant for 3 consecutive days &#40;125<span class="elsevierStyleHsp" style=""></span>mg on the first day and 80<span class="elsevierStyleHsp" style=""></span>mg on the second and third days&#41;&#8212;there was a marked symptomatic improvement at each 2-weekly evaluation &#40;score of 3&#47;10 on the verbal numerical scale&#41;&#44; and this led to a considerable improvement in the patient&#39;s quality of life until her death 13 months after diagnosis of the lymphoma&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Substance P is a potent inducer of pruritus&#46; It activates the neurokinin-1 receptors present on keratinocytes and mast cells and also on the neurons of the sensory dorsal root ganglion&#46; Aprepitant inhibits the effect of substance P by blocking the neurokinin receptors&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> It acts by blocking signal conduction along peripheral nerve C fibers&#8212;inhibiting the release of nerve growth factor from keratinocytes&#8212;or by blocking signal transmission in the dorsal horn&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In 2009&#44; Duval et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> reported 3 patients with pruritus secondary to S&#233;zary syndrome in whom aprepitant was used at a dose of 80<span class="elsevierStyleHsp" style=""></span>mg&#47;d continuously and led to successful control of the pruritus&#46; Subsequently&#44; Booken et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> published the cases of 5 patients with pruritus secondary to erythrodermic cutaneous T-cell lymphoma who were treated with aprepitant on a 3-day regimen &#40;125<span class="elsevierStyleHsp" style=""></span>mg on day 1 and 80<span class="elsevierStyleHsp" style=""></span>mg on days 2 and<span class="elsevierStyleHsp" style=""></span>3&#41; every 2 weeks&#44; with improvement of the pruritus in 4 cases&#46; Later&#44; Torres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> described 2 patients with pruritus secondary to S&#233;zary syndrome&#59; both responded well to aprepitant at a dose of 80<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; Most recently&#44; Ladizinski et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> were the first to report the efficacy of aprepitant in a patient with nonerythrodermic cutaneous T-cell lymphoma&#59; they administered the drug at a dose of 80<span class="elsevierStyleHsp" style=""></span>mg 3 times a week &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Aprepitant has also been effective in the control of chronic itching in patients with atopic dermatitis or nodular pruritus&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in patients with solid tumors&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and in those with erlotinib-induced pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Aprepitant has a good pharmacological safety profile&#46; It is important to remember that this drug is able to inhibit CYP3A4&#44; and it must not therefore be administered to patients on treatment with pimozide&#44; terfenadine&#44; astemizole&#44; or cisapride&#46; It can also induce elevations of the aminotransferases and must be used with caution in patients with altered liver function&#46; The common side effects of aprepitant include hiccup&#44; fatigue&#44; constipation&#44; headache&#44; and anorexia&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In summary&#44; we have presented the case of a patient in whom aprepitant was used successfully to treat refractory pruritus secondary to cutaneous T-cell lymphoma&#46; This treatment produced a marked improvement in patient&#39;s quality of life&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Borja-Consigliere HA&#44; L&#243;pez-Pesta&#241;a A&#44; Vidal-Mance&#241;ido MJ&#44; Tuneu-Valls A&#46; Tratamiento con aprepitant del prurito refractario secundario a linfoma cut&#225;neo de c&#233;lulas T&#46; Actas Dermosifiliogr&#46; 2014&#59;105&#58;716&#8211;718&#46;</p>"
      ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Plaques and tumors on the trunk&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; VAS&#44; visual analogue scale&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; of Cases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Aprepitant Regimen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">VAS &#40;0-10&#41;Pretreatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">VAS &#40;0-10&#41;After Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duval et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80<span class="elsevierStyleHsp" style=""></span>mg&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#44; 8&#44; 9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#44; 3&#44; 2&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
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                  \t\t\t\t">Booken et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">125<span class="elsevierStyleHsp" style=""></span>mg&#44; 80<span class="elsevierStyleHsp" style=""></span>mg&#44; and 80<span class="elsevierStyleHsp" style=""></span>mg on 3 consecutive days every 2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4&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
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                  \t\t\t\t">Torres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">80<span class="elsevierStyleHsp" style=""></span>mg&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8&#44; 9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#44; 3&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
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                  \t\t\t\t">Ladizinski et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">80<span class="elsevierStyleHsp" style=""></span>mg&#47;d 3 times a week&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Published Cases of the Use of Aprepitant to Treat Pruritus Secondary to Cutaneous Lymphoma&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quality of life and psychological distress in patients with cutaneous lymphoma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Sampogna"
                            1 => "M&#46; Frontani"
                            2 => "G&#46; Baliva"
                            3 => "G&#46;A&#46; Lombardo"
                            4 => "G&#46; Alvetreti"
                            5 => "C&#46; Di Pietro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2008.08992.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2009"
                        "volumen" => "160"
                        "paginaInicial" => "815"
                        "paginaFinal" => "822"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19120325"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Targeting the neurokinin receptor 1 with aprepitant&#58; A novel antipruritic strategy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46; St&#228;nder"
                            1 => "D&#46; Siepmann"
                            2 => "I&#46; Herrgott"
                            3 => "C&#46; Sunderk&#246;tter"
                            4 => "T&#46;A&#46; Luger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0010968"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS One"
                        "fecha" => "2010"
                        "volumen" => "5"
                        "paginaInicial" => "e10968"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20532044"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pathophysiology of itch and new treatments"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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