Case and Research Letters
Initial Evaluation of Patients with Pigmented Skin Lesions
Valoración inicial del paciente con lesiones cutáneas pigmentadas
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Imbernón-Moya, S. Podlipnik, J. Malvehy, S. Puig" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Imbernón-Moya" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Podlipnik" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Malvehy" ] 3 => array:2 [ "nombre" => "S." 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B, Melanin-containing dendritic cells and positive staining for S100 protein (S100, original magnification ×200).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.J. Añón-Requena, M. Pico-Valimaña, G. Muñoz-Arias" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M.J." "apellidos" => "Añón-Requena" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Pico-Valimaña" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Muñoz-Arias" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S000173101600017X" "doi" => "10.1016/j.ad.2015.10.017" "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/S000173101600017X?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301482?idApp=UINPBA000044" "url" => "/15782190/0000010700000007/v2_201704140340/S1578219016301482/v2_201704140340/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219016301469" "issn" => "15782190" "doi" => "10.1016/j.adengl.2016.06.015" "estado" => "S300" "fechaPublicacion" => "2016-09-01" "aid" => "1376" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2016;107:614-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1057 "formatos" => array:3 [ "EPUB" => 43 "HTML" => 822 "PDF" => 192 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Nevus <span class="elsevierStyleItalic">Spilus</span> Associated With Agminated Blue Nevus: A Rare Combination" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "614" "paginaFinal" => "616" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nevo <span class="elsevierStyleItalic">spilus</span> asociado a nevus azul agminado: una combinación infrecuente" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 686 "Ancho" => 975 "Tamanyo" => 224334 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathology revealed a combined lesion, with findings characteristic of a blue nevus (a dermal proliferation of spindle-shaped melanocytes associated with melanophages) and findings corresponding to nevus spilus (a lentiginous proliferation of melanocytes at the dermoepidermal junction and nests of melanocytes with no atypia in the superficial dermis). Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>x10.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Ayala, M.D. Ramón, M. Cabezas, E. Jordá" "autores" => array:4 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Ayala" ] 1 => array:2 [ "nombre" => "M.D." "apellidos" => "Ramón" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Cabezas" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Jordá" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S000173101600096X" "doi" => "10.1016/j.ad.2016.01.013" "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/S000173101600096X?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301469?idApp=UINPBA000044" "url" => "/15782190/0000010700000007/v2_201704140340/S1578219016301469/v2_201704140340/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Initial Evaluation of Patients with Pigmented Skin Lesions" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "616" "paginaFinal" => "618" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Imbernón-Moya, S. Podlipnik, J. Malvehy, S. Puig" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Imbernón-Moya" "email" => array:1 [ 0 => "adrian_imber88@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Podlipnik" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Malvehy" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "S." "apellidos" => "Puig" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Severo Ochoa, Leganés, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valoración inicial del paciente con lesiones cutáneas pigmentadas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of melanoma has increased significantly in Spain in recent decades, and this tumor is now a public health problem.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The role of the dermatologist is fundamental to the identification of high-risk patients and to the adoption of appropriate primary and secondary preventive measures for the early detection of skin cancer.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Several well-standardized international clinical guidelines have been drawn up on the management of patients with melanoma,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4–9</span></a> but no protocols exist on how to take an appropriate medical history and physical examination. The Australian guideline proposes an initial evaluation to determine the future risk of melanoma (grade B recommendation) looking at various factors, including age, sex, past history of melanoma or nonmelanoma skin cancer, family history of melanoma, number of melanocytic and atypical nevi, skin and hair color, skin phototype, and actinic damage.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">When a patient attends dermatology outpatients for an initial clinical evaluation of a nevus or suspected melanoma, an exhaustive medical history must be taken to detect the main risk factors (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) and a complete physical examination performed.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> In the literature, we have found no descriptions of a protocol for the initial clinical evaluation of this type of patient. We therefore present our standard approach to the first consultation in the melanoma unit of Hospital Clínic in Barcelona:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">−</span><p id="par0020" class="elsevierStylePara elsevierViewall">Personal history of drug allergy, drinking and smoking, current and previous occupations, known diseases, surgical history, noncutaneous tumors, and usual medical treatments.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">−</span><p id="par0025" class="elsevierStylePara elsevierViewall">Past dermatologic history: known dermatoses, history of skin tumors, dysplastic nevus syndrome, treatments performed, previously excised nevi, and risk classification (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">−</span><p id="par0030" class="elsevierStylePara elsevierViewall">Family history of dysplastic nevus syndrome and of skin and other tumors.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">−</span><p id="par0035" class="elsevierStylePara elsevierViewall">History of sun exposure, UV protection (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), pattern of intermittent or chronic exposure, and time dedicated to outdoor occupational or leisure activities.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">−</span><p id="par0040" class="elsevierStylePara elsevierViewall">Detailed history of the suspected melanoma lesion<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,10</span></a>: site, time since onset, presence of a precursor lesion, symptom or sign that prompted consultation, pruritus, pain, bleeding, erosion, ulceration, suppuration, changes in color (multiple shades of dark brown or black, or appearance of various colors, including light brown, dark brown, black, red, blue, gray, and white), changes in morphology (appearance of irregular margins), change in size (rapid or continuous growth), elevation of the lesion, changes in the surrounding skin (erythema, edema, satellite pigmentation), changes in consistency (softening, friability), and previous treatment of the lesion.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">−</span><p id="par0045" class="elsevierStylePara elsevierViewall">Systems review: constitutional, neurologic, otorhinolaryngologic, respiratory, musculoskeletal, hepatic, gastrointestinal, cutaneous, subcutaneous, and lymphatic signs and symptoms.</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">We also present our standard procedure for complete physical examination:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0055" class="elsevierStylePara elsevierViewall">Skin phototype (I-VI),<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> race (white, black, yellow), eye color (green, blue, gray, brown, black), hair color at 18 years of age (red, fair, brown, black).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">–</span><p id="par0060" class="elsevierStylePara elsevierViewall">Complete dermatologic examination, including scalp, intertriginous areas, oral, ocular, genital, and anal mucosas, palms, soles, and nails.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">–</span><p id="par0065" class="elsevierStylePara elsevierViewall">Presence of freckles, solar elastosis, solar lentigines in sun-exposed areas, actinic keratoses, basal cell carcinoma, and squamous cell carcinoma.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">–</span><p id="par0070" class="elsevierStylePara elsevierViewall">Estimation of the total number of acquired melanocytic nevi, whatever their size (<<span class="elsevierStyleHsp" style=""></span>50, 50-100, 100-200, ><span class="elsevierStyleHsp" style=""></span>200). Evaluation of the number of these lesions and of the clinical type (junctional, compound, intradermal) and size (small, 2-6<span class="elsevierStyleHsp" style=""></span>mm; intermediate, 6-15<span class="elsevierStyleHsp" style=""></span>mm; or large,<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm) on the trunk and on the upper limbs. Evaluation of the number of clinically atypical nevi and presence of congenital nevi.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">–</span><p id="par0075" class="elsevierStylePara elsevierViewall">Description of the suspected lesion: site, diameter, palpation, presence of papules or nodules, size, pigmentation, clinical type, ulceration, areas of regression, adjacent nevi. Physical examination of the regional lymph nodes, presence of hepatomegaly, splenomegaly, and locoregional and/or distant subcutaneous masses or nodules.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">–</span><p id="par0080" class="elsevierStylePara elsevierViewall">Dermoscopic features.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">–</span><p id="par0085" class="elsevierStylePara elsevierViewall">Photographs of the lesions prior to the surgical excision of suspicious skin lesions (essential).</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion, the objective of this article has been to present the guideline used in our center for the initial clinical evaluation of nevi or suspected melanoma in the hope that it will help dermatologists evaluating patients with such lesions. Finally, it is essential that we undertake patient education regarding periodic self-examination, the clinical characteristics of melanoma (ABCDE rule and ugly duckling sign), and appropriate measures of photoprotection.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3,10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Imbernón-Moya A, Podlipnik S, Malvehy J, Puig S. Valoración inicial del paciente con lesiones cutáneas pigmentadas. Actas Dermosifiliogr. 2016;107:616–618.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phenotype \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">White race<br>Fitzpatrick phototypes I and II<br>Advanced age (> 65 years)<br>Male sex<br>Fair or red hair<br>Blue or green eyes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">External factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prolonged and intense sun exposure<br>Sunburn in childhood<br>Artificial UV-A tanning beds<br>Residence in equatorial countries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Past history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Past history of melanoma and/or nonmelanoma skin cancer (basal cell carcinoma, squamous cell carcinoma, actinic keratosis)<br>History of surgical excision of a dysplastic nevus<br>Parkinson disease<br>Acquired or iatrogenic immunosuppression (solid-organ or hematologic tumors, transplant recipients, immunosuppressant treatments, HIV infection) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Genetic syndromes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Albinism<br>Xeroderma pigmentosum \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First or second degree relative with a history of melanoma, dysplastic nevus syndrome, or other melanoma-associated tumor (pancreas, renal, breast, lung, colon, central nervous system) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical characteristics of the patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">More than 100 clinically typical or more than 5 clinically atypical acquired melanocytic nevi (ABCDE rule).<br>Dysplastic nevus syndrome (more than 100 acquired melanocytic nevi with 1 or more larger than 6<span class="elsevierStyleHsp" style=""></span>mm and 1 or more with histology of dysplastic nevus), multiple freckles or solar lentigines<br>Giant congenital melanocytic nevus (><span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Genetic factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mutations in genes <span class="elsevierStyleItalic">BRAF, MITF, BAP1, CDK4, CDKN2A</span>.<br><span class="elsevierStyleItalic">MC1R</span> gene polymorphism \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1393461.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Main Risk Factors for Melanoma.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No history of melanoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Personal past history of melanoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First or second degree relative with melanoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Personal past history of 2 or more melanomas or personal or family history of melanoma \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1393462.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Classification of Risk of Melanoma.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Cumulative sun exposure</span>: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><10 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10-18 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>18 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Current \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intense (><span class="elsevierStyleHsp" style=""></span>120<span class="elsevierStyleHsp" style=""></span>h/y) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate (50-120<span class="elsevierStyleHsp" style=""></span>h/y) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mild (<<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>h/y) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>None (0<span class="elsevierStyleHsp" style=""></span>h/y) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Adequate sun protection</span>: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><10 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10-18 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>18 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Current \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Always \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Usually \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Occasionally \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Never/hardly ever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Level of exposure to artificial UV</span>: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">UV-A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PUV-A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">UV-AB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intense (><span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>h/y) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate (20-40<span class="elsevierStyleHsp" style=""></span>h/y) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mild (<<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>h/y) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sunburn/UV radiation burn</span>: (E= erythema. B= blisters) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><10 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10-18 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>18 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Current \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>5 episodes/year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3-5 episodes/year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1-3 episodes/year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1393460.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical Data to Be Considered in the History of Sun Exposure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "599.e1-599.e12" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Screening, early detection, education, and trends for melanoma: Current status (2007-2013) and future directions: Part I. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 8 | 9 | 17 |
| 2024 Octubre | 89 | 43 | 132 |
| 2024 Septiembre | 73 | 38 | 111 |
| 2024 Agosto | 106 | 52 | 158 |
| 2024 Julio | 88 | 37 | 125 |
| 2024 Junio | 99 | 32 | 131 |
| 2024 Mayo | 69 | 31 | 100 |
| 2024 Abril | 72 | 27 | 99 |
| 2024 Marzo | 61 | 29 | 90 |
| 2024 Febrero | 69 | 30 | 99 |
| 2024 Enero | 53 | 32 | 85 |
| 2023 Diciembre | 65 | 32 | 97 |
| 2023 Noviembre | 88 | 31 | 119 |
| 2023 Octubre | 89 | 28 | 117 |
| 2023 Septiembre | 51 | 32 | 83 |
| 2023 Agosto | 40 | 19 | 59 |
| 2023 Julio | 44 | 29 | 73 |
| 2023 Junio | 34 | 22 | 56 |
| 2023 Mayo | 46 | 34 | 80 |
| 2023 Abril | 39 | 26 | 65 |
| 2023 Marzo | 24 | 25 | 49 |
| 2023 Febrero | 30 | 25 | 55 |
| 2023 Enero | 38 | 24 | 62 |
| 2022 Diciembre | 37 | 43 | 80 |
| 2022 Noviembre | 13 | 28 | 41 |
| 2022 Octubre | 60 | 18 | 78 |
| 2022 Septiembre | 22 | 33 | 55 |
| 2022 Agosto | 41 | 30 | 71 |
| 2022 Julio | 26 | 32 | 58 |
| 2022 Junio | 22 | 22 | 44 |
| 2022 Mayo | 25 | 32 | 57 |
| 2022 Abril | 36 | 38 | 74 |
| 2022 Marzo | 39 | 36 | 75 |
| 2022 Febrero | 33 | 25 | 58 |
| 2022 Enero | 32 | 35 | 67 |
| 2021 Diciembre | 25 | 42 | 67 |
| 2021 Noviembre | 37 | 38 | 75 |
| 2021 Octubre | 32 | 43 | 75 |
| 2021 Septiembre | 30 | 39 | 69 |
| 2021 Agosto | 34 | 32 | 66 |
| 2021 Julio | 28 | 23 | 51 |
| 2021 Junio | 23 | 33 | 56 |
| 2021 Mayo | 38 | 46 | 84 |
| 2021 Abril | 75 | 56 | 131 |
| 2021 Marzo | 58 | 38 | 96 |
| 2021 Febrero | 49 | 29 | 78 |
| 2021 Enero | 33 | 12 | 45 |
| 2020 Diciembre | 23 | 17 | 40 |
| 2020 Noviembre | 26 | 29 | 55 |
| 2020 Octubre | 34 | 10 | 44 |
| 2020 Septiembre | 34 | 19 | 53 |
| 2020 Agosto | 26 | 14 | 40 |
| 2020 Julio | 23 | 20 | 43 |
| 2020 Junio | 36 | 31 | 67 |
| 2020 Mayo | 24 | 18 | 42 |
| 2020 Abril | 28 | 16 | 44 |
| 2020 Marzo | 34 | 20 | 54 |
| 2020 Febrero | 3 | 0 | 3 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 3 | 0 | 3 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 5 | 0 | 5 |
| 2019 Abril | 2 | 2 | 4 |
| 2019 Marzo | 2 | 1 | 3 |
| 2019 Enero | 3 | 0 | 3 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Febrero | 11 | 3 | 14 |
| 2018 Enero | 18 | 8 | 26 |
| 2017 Diciembre | 26 | 8 | 34 |
| 2017 Noviembre | 23 | 7 | 30 |
| 2017 Octubre | 30 | 8 | 38 |
| 2017 Septiembre | 29 | 8 | 37 |
| 2017 Agosto | 35 | 6 | 41 |
| 2017 Julio | 22 | 10 | 32 |
| 2017 Junio | 34 | 4 | 38 |
| 2017 Mayo | 23 | 8 | 31 |
| 2017 Abril | 23 | 8 | 31 |
| 2017 Marzo | 12 | 3 | 15 |
| 2017 Febrero | 20 | 7 | 27 |
| 2017 Enero | 16 | 4 | 20 |
| 2016 Diciembre | 40 | 20 | 60 |
| 2016 Noviembre | 25 | 12 | 37 |
| 2016 Octubre | 32 | 23 | 55 |
| 2016 Septiembre | 0 | 1 | 1 |
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