Case and Research Letters
Initial Assessment of Patients With Contact Eczema
Valoración inicial del paciente con eczema de contacto
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Imbernón-Moya, F.J. Ortiz-de Frutos, A.M. Delgado-Márquez, F. Vanaclocha-Sebastián" "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" => "F.J." "apellidos" => "Ortiz-de Frutos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A.M." "apellidos" => "Delgado-Márquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Vanaclocha-Sebastián" "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 Universitario Severo Ochoa, Leganés, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital 12 de Octubre, Madrid, 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 eczema de contacto" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Eczema is an inflammatory skin reaction that can have different etiologies. It is characterized clinically by pruritus and polymorphous skin lesions that can progress successively through erythema, macules, papules, edema, vesicles or blisters, excoriation, erosions, scabs, flaking, hyperkeratosis, lichenification, and fissures.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Histologically it is characterized by spongiosis; other findings include acanthosis, parakeratosis, and a lymphocytic perivascular infiltrate in the upper dermis that may show epidermotropism and that includes a variable number of eosinophils.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Contact eczema develops when the skin surface comes into contact with an exogenous substance. Irritant contact eczema (ICE) accounts for 80% of cases and is due to a local toxic effect caused by single or repeated contact with irritant substances. It is limited to the area of exposure in the majority of cases. ICE most commonly affects hands (80%) and face (10%).<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> Allergic contact eczema (ACE) accounts for the remaining 20%. This is a delayed hypersensitivity reaction triggered by contact with a substance to which the patient has previously become sensitized. ACE develops in the area of exposure and occasionally also at distant sites.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The clinical manifestations can be similar in the 2 forms of contact eczema, and a detailed medical history and physical examination are therefore essential in the search for the main risk factors.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3–9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the literature, we have found no descriptions of a protocol for the initial clinical evaluation of this type of patient. The German clinical guideline for hand eczema proposes a detailed medical history and meticulous physical examination (grade A recommendation), paying particular attention to the site and morphology of the skin lesions.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> We therefore present our standard approach to the first consultation in the Eczema Unit of Hospital 12 de Octubre in Madrid, Spain:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Individual characteristics of the eczema<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3–9</span></a>: initial site, disease duration, symptoms (pruritus, pain, soreness), clinical behavior and extension, clinical course (persistent or intermittent), exacerbations and remissions, previous episodes of eczema, aggravating factors, seasonal variations, previous treatments, and relationship with weekends, holidays, periods off work, and exposure to sunlight.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Predisposing factors:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0030" class="elsevierStylePara elsevierViewall">Age and sex: ICE is more common in women, children, and the elderly.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4,7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0035" class="elsevierStylePara elsevierViewall">Past history of allergy and supporting additional tests.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0040" class="elsevierStylePara elsevierViewall">A personal or family history of atopic dermatitis, asthma, or allergic rhinoconjunctivitis is associated with a higher risk of ICE.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4,7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0045" class="elsevierStylePara elsevierViewall">Past history of other dermatoses: Seborrheic dermatitis is associated with an increase in the levels of the proinflammatory cytokine interleukin-1α, leading to a higher risk of ICE.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0050" class="elsevierStylePara elsevierViewall">Genetic factors: Polymorphism of tumor necrosis factor-308 and mutations of the filaggrin gene probably constitute a risk factor for ICE.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">c)</span><p id="par0055" class="elsevierStylePara elsevierViewall">Factors related to exposure:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">–</span><p id="par0060" class="elsevierStylePara elsevierViewall">Past and present occupational and domestic exposure (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>)<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3–5</span></a>: Determine the use of personal protection measures, such as gloves, goggles, face masks, and protective clothing.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">–</span><p id="par0065" class="elsevierStylePara elsevierViewall">Exposure to irritant substances (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">–</span><p id="par0070" class="elsevierStylePara elsevierViewall">Work in a moist environment: This is defined as exposure to water for more than 2<span class="elsevierStyleHsp" style=""></span>hours a day, hand washing more than 20 times a day, or the use of gloves for more than 2<span class="elsevierStyleHsp" style=""></span>hours a day.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">–</span><p id="par0075" class="elsevierStylePara elsevierViewall">Leisure activities and hobbies.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">–</span><p id="par0080" class="elsevierStylePara elsevierViewall">Use of skincare products, perfumes, cosmetics, metals, topical medicines.</p></li></ul></p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">We also present our standard procedure for complete physical examination:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">–</span><p id="par0090" class="elsevierStylePara elsevierViewall">Description of the eczematous lesions<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3–6,9</span></a>: site, pattern (acute, subacute, chronic), distribution (single, patchy, linear, diffuse, disseminated), morphology, intensity, size, palpation, ulceration, scabs, signs of superinfection, hyperkeratosis, and lichenification.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">–</span><p id="par0095" class="elsevierStylePara elsevierViewall">Complete dermatologic examination, including scalp, intertriginous areas, palms, soles, and nails.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">–</span><p id="par0100" class="elsevierStylePara elsevierViewall">Thorough inspection for clinical signs of dermatophytosis, psoriasis, and atopy (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3–5,10</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">A number of differential diagnoses must be considered in patients with a pruritic erythematous skin rash with eczematous lesions, including seborrheic dermatitis, atopic dermatitis, psoriasis, erythematous rosacea, asteatotic eczema, dyshidrotic eczema, dermatitis herpetiformis, lichen simplex, dermatophytosis, scabies, and mycosis fungoides.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–5</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The information obtained can help to guide the choice of diagnostic procedures required, such as patch tests, prick tests, culture, and skin biopsy.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–9</span></a> In conclusion, the aim of this article has been to present the initial clinical evaluation guideline used in our center in the hope that it will help dermatologists in their evaluation of patients with contact eczema. The medical history and dermatologic examination will orient the diagnosis and the search for the etiology, will establish the relevant additional tests, and will facilitate patient education. The German guideline recommends secondary prevention measures in high-risk groups through avoidance of exposure to known irritants and allergens by the use of appropriate skin protection (level B evidence).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Finally, the role of the dermatologist is essential in the identification of high-risk patients and the adoption of appropriate primary and secondary measures of prevention.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "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, Ortiz-de Frutos FJ, Delgado-Márquez AM, Vanaclocha-Sebastián F. Valoración inicial del paciente con eczema de contacto. Actas Dermosifiliogr. 2016;107:791–793.</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:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Adapted from Cohen DE and Jacob SE,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Cohen DE and de Souza A,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Wilkinson SM and Beck MH,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and Beck MH and Wilkinson SM.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hairdressing \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">Bakery \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">Meat processing \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">Fishing \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">Health professionals (physicians, dentists, nurses, auxiliaries) \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">Veterinary surgeons \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">Cleaning \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">Florists \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">Metallurgical industry \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">Agriculture \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">Food processing and catering \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">Printing and painting \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">Mechanical engineering \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">Construction \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1242641.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Occupations Most Commonly Associated With Contact Eczema.</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:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Adapted from Cohen DE and de Souza A<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and Wilkinson SM and Beck MH.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Most common irritants:</span> \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>Soaps \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>Detergents \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>Cleaning products \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>Water \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>Organic solvents \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>Oxidizing and reducing agents \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>Cutting oils \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>Acid and alkaline substances \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>Plants \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>Pesticides \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="elsevierStyleVsp" style="height:0.5px"></span> \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="elsevierStyleItalic">Physical and chemical characteristics:</span> \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>Molecule size \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>Ionization \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>Polarity \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>Solubility \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>Volatility \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>Potential \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>pH \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="elsevierStyleVsp" style="height:0.5px"></span> \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="elsevierStyleItalic">Conditions of exposure:</span> \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>Concentration \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>Volume \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>Duration of contact \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>Repetition \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="elsevierStyleVsp" style="height:0.5px"></span> \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="elsevierStyleItalic">Environmental factors:</span> \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>Temperature \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>Meteorological conditions \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>Friction \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>Humidity \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>Occlusion \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>Trauma \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1242640.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The Characteristics of Irritant Substances.</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:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Adapted from Cohen DE and Jacob SE,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Cohen DE and de Souza A,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Wilkinson SM and Beck MH,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Beck MH and Wilkinson SM,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and Bieber T and Bussmann C.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Xerosis \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">Ichthyosis vulgaris \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">Keratosis pilaris \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">Follicular prominence \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">Hyperlinearity of the palms and soles \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">Double palpebral fold \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">Palpebral hyperpigmentation associated with edema and lichenification \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">Horizontal folds in the central region of the anterior neck \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">Thinning or absence of the lateral portion of the eyebrows \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">White dermographism \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">Pityriasis alba \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">Lichenification on the dorsum of the hands and fingers and of the anatomical snuffbox \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">Areolar eczema \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">Digital pulpitis \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">Juvenile plantar dermatitis \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">Atopic cheilitis \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">Prurigo simplex \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1242639.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Signs of Atopy.</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:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Allergic Contact Dermatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.E. Cohen" 1 => "S.E. Jacob" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Fitzpatrick's Dermatology in General Medicine" "paginaInicial" => "135" "paginaFinal" => "145" "serieFecha" => "2008" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Weedon's Skin Pathology Essentials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.B. Johnston" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "3rd ed." "fecha" => "2012" "editorial" => "Elsevier Limited" "editorialLocalizacion" => "Edinburgh" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Irritant Contact Dermatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.E. Cohen" 1 => "A. de Souza" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Dermatology" "paginaInicial" => "249" "paginaFinal" => "259" "serieFecha" => "2012" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Contact Dermatitis: Irritant" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.M. Wilkinson" 1 => "M.H. Beck" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Rook's Textbook of Dermatology" "paginaInicial" => "1071" "paginaFinal" => "1096" "serieFecha" => "2010" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Contact Dermatitis: Allergic" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.H. Beck" 1 => "S.M. Wilkinson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Rook's Textbook of Dermatology" "paginaInicial" => "1097" "paginaFinal" => "1202" "serieFecha" => "2010" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for diagnosis, prevention and treatment of hand eczema" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.L. Diepgen" 1 => "K.E. Andersen" 2 => "O. Chosidow" 3 => "P.J. Coenraads" 4 => "P. Elsner" 5 => "J. English" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ddg.12783" "Revista" => array:6 [ "tituloSerie" => "J Dtsch Dermatol Ges" "fecha" => "2015" "volumen" => "13" "paginaInicial" => "1" "paginaFinal" => "22" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26289031" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genetics and Individual Predispositions in Contact Dermatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Schnuch" 1 => "B.C. Carlsen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Contact Dermatitis" "paginaInicial" => "13" "paginaFinal" => "42" "serieFecha" => "2011" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Validity of self-reported nickel allergy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Josefson" 1 => "G. Färm" 2 => "B. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 12 | 9 | 21 |
| 2024 Octubre | 82 | 44 | 126 |
| 2024 Septiembre | 112 | 22 | 134 |
| 2024 Agosto | 127 | 81 | 208 |
| 2024 Julio | 98 | 36 | 134 |
| 2024 Junio | 77 | 32 | 109 |
| 2024 Mayo | 65 | 35 | 100 |
| 2024 Abril | 63 | 20 | 83 |
| 2024 Marzo | 82 | 35 | 117 |
| 2024 Febrero | 74 | 35 | 109 |
| 2024 Enero | 52 | 33 | 85 |
| 2023 Diciembre | 82 | 36 | 118 |
| 2023 Noviembre | 73 | 30 | 103 |
| 2023 Octubre | 69 | 20 | 89 |
| 2023 Septiembre | 75 | 29 | 104 |
| 2023 Agosto | 47 | 17 | 64 |
| 2023 Julio | 49 | 24 | 73 |
| 2023 Junio | 49 | 20 | 69 |
| 2023 Mayo | 55 | 26 | 81 |
| 2023 Abril | 39 | 18 | 57 |
| 2023 Marzo | 56 | 21 | 77 |
| 2023 Febrero | 40 | 22 | 62 |
| 2023 Enero | 41 | 33 | 74 |
| 2022 Diciembre | 47 | 47 | 94 |
| 2022 Noviembre | 33 | 18 | 51 |
| 2022 Octubre | 25 | 25 | 50 |
| 2022 Septiembre | 32 | 31 | 63 |
| 2022 Agosto | 23 | 30 | 53 |
| 2022 Julio | 22 | 27 | 49 |
| 2022 Junio | 25 | 15 | 40 |
| 2022 Mayo | 45 | 32 | 77 |
| 2022 Abril | 48 | 31 | 79 |
| 2022 Marzo | 53 | 39 | 92 |
| 2022 Febrero | 55 | 20 | 75 |
| 2022 Enero | 50 | 33 | 83 |
| 2021 Diciembre | 40 | 23 | 63 |
| 2021 Noviembre | 60 | 38 | 98 |
| 2021 Octubre | 58 | 44 | 102 |
| 2021 Septiembre | 58 | 46 | 104 |
| 2021 Agosto | 47 | 25 | 72 |
| 2021 Julio | 33 | 26 | 59 |
| 2021 Junio | 41 | 20 | 61 |
| 2021 Mayo | 56 | 38 | 94 |
| 2021 Abril | 100 | 45 | 145 |
| 2021 Marzo | 72 | 22 | 94 |
| 2021 Febrero | 41 | 22 | 63 |
| 2021 Enero | 22 | 7 | 29 |
| 2020 Diciembre | 26 | 13 | 39 |
| 2020 Noviembre | 28 | 22 | 50 |
| 2020 Octubre | 27 | 7 | 34 |
| 2020 Septiembre | 37 | 14 | 51 |
| 2020 Agosto | 23 | 16 | 39 |
| 2020 Julio | 27 | 13 | 40 |
| 2020 Junio | 42 | 31 | 73 |
| 2020 Mayo | 39 | 9 | 48 |
| 2020 Abril | 22 | 11 | 33 |
| 2020 Marzo | 30 | 10 | 40 |
| 2020 Febrero | 3 | 1 | 4 |
| 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 | 4 | 0 | 4 |
| 2019 Abril | 2 | 5 | 7 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 2 | 0 | 2 |
| 2019 Enero | 4 | 0 | 4 |
| 2018 Diciembre | 3 | 0 | 3 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 4 | 2 | 6 |
| 2018 Febrero | 34 | 2 | 36 |
| 2018 Enero | 28 | 5 | 33 |
| 2017 Diciembre | 76 | 8 | 84 |
| 2017 Noviembre | 22 | 3 | 25 |
| 2017 Octubre | 31 | 6 | 37 |
| 2017 Septiembre | 19 | 1 | 20 |
| 2017 Agosto | 32 | 7 | 39 |
| 2017 Julio | 52 | 14 | 66 |
| 2017 Junio | 35 | 7 | 42 |
| 2017 Mayo | 31 | 5 | 36 |
| 2017 Abril | 25 | 5 | 30 |
| 2017 Marzo | 17 | 13 | 30 |
| 2017 Febrero | 18 | 5 | 23 |
| 2017 Enero | 10 | 6 | 16 |
| 2016 Diciembre | 34 | 26 | 60 |
| 2016 Noviembre | 48 | 44 | 92 |
| 2016 Octubre | 6 | 4 | 10 |
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