Case and Research Letter
Initial Evaluation of the Adult Patient with Condylomata Acuminata
Valoración inicial del paciente adulto con condilomas acuminados
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Imbernón-Moya, J. Ballesteros" "autores" => array:2 [ 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" => "J." "apellidos" => "Ballesteros" "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" => "Centro Sanitario Sandoval, 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 adulto con condilomas acuminados" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Condylomata acuminata (genital warts) is the sexually transmitted infection (STI) that most often prompts patients to seek medical attention.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> In Spain, the annual incidence of genital warts is estimated to be 160.4 new cases per 100 000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Genital warts are mainly diagnosed by visual inspection. In the initial clinical assessment of patients who seek care for genital warts, an exhaustive clinical history should be taken and a complete physical examination should be carried out.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Various international bodies have published standardized guidelines on the management of genital warts.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4–10</span></a> At present, there is no protocol on how to carry out an adequate medical history and physical examination. The following is the routine approach that we follow during a patient's first visit to the STI unit at Centro Sanitario Sandoval in Madrid:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">Demographic data: age, sex.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">Pregnancy and lactation status.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">Employment and social status: previous and current occupation, socioeconomic status, sociocultural level. These data provide information about likelihood of adherence to treatment.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">Toxic habits: Use of tobacco, alcohol, or other drugs in the past 12 months (recorded using the form shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0040" class="elsevierStylePara elsevierViewall">Personal medical history: Drug allergies; known diseases; abortions; previous surgical procedures; regular medical treatment; cellular immunodeficiency (human immunodeficiency virus [HIV] infection, solid organ transplant, hematologic malignancies, chronic renal insufficiency, hemodialysis, treatment with immunosuppressants); and vaccination status for human papillomavirus (HPV) (including genotypes covered), hepatitis B, and hepatitis A.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall">Gynecologic history: This information helps to identify women who have not been properly screened.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">Oncologic history: Personal and/or family history of malignant neoplasms of the cervix, vagina, vulva, penis, rectum, anus, and head and neck (especially oropharynx).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">Dermatologic history: Known skin diseases, cutaneous and mucosal neoplasms, and STIs.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Sexual history: Age at first sexual activity; number of sexual partners per year (<<span class="elsevierStyleHsp" style=""></span>5, 5-10, 10-20, ><span class="elsevierStyleHsp" style=""></span>20); sexual practices (oral, anal, vaginal, other); type of partner (stable, sporadic); frequency of sexual activity (intermittent, sporadic, regular). Barrier contraceptives and type of use: With a stable partner; during sporadic contact; during vaginal, oral, and/or anal penetration; never; occasionally (<<span class="elsevierStyleHsp" style=""></span>50%); usually (><span class="elsevierStyleHsp" style=""></span>50%); always; accidents during use. Use of other types of contraceptives. Women who use hormonal but not barrier contraceptives are more exposed to STIs. The use of barrier contraceptives does not protect against HPV infection but it does reduce the risk.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Detailed history of genital warts<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,10</span></a>: Site; time since onset; extent; areas exposed to sexual contact; signs or symptoms that prompted the patient to seek care (pruritus, pain, stinging sensation, bleeding, erosion, ulceration, suppuration, anxiety); rapid or steady growth; recent appearance of new lesions; changes in the surrounding skin; and previous episodes and treatments.</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">The following is our routine procedure for the full physical examination:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Careful examination of the genital, paragenital, anal, perianal, and oral areas. The examination should be carried out in a room with adequate light of sufficient power and a systematic and specific order of inspection should be followed. In women, genital warts usually appear on the labia majora, the labia minora, the frenulum labiorum pudendi, the vulval vestibule, and the perineum. In men, the lesions tend to appear on the inner or outer aspect of the foreskin, the corona of glans penis, and the frenulum of prepuce. The examination should also include the pubic region, the inner aspect of the thighs, the buttocks, the perioral region, the periocular region, the fingers, and areas around skin folds. Depending on the patient's sexual history, other related anatomic sites are observed. If there are vaginal manifestations, the patient is referred to the gynecology department. If there are anal manifestations, the patient is referred to the general surgery department.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">Description of the genital warts: Number of lesions; volume; size; site; extent; distribution; morphology (flat, excrescent, vegetative, exophytic); color (skin-colored, white, pink, red, brown, grayish); pigmentation (brown, black); texture, palpation; degree of keratosis; vascularization; ulceration; surface (smooth or verrucose, projections); edges (rounded, irregular); and base (flat, sessile, pedunculated). The color provides a clue about the age of the lesions. Recent lesions are pearly white, whereas older lesions are grayish-brown or brownish. A papillomatous surface tends to indicate recent lesions, whereas a flat surface indicates older lesions.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Rule out the presence of clinical findings associated with other STIs, including syphilis, HIV, hepatitis B, hepatitis C, gonorrhea, chlamydia, herpes simplex, and lymphogranuloma venereum.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">The regional lymph nodes are examined if the presence of other STIs, such as genital herpes or lymphogranuloma venereum, is suspected.</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">Skin biopsy is recommended only in certain cases (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). When genital warts are suspected, various diseases must be considered in the differential diagnosis (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">It is essential to reassure the patient and explain that genital warts are benign and, in most cases, self-resolving. It is not necessary to establish prevention strategies beyond vaccination. Smoking is associated with a higher rate of HPV infection and poorer outcomes for associated dysplasias. We consider that all sexually active people are at risk for HPV infection. Population screening is therefore carried out periodically for the prevention of associated neoplasms (of the cervix, anus, and rectum) and the treatment of visible genital warts. If a patient is found to have either condition, his or her partners should seek medical attention. Finally, a good doctor-patient relationship is necessary in order to modify high-risk sexual behaviors and achieve adequate adherence to treatment and follow-up.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0105" 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, Ballesteros J. Valoración inicial del paciente adulto con condilomas acuminados. Actas Dermosifiliogr. 2017;108:273–275.</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=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Times per<br>Week \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Times per<br>Month \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Times per<br>Year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Route of Administration<br>(Smoking, Inhalation, Injection, Oral, Anal, Genital, Other) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Used for Sexual Purposes<br>Never, Sometimes (<<span class="elsevierStyleHsp" style=""></span>50%), Usually (><span class="elsevierStyleHsp" style=""></span>50%), Always \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><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">MDMA (3,4-methylenedioxymethamphetamine)</span><br>Ecstasy, molly, pills \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><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="elsevierStyleItalic">Methamphetamine</span><br>Crystal, speed, meth, ice \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><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="elsevierStyleItalic">GHB (gammahydroxybutrate)</span><br>Liquid ecstasy \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><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="elsevierStyleItalic">Cocaine</span><br>Coca, snow, coke, blow, percy \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><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="elsevierStyleItalic">Ketamine</span><br>Kit kat, special K \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><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="elsevierStyleItalic">Mephedrone</span><br>Meph, meow \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><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="elsevierStyleItalic">Poppers</span> \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><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 => "xTab1378648.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Consumption of Recreational Drugs in the Last 12 Months.</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">Diagnostic uncertainty \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">Lack of improvement or worsening with treatment \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">Multiple or rapid recurrences on completion of treatment \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">Situations of cellular immunodeficiency associated with clinical warning signs \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">Human immunodeficiency virus infection with a CD4 cell count below 200 \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">Atypical lesions: fast-growing, more than 1<span class="elsevierStyleHsp" style=""></span>cm in diameter, ulcerated, bleeding, infiltrated, pigmented \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1378647.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical Situations Warranting Skin Biopsy in Patients with Genital Warts.</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">Hirsuties coronae glandis \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">Vestibular papillomatosis \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">Soft fibromas \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">Seborrheic keratoses \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">Fordyce spots \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">Molluscum contagiosum \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">Angiokeratomas \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">Bowenoid papulosis \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">Buschke-Löwenstein tumor \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">Flat condyloma \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">Hemorrhoidal skin tags \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1378649.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Differential Diagnosis of Lesions Suggestive of Genital Warts.</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" => "Genital human papillomavirus infection: Incidence and risk factors in a cohort of female university students" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.L. 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| año/Mes | Html | Total | |
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| 2022 Junio | 31 | 29 | 60 |
| 2022 Mayo | 65 | 83 | 148 |
| 2022 Abril | 107 | 42 | 149 |
| 2022 Marzo | 119 | 48 | 167 |
| 2022 Febrero | 89 | 36 | 125 |
| 2022 Enero | 70 | 53 | 123 |
| 2021 Diciembre | 54 | 45 | 99 |
| 2021 Noviembre | 81 | 51 | 132 |
| 2021 Octubre | 76 | 68 | 144 |
| 2021 Septiembre | 48 | 47 | 95 |
| 2021 Agosto | 49 | 40 | 89 |
| 2021 Julio | 54 | 45 | 99 |
| 2021 Junio | 36 | 35 | 71 |
| 2021 Mayo | 82 | 45 | 127 |
| 2021 Abril | 107 | 81 | 188 |
| 2021 Marzo | 90 | 42 | 132 |
| 2021 Febrero | 80 | 41 | 121 |
| 2021 Enero | 45 | 27 | 72 |
| 2020 Diciembre | 37 | 21 | 58 |
| 2020 Noviembre | 34 | 23 | 57 |
| 2020 Octubre | 30 | 16 | 46 |
| 2020 Septiembre | 40 | 19 | 59 |
| 2020 Agosto | 35 | 31 | 66 |
| 2020 Julio | 29 | 20 | 49 |
| 2020 Junio | 31 | 32 | 63 |
| 2020 Mayo | 21 | 11 | 32 |
| 2020 Abril | 23 | 10 | 33 |
| 2020 Marzo | 32 | 14 | 46 |
| 2020 Febrero | 3 | 0 | 3 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 6 | 0 | 6 |
| 2019 Septiembre | 6 | 0 | 6 |
| 2019 Agosto | 5 | 0 | 5 |
| 2019 Julio | 6 | 0 | 6 |
| 2019 Junio | 13 | 0 | 13 |
| 2019 Mayo | 9 | 0 | 9 |
| 2019 Abril | 13 | 3 | 16 |
| 2019 Marzo | 3 | 0 | 3 |
| 2019 Febrero | 3 | 0 | 3 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 9 | 0 | 9 |
| 2018 Noviembre | 4 | 0 | 4 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 6 | 0 | 6 |
| 2018 Febrero | 20 | 5 | 25 |
| 2018 Enero | 30 | 7 | 37 |
| 2017 Diciembre | 23 | 5 | 28 |
| 2017 Noviembre | 26 | 3 | 29 |
| 2017 Octubre | 27 | 5 | 32 |
| 2017 Septiembre | 25 | 39 | 64 |
| 2017 Agosto | 28 | 38 | 66 |
| 2017 Julio | 21 | 14 | 35 |
| 2017 Junio | 41 | 8 | 49 |
| 2017 Mayo | 50 | 11 | 61 |
| 2017 Abril | 173 | 50 | 223 |
| 2017 Marzo | 23 | 25 | 48 |
| 2017 Febrero | 0 | 3 | 3 |
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