Case and Research Letters
Lupus Erythematosus Affecting the Genitalia: An Unusual Site
Lupus eritematoso con afectación genital: una localización inusual
E. del Alcázar-Viladomiu
, A. López-Pestaña, A. Tuneu-Valls
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Servicio de Dermatología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
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López-Pestaña, A. Tuneu-Valls" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "del Alcázar-Viladomiu" "email" => array:1 [ 0 => "elenadelalcazarviladomiu@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "López-Pestaña" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Tuneu-Valls" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lupus eritematoso con afectación genital: una localización inusual" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1014 "Ancho" => 1800 "Tamanyo" => 466818 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Bilateral ulcers at the introitus and on the labia minora. B, Epidermis with focal ulceration, foci of parakeratosis, and marked vacuolar degeneration of the basal layer, with necrotic keratinocytes and a chronic inflammatory infiltrate in the superficial dermis. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×200.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Lupus erythematosus (LE) rarely affects the genitalia, and few cases have been reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–6</span></a> In all types of LE, the skin lesions typically appear in sun-exposed areas. However, involvement of nonexposed areas, such as the scalp, the oral mucosa, or the palms and soles, is common and has been extensively described.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Genital involvement, on the other hand, is rare and reports in the literature are sparse, for which reason we consider it interesting to report the different genital manifestations observed in 2 patients with LE.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 65-year-old woman with a past history of depressive syndrome on treatment with venlafaxine, alprazolam, and lorazepam, was referred from gynecology for asymptomatic skin lesions that had arisen a year earlier on her external genitalia. Whitish, atrophic, alopecic plaques with hyperpigmented borders were observed on the labia majora (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). In addition, examination revealed erythematous edematous plaques on her arms and scarring alopecic on her scalp. A biopsy taken from the genital region showed hyperkeratosis, a lichenoid infiltrate, vacuolar degeneration of the basal layer, and mucin deposits (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). In the blood tests, the antinuclear antibody titer was 1:160, and antiribonucleoprotein antibodies were positive. With a diagnosis of discoid LE (DLE), treatment was started with topical clobetasol for 2 months plus hydroxychloroquine, 400<span class="elsevierStyleHsp" style=""></span>mg/d, for 5 months, leading to an improvement in the edematous plaques on the arms and in the erythema of the alopecia on the scalp, while the genital lesions remained stable. At the time of writing, the patient was taking hydroxychloroquine, 200<span class="elsevierStyleHsp" style=""></span>mg/d, and had no active DLE lesions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A woman aged 35 years, diagnosed with systemic LE (SLE) 10 years earlier, had presented numerous distinct cutaneous manifestations of SLE and DLE, for which she had received treatment with chloroquine, hydroxychloroquine, methotrexate, thalidomide, and immunoglobulins. She was seen for a 3-month history of painful genital ulcers that appeared to be related to menstruation and lasted for about 10 days. Examination revealed bilateral erosions at the introitus (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A), labia minora, and perianal region. Herpesvirus culture was negative and biopsy showed parakeratosis, focal ulceration, and vacuolar degeneration of the basal layer, with apoptotic keratinocytes in the epidermis and a chronic inflammatory infiltrate in the superficial dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B), consistent with<span class="elsevierStyleHsp" style=""></span>LE. Topical clobetasol was prescribed for the outbreaks of genital lesions, leading to an improvement in the pain and duration of the ulcers, though they continued to appear intermittently.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The genital manifestations of LE have been described on few occasions in the literature. In 1989, Burge et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> estimated a prevalence of 5% in patients with chronic DLE, whereas Fresko et al.,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> in 1993, found no genital lesions in a series of 48 women with SLE.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We have found only 8 published cases (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>),<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–6</span></a> of which 7 were women. Five of those patients had DLE and 3 SLE. Clinically the lesions include ulcers and erosions,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–4</span></a> as well as erythematous atrophic plaques with scarring alopecia characteristic of DLE.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2,5,6</span></a> Both the ulcers and the plaques typical of DLE can appear in patients with SLE or DLE. Although they are usually asymptomatic, 2 women reported dyspareunia<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,5</span></a> and one described pruritus and discomfort on passing urine or defecating.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The histology is typical of LE, with hyperkeratosis, a perivascular and periadnexal inflammatory infiltrate, vacuolar degeneration of the basal layer, apoptotic keratinocytes, and mucin deposits, although not all findings are always present.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–6</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A recent publication from 2015 described a series of 22 patients with bullous LE, in which 2 of the patients presented genital lesions. However, the morphology, site, duration, and time since onset of the genital manifestations were not reported.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> We have found no cases of subacute LE affecting the genitalia.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our 2 patients illustrate the 2 identified profiles of genital manifestations in LE: one of them had the typical plaques of DLE, which enabled us to make the diagnosis, while the other patient presented ulcers, leading to a broader differential diagnosis, mainly including sexually transmitted infections such as herpes simplex and syphilis, and aphthous disorders, including Behçet disease, fixed pigmented erythema, and erosive lichen planus.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogenic mechanisms responsible for the skin lesions of LE are not fully understood. In one study, no differences were found in cytokine expression between the lips (sun-exposed area) and the oral mucosa (sun-protected area). This would suggest that although UV light may be the most relevant environmental factor in the induction of skin lesions, there could be other intrinsic mechanisms that are similar in the 2 areas.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> In addition, other factors, such as the Köebner phenomenon, could be the key to involvement of the genitalia.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Therapy is the same as for other manifestations of lupus erythematosus. The treatments of choice are a high-potency topical corticosteroids plus systemic hydroxychloroquine or chloroquine.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,4,5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We have presented 2 cases of LE affecting the genitalia. One patient with DLE who presented asymptomatic, whitish atrophic plaques, and another with long-standing SLE in which painful erosions developed at the introitus. Genital involvement is rare in LE and is perhaps underdiagnosed. It can present in the 2 clinical forms described. It is important to be aware of these presentations to make a correct diagnosis, and the existence of genital lesions or discomfort should be recorded in the medical history.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of Interest" ] 3 => 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: del Alcázar-Viladomiu E, López-Pestaña A, Tuneu-Valls A. Lupus eritematoso con afectación genital: una localización inusual. Actas Dermosifiliogr. 2018;109:78–80.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 873 "Ancho" => 1800 "Tamanyo" => 467929 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Pubic region and labia majora showing whitish, atrophic plaques with scarring alopecia and hyperpigmented borders. B, Hyperkeratosis, a lichenoid infiltrate in the superficial dermis and perifollicular regions, vacuolar degeneration of the basal layer, and apoptotic keratinocytes. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×100.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1014 "Ancho" => 1800 "Tamanyo" => 466818 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Bilateral ulcers at the introitus and on the labia minora. B, Epidermis with focal ulceration, foci of parakeratosis, and marked vacuolar degeneration of the basal layer, with necrotic keratinocytes and a chronic inflammatory infiltrate in the superficial dermis. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×200.</p>" ] ] 2 => 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="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: DLE, discoid lupus erythematosus; F, female; LE, lupus erythematosus; M, male; NA, not available.</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=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author and 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">Sex \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">Type of LE \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Genital Involvement</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical Presentation \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">Other Areas Affected \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Burge et al., 1989<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Introitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \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">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vulva \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \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">Biasi et al., 1994<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right labium minus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dyspareunia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Butterfly rash \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">Bilenchi et al., 2004<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right labium majus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dyspareunia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Auricle of the ear, nasal fossa \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">Jolly and Patel, 2006<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right labium majus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face, back \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">Darwish, 2008<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Labia minora, anus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain and pruritus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Romiti et al., 2014<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pubis, labia majora \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scalp \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">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulcer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Preputial balanic sulcus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face, ears \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Our cases</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Labia majora \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arms, scalp \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">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Introitus, labia minora, perianal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scalp, face, lips of the mouth, hands, thighs \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1631803.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Our Patients and of Those Described in the Literature.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genital discoid lupus: A rare manifestation of cutaneous lupus erythematosus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. 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| año/Mes | Html | Total | |
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| 2021 Julio | 673 | 48 | 721 |
| 2021 Junio | 634 | 52 | 686 |
| 2021 Mayo | 711 | 71 | 782 |
| 2021 Abril | 1384 | 134 | 1518 |
| 2021 Marzo | 829 | 53 | 882 |
| 2021 Febrero | 676 | 61 | 737 |
| 2021 Enero | 577 | 47 | 624 |
| 2020 Diciembre | 582 | 41 | 623 |
| 2020 Noviembre | 596 | 51 | 647 |
| 2020 Octubre | 405 | 31 | 436 |
| 2020 Septiembre | 485 | 25 | 510 |
| 2020 Agosto | 397 | 38 | 435 |
| 2020 Julio | 313 | 31 | 344 |
| 2020 Junio | 249 | 47 | 296 |
| 2020 Mayo | 146 | 19 | 165 |
| 2020 Abril | 79 | 20 | 99 |
| 2020 Marzo | 44 | 21 | 65 |
| 2020 Febrero | 3 | 0 | 3 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 5 | 0 | 5 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Marzo | 2 | 0 | 2 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Febrero | 96 | 23 | 119 |
| 2018 Enero | 235 | 38 | 273 |
| 2017 Diciembre | 14 | 17 | 31 |
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