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which had appeared on his left leg 3 years earlier&#46; These changes began with a halo and subsequent disappearance of pigment on the surface and of the hair covering the lesion&#46; At the same time&#44; the patient developed distant achromic lesions &#40;in the region of the right iliac fossa and in the occipital region of the scalp&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A-<span class="elsevierStyleSmallCaps">C</span>&#41;&#46; Topical treatment was instated with mometasone furoate for 3 weeks&#44; followed by tacrolimus 0&#46;1&#37; ointment&#44; and repigmentation was achieved by sectors of both the nevus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41; and the distant achromic lesions&#44; though without changes to the poliosis&#46;</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 5-year-old girl was examined due to changes in CMN lesions&#44; which had appeared a month earlier&#46; Physical examination revealed a brown lesion measuring 9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm&#59; the lesion was brown with a whitish central area&#44; a corrugated surface&#44; and a fibrous appearance&#44; and had white hairs on the surface &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; At the same time&#44; an achromic macule appeared on the upper left eyelid&#46; Treatment was instated with tacrolimus 0&#46;03&#37; ointment for both lesions&#46; The patient did not return&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case 3</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 5-year-old girl was examined due to progressive depigmentation of her CMN lesions&#59; this process had begun with a halo and gradual reduction of the pigment on the surface of the halo&#46; At the same time&#44; the patient developed achromic lesions on the upper eyelids&#46; In the following years&#44; she developed areas of fibrosis and follicular atrophy inside the CMN lesions&#46; Treatment with pimecrolimus 1&#37; was instated for the distant achromic lesions and no repigmentation was observed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A-C&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In all of the patients&#44; histology revealed nevus cells and a predominantly lymphocytic inflammatory infiltrate in the deep dermis&#46; Replacement of the nevus cells with fibrous tissue was observed in Cases 2 and 3 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In all 3 cases&#44; dermatoscopy revealed perifollicular hyperpigmentation&#44; a blue-gray pigment associated with the deep component&#44; globules&#44; and pink areas without structures&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">CMN are classified by size into small &#40;less than 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; medium &#40;1&#46;5 to 10<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; large &#40;10 to 20<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and giant &#40;greater than 20<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46; They may be located on any part of the skin surface and may appear in isolation or as part of more complex syndromes&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Torrelo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> suggest that nevi reflect mosaicisms and show that they follow certain skin patterns and phenotypic characteristics&#46; Postzygotic mutations of the H-Ras gene have also been shown in these nevi&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;6&#44;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The course of CMN is variable and they may remain stable throughout life&#44; increase in size&#44; change color and thickness&#44; become more hairy&#44; become malignant&#44; and even regress&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> To date&#44; multiple forms have been reported in which these nevi show signs of regression&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5</span></a> The most frequent form starts with a halo phenomenon that spontaneously regresses from the periphery to the center&#46; Another more frequent form lacks this halo phenomenon&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In exceptional cases&#44; regression occurs by means fibrosis of the lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The halo phenomenon is an area of depigmentation that may occur around CMN and other entities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> It affects 1&#37; of the general population and incidence is higher in patients with pediatric vitiligo&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;8</span></a> There are many theories regarding its pathophysiology&#44; including cellular and&#47;or humoral immune responses to nevus cells or melanocytic nevi&#44; which may present associated antigens or nonspecific abnormalities&#44; even leading to cross-reactivity with distant melanocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The latter would explain the appearance of distant achromic lesions&#46; Drakensj&#246; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> believed that nevus cells remained in the dermis despite the regression&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Both vitiligo and the halo phenomenon share immunologic mechanisms and it has been shown that&#44; when both are present&#44; they are associated with some subtypes of the human leukocyte antigen HLA complex&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Regression of CMN without the halo phenomenon is very rare and alternative regression mechanisms have been proposed&#44; such as reduced melanin synthesis and&#47;or nevus cell apoptosis&#46; In Case 2&#44; the CMN regressed without a prior halo phenomenon but with distant achromic lesions&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Regression by means of fibrosis has been reported very rarely and the underlying mechanism is unknown&#46; One variant of this form of regression by fibrosis&#44; described by Ruiz-Maldonado et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> is desmoplastic nevus&#46; In that case&#44; the authors proposed the immune system as a trigger&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> Histology shows replacement of nevus cells with connective tissue&#44; and the most salient clinical finding is induration of the lesion&#46; The principal differential diagnosis is malignant transformation and clinical and histologic follow-up is therefore essential&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The immune response to neoplastic cells would act concomitantly against the melanocytic nevus cells&#46; Although an association has been described between the halo phenomenon and melanoma&#44; it is rarely associated with CMN&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">We believe that these clinical cases are of interest as they provide examples of the different forms of regression&#46; Knowledge of this process will make it possible to anticipate the potential development of vitiligo and follow-up with therefore allow for dearly diagnosis and treatment&#46; Case 2 is notable&#44; as regression occurred without a prior halo phenomenon&#44; despite the appearance of distant achromic lesions&#44; suggesting that the immune system played an important role in the process&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alperovich R&#44; Fiandrino MJ&#44; Asial R&#44; Boente MC&#46; Spontaneous Regression of Medium-Sized Congenital Melanocytic Nevi&#58; Report of 3 New Cases&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;414&#8211;416&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; CMN showing loss of pigment and persistence of pigment in the central area&#46; B&#44; Achromic macule in the right iliac fossa&#46; C&#44; Occipital poliosis&#46; D&#44; Areas of repigmentation of the CMN 4 months after treatment&#46; gr1&#46;</p>"
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Case and Research Letters
Spontaneous Regression of Medium-Sized Congenital Melanocytic Nevi: Report of 3 New Cases
Regresión espontánea de tres nevus melanocíticos congénitos medianos
R. Alperovicha,
Autor para correspondencia
ruthalperovich@hotmail.com

Corresponding author.
, M.J. Fiandrinoa, R. Asialb, M.C. Boenteb
a Dermatología, Hospital del Niño Jesús, Tucumán, Argentina
b Centro Integral de Dermatología, Tucumán, Argentina
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which had appeared on his left leg 3 years earlier&#46; These changes began with a halo and subsequent disappearance of pigment on the surface and of the hair covering the lesion&#46; At the same time&#44; the patient developed distant achromic lesions &#40;in the region of the right iliac fossa and in the occipital region of the scalp&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A-<span class="elsevierStyleSmallCaps">C</span>&#41;&#46; Topical treatment was instated with mometasone furoate for 3 weeks&#44; followed by tacrolimus 0&#46;1&#37; ointment&#44; and repigmentation was achieved by sectors of both the nevus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41; and the distant achromic lesions&#44; though without changes to the poliosis&#46;</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 5-year-old girl was examined due to changes in CMN lesions&#44; which had appeared a month earlier&#46; Physical examination revealed a brown lesion measuring 9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm&#59; the lesion was brown with a whitish central area&#44; a corrugated surface&#44; and a fibrous appearance&#44; and had white hairs on the surface &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; At the same time&#44; an achromic macule appeared on the upper left eyelid&#46; Treatment was instated with tacrolimus 0&#46;03&#37; ointment for both lesions&#46; The patient did not return&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case 3</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 5-year-old girl was examined due to progressive depigmentation of her CMN lesions&#59; this process had begun with a halo and gradual reduction of the pigment on the surface of the halo&#46; At the same time&#44; the patient developed achromic lesions on the upper eyelids&#46; In the following years&#44; she developed areas of fibrosis and follicular atrophy inside the CMN lesions&#46; Treatment with pimecrolimus 1&#37; was instated for the distant achromic lesions and no repigmentation was observed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A-C&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In all of the patients&#44; histology revealed nevus cells and a predominantly lymphocytic inflammatory infiltrate in the deep dermis&#46; Replacement of the nevus cells with fibrous tissue was observed in Cases 2 and 3 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In all 3 cases&#44; dermatoscopy revealed perifollicular hyperpigmentation&#44; a blue-gray pigment associated with the deep component&#44; globules&#44; and pink areas without structures&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">CMN are classified by size into small &#40;less than 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; medium &#40;1&#46;5 to 10<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; large &#40;10 to 20<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and giant &#40;greater than 20<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46; They may be located on any part of the skin surface and may appear in isolation or as part of more complex syndromes&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Torrelo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> suggest that nevi reflect mosaicisms and show that they follow certain skin patterns and phenotypic characteristics&#46; Postzygotic mutations of the H-Ras gene have also been shown in these nevi&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;6&#44;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The course of CMN is variable and they may remain stable throughout life&#44; increase in size&#44; change color and thickness&#44; become more hairy&#44; become malignant&#44; and even regress&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> To date&#44; multiple forms have been reported in which these nevi show signs of regression&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5</span></a> The most frequent form starts with a halo phenomenon that spontaneously regresses from the periphery to the center&#46; Another more frequent form lacks this halo phenomenon&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In exceptional cases&#44; regression occurs by means fibrosis of the lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The halo phenomenon is an area of depigmentation that may occur around CMN and other entities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> It affects 1&#37; of the general population and incidence is higher in patients with pediatric vitiligo&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;8</span></a> There are many theories regarding its pathophysiology&#44; including cellular and&#47;or humoral immune responses to nevus cells or melanocytic nevi&#44; which may present associated antigens or nonspecific abnormalities&#44; even leading to cross-reactivity with distant melanocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The latter would explain the appearance of distant achromic lesions&#46; Drakensj&#246; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> believed that nevus cells remained in the dermis despite the regression&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Both vitiligo and the halo phenomenon share immunologic mechanisms and it has been shown that&#44; when both are present&#44; they are associated with some subtypes of the human leukocyte antigen HLA complex&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Regression of CMN without the halo phenomenon is very rare and alternative regression mechanisms have been proposed&#44; such as reduced melanin synthesis and&#47;or nevus cell apoptosis&#46; In Case 2&#44; the CMN regressed without a prior halo phenomenon but with distant achromic lesions&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Regression by means of fibrosis has been reported very rarely and the underlying mechanism is unknown&#46; One variant of this form of regression by fibrosis&#44; described by Ruiz-Maldonado et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> is desmoplastic nevus&#46; In that case&#44; the authors proposed the immune system as a trigger&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> Histology shows replacement of nevus cells with connective tissue&#44; and the most salient clinical finding is induration of the lesion&#46; The principal differential diagnosis is malignant transformation and clinical and histologic follow-up is therefore essential&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The immune response to neoplastic cells would act concomitantly against the melanocytic nevus cells&#46; Although an association has been described between the halo phenomenon and melanoma&#44; it is rarely associated with CMN&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">We believe that these clinical cases are of interest as they provide examples of the different forms of regression&#46; Knowledge of this process will make it possible to anticipate the potential development of vitiligo and follow-up with therefore allow for dearly diagnosis and treatment&#46; Case 2 is notable&#44; as regression occurred without a prior halo phenomenon&#44; despite the appearance of distant achromic lesions&#44; suggesting that the immune system played an important role in the process&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alperovich R&#44; Fiandrino MJ&#44; Asial R&#44; Boente MC&#46; Spontaneous Regression of Medium-Sized Congenital Melanocytic Nevi&#58; Report of 3 New Cases&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;414&#8211;416&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; CMN showing loss of pigment and persistence of pigment in the central area&#46; B&#44; Achromic macule in the right iliac fossa&#46; C&#44; Occipital poliosis&#46; D&#44; Areas of repigmentation of the CMN 4 months after treatment&#46; gr1&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; CMN with blackish-brown coloring and a whitish central area with a fibrotic appearance&#46; Note the white hairs in this area&#46; B&#44; Histology&#58; areas of collagen homogeneization &#40;<span class="elsevierStyleBold">&#62;</span>&#41; in the deep dermis&#44; involving adnexa&#44; surrounded by nevus cells and an inflammatory infiltrate &#40;&#42;&#41;&#46; gr2&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Medium CMN with small areas of regression&#46; B&#44; Follow-Up&#58; note the progressive loss of pigmentation to follicular predominance&#46; C&#46; Detail of follicular atrophy&#46; Note the unpigmented hairs&#46; gr3&#46;</p>"
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2021 Enero 32 18 50
2020 Diciembre 29 8 37
2020 Noviembre 15 15 30
2020 Octubre 18 14 32
2020 Septiembre 41 6 47
2020 Agosto 24 10 34
2020 Julio 24 13 37
2020 Junio 41 20 61
2020 Mayo 29 10 39
2020 Abril 11 10 21
2020 Marzo 14 4 18
2020 Febrero 2 0 2
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?