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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Necrobiosis lipoidica &#40;NL&#41; is a rare&#44; chronic&#44; granulomatous disease that typically affects young women and is frequently associated with diabetes mellitus &#40;DM&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinically&#44; the disease is characterized by the progressive appearance of plaques with a raised red-violaceous border and an atrophic yellow-brown center&#46; The plaques are usually located bilaterally on the anterior surface of the lower extremities&#46; Other less common locations include the upper extremities&#44; face&#44; and scalp&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Although they are typically asymptomatic&#44; some patients may experience pruritus&#44; dysesthesia&#44; or pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Histologically&#44; they are characterized by degeneration of collagen&#44; formation of granulomas in palisade and thickening of the vascular walls&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">NL has historically been a difficult disease to treat&#46; Several therapeutic options are available&#44; although most of them provide minimal and inconsistent results&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Some publications describe the use of photodynamic therapy &#40;PDT&#41; as second-line treatment in refractory cases&#44; with variable results&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe our experience in the treatment with PDT of 4 patients with NL&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><p id="par0020" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the clinical characteristics of the 4 patients treated in our department using PDT&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The 4 patients were women&#44; aged 21&#44; 22&#44; 31&#44; and 61 years&#46; All had DM&#59; the first 3 had type-1 DM and the last had type-2 DM&#46; All had received at least 2 prior treatments&#44; with minimal or no response&#46; These treatments included topical corticosteroids&#44; topical calcineurin inhibitors&#44; topical calcitriol&#44; pentoxifylline&#44; acetylsalicylic acid&#44; pulsed dye laser&#44; and cryotherapy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The time from diagnosis to start of PDT was 2&#44; 8&#44; 72&#44; and 120 months&#44; respectively&#46; The first 2 cases were treated with methyl aminolevulinate &#40;MAL&#59; Metvix&#174;&#44; Galderma&#44; Lausanne&#44; Switzerland&#41;&#46; Cases 3 and 4 combined MAL and 5-aminolevulinic acid &#40;BF-200 ALA&#59; Ameluz&#174;&#44; Biofrontera&#44; Leverkusen&#44; Germany&#41;&#46; The photosensitizing agent was incubated for 3 hours in the case of MAL&#44; and 2&#8239;hours and 30&#8239;minutes in the case of BF-200 ALA&#44; in accordance with the protocol that we follow in our hospital&#46; The illumination used was red visible light &#40;Aktilite&#174; CL128&#44; Galderma&#44; Lausanne&#44; Switzerland&#41;&#44; with a peak wavelength of 630&#8239;nm and total energy of 37&#8239;J&#47;cm<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; for a period of 9&#8239;minutes 50&#8239;seconds&#46; Anesthesia was not needed in any of the cases owing to the good tolerance of the technique&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Two sessions with an interval of 2 weeks between sessions were initially indicated&#46; The lesions were then re-evaluated&#44; and a new cycle of treatment was indicated if the effect obtained was insufficient&#46; The mean total number of sessions per patients was 11&#46;3 &#40;interval&#44; 6&#8211;18&#41;&#46; Each of the lesions received an average of 3&#46;2 sessions &#40;interval&#44; 1&#8211;5&#41;&#46; The fluorescence observed with the Wood light was low intensity&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a> show the appearance of the lesions at the start and after treatment&#46; The plaques&#44; with raised violaceous edges&#44; resolved completely&#59; only residual atrophic skin persisted&#46; No signs of active disease were therefore visible after completion of the treatment&#46; Also noteworthy is the rapid improvement of the symptoms after starting treatment&#46; Specifically&#44; the patient in case 1 suffered intense dysesthesia&#44; for which she had been studied in a neurophysiology department&#46; After start of treatment and from the first sessions&#44; the patient presented a considerable improvement in symptoms and became completely asymptomatic&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Subsequently&#44; during follow-up&#44; cases 1&#44; 2&#44; and 3 presented new NL plaques&#44; some of which were distant from the original plaques&#46; Due to the chronic course of the disease&#44; it is difficult to distinguish whether this is persistence or the appearance of new lesions&#46; Nevertheless&#44; the new lesions continue to respond well to treatment with PDT&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Photodynamic therapy is a technique approved for the treatment of actinic keratosis&#44; superficial basal cell carcinoma&#44; and Bowen disease&#46; Its use is increasingly frequent off data sheet in infectious and inflammatory diseases&#46; One of these new indications may be treatment of NL&#46; Its immune-modulating effect&#44; the product of modified cytokine expression &#40;IL1-&#946;&#44; IL-2&#44; and TNF-&#945;&#41; and immune specific response induction&#44; may explain the response of the NL lesions to PDT<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In this regard&#44; several articles have been published on single cases satisfactorily treated with conventional PDT&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> Nevertheless&#44; the first publications of case series treated with PDT showed more discreet results&#44; such as the study by Berking et al&#46;&#44; in which they retrospectively analyzed 18 cases of patients with NL treated with PDT with MAL&#44; and in which they obtained an overall response rate of 39&#37;&#44; with a single case of complete response and more than 60&#37; of nonresponding patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">More recently&#44; the Kaae group published a series of 65 patients with NL treated with conventional PDT and natural daylight PDT with MAL&#46; In their article&#44; those authors place particular emphasis on the need to perform prior superficial curettage of the lesions&#44; as this would increase levels of protoporphyrin IX and&#44; thus&#44; increase the efficacy of the PDT&#46; The percentage of complete responses obtained was 66&#37;&#44; with 90&#37; partial responses and with no statistically significant differences between conventional PDT and natural daylight PDT&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Our results are closer to those of this second study&#46; Nevertheless&#44; we have no experience in prior curettage of the lesions or in the use of natural daylight in the treatment of NL&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">With regard to predictive factors of response to PDT in NL&#44; those authors found no statistically significant differences between response and age&#44; sex&#44; duration&#44; and number of lesions&#46; DM was not a predictive factor&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Due to the chronic course of the disease&#44; the appearance of new lesions during follow-up is frequent&#46; In these cases&#44; new treatment cycles may be indicated&#46; Our impression is that the patients who respond well initially continue to do so with the new sessions&#46; We have not considered maintenance treatment in any of the cases&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report 4 patients with NL&#44; treated with conventional PDT with a complete response&#46; The latest publications situate PDT as one of the most effective treatments&#44; with response rates of between 39&#37; and 90&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8</span></a> Long periods of treatment are frequently required to obtain definitive results&#46; Because pain may be a limiting factor&#44; some publications support the use of natural daylight PDT with similar results to those of conventional PDT&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Due to the low levels of evidence of existing published studies&#44; prospective randomized&#44; controlled prospective studies are required to try to define the real potential of this technique&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:9 [
        0 => array:3 [
          "identificador" => "xres1388103"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1273667"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1388102"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1273666"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case Descriptions"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conflicts of Interest"
        ]
        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-11-02"
    "fechaAceptado" => "2019-01-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1273667"
          "palabras" => array:7 [
            0 => "Necrobiosis lipoidica"
            1 => "Diabetes"
            2 => "Photodynamic therapy"
            3 => "Treatment"
            4 => "Methyl aminolevulinate &#40;MAL&#41;"
            5 => "5-aminolevulinic acid &#40;ALA&#41;"
            6 => "BF-200 ALA"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1273666"
          "palabras" => array:8 [
            0 => "Necrobiosis lipo&#237;dica"
            1 => "Diabetes"
            2 => "Terapia fotodin&#225;mica"
            3 => "Tratamiento"
            4 => "Metil aminolevulinato"
            5 => "MAL"
            6 => "&#225;cido 5 aminolevul&#237;nico"
            7 => "BF-200 ALA"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Necrobiosis lipoidica is a rare chronic granulomatous disease&#46; Multiple treatment approaches are available&#44; but results are generally minimal and inconsistent&#46; Some publications report variable results with photodynamic therapy &#40;PDT&#41; as a second line of treatment for refractory cases&#46; We report 4 cases of necrobiosis lipoidica treated satisfactorily with conventional PDT using methyl aminolevulinate or 5-aminolevulinic acid BF-200 as the photosensitizing agent&#46; All 4 patients were women with diabetes mellitus who had undergone treatment at least twice in the past&#44; with little improvement&#46; The lesions resolved completely with PDT&#44; leaving only residual atrophy after a mean of 3&#46;2 sessions per lesion&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La necrobiosis lipoidica &#40;NL&#41; es una enfermedad granulomatosa cr&#243;nica poco frecuente para la que existen multitud de tratamientos disponibles&#46; No obstante&#44; estos ofrecen habitualmente m&#237;nimos e inconsistentes resultados&#46; En algunas publicaciones se describe el tratamiento con terapia fotodin&#225;mica &#40;TFD&#41; como tratamiento de segunda l&#237;nea en casos refractarios&#44; con resultados variables&#46; Comunicamos cuatro casos de NL tratados satisfactoriamente con TFD convencional con MAL y BF-200 ALA&#46; Las cuatro pacientes eran mujeres afectas de diabetes mellitus y todas hab&#237;an recibido al menos 2 tratamientos previos con escaso resultado&#46; Tras una media de 3&#44;2 sesiones de TFD por lesi&#243;n&#44; las cuatro pacientes presentaron una resoluci&#243;n completa de las lesiones&#44; persistiendo &#250;nicamente atrofia residual&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bernia E&#44; Llombart B&#44; Bancalari B&#44; Diago A&#44; Serra-Guill&#233;n C&#46; Tratamiento de la necrobiosis lipo&#237;dica con terapia fotodin&#225;mica convencional&#58; serie de 4 casos tratados con &#233;xito&#46; Actas Dermosifiliogr&#46; 2020&#59;111&#58;605&#8211;608&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1542
            "Ancho" => 2181
            "Tamanyo" => 512887
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; A 21-year-old woman with DM1 and necrobiosis lipoidica with a long time since onset &#40;72 months&#41;&#46; Appearance of the lesions at the start &#40;A and B&#41; and after completing treatment with conventional PDT with MAL &#40;C and D&#41;&#46; gr1&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1486
            "Ancho" => 2097
            "Tamanyo" => 328379
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 2&#46; A 32-year-old woman with DM1 and necrobiosis lipoidica with less time since onset &#40;8 months&#41;&#46; Appearance of the lesions at the start &#40;A and B&#41; and after completing treatment with conventional PDT with MAL &#40;C and D&#41;&#46; gr2&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Table "
            "rol" => "short"
          ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#44; ASA indicates acetylsalicylic acid&#59; BF-200 ALA&#44; 5-aminolevulinic acid&#59; DM1&#44; type 1 diabetes mellitus&#59; DM2&#44; type 2 diabetes mellitus&#59; MAL&#44; methyl-aminolevulinate&#59; PDL&#44; pulsed dye laser&#46;</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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Medical History&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Time Since Onset&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Previous Treatments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; of Sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Photosensitizing Agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Response&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-Up Time&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1&#44; Graves-Basedow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pentoxifylline&#44; ASA&#44; clobetasol&#44; tacrolimus&#44; calcitriol&#44; PDL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pentoxifylline&#44; clobetasol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clobetasol&#44; pimecrolimus&#44; PDL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAL&#44; BF-200 ALA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM2&#44; leiomyosarcoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clobetasol&#44; cryotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">MAL&#44; BF-200 ALA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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Brief Comunication
Photodynamic Therapy for Necrobiosis Lipoidica: Successful Treatment in a Series of 4 cases
Tratamiento de la necrobiosis lipoídica con terapia fotodinámica convencional: serie de 4 casos tratados con éxito
E. Bernia
Autor para correspondencia
eduardobernia@gmail.com

Corresponding author.
, B. Llombart, B. Bancalari, A. Diago, C. Serra-Guillén
Servicio de Dermatología, Instituto Valenciano de Oncología (IVO), Valencia, España
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; A 21-year-old woman with DM1 and necrobiosis lipoidica with a long time since onset &#40;72 months&#41;&#46; Appearance of the lesions at the start &#40;A and B&#41; and after completing treatment with conventional PDT with MAL &#40;C and D&#41;&#46; gr1&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Necrobiosis lipoidica &#40;NL&#41; is a rare&#44; chronic&#44; granulomatous disease that typically affects young women and is frequently associated with diabetes mellitus &#40;DM&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinically&#44; the disease is characterized by the progressive appearance of plaques with a raised red-violaceous border and an atrophic yellow-brown center&#46; The plaques are usually located bilaterally on the anterior surface of the lower extremities&#46; Other less common locations include the upper extremities&#44; face&#44; and scalp&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Although they are typically asymptomatic&#44; some patients may experience pruritus&#44; dysesthesia&#44; or pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Histologically&#44; they are characterized by degeneration of collagen&#44; formation of granulomas in palisade and thickening of the vascular walls&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">NL has historically been a difficult disease to treat&#46; Several therapeutic options are available&#44; although most of them provide minimal and inconsistent results&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Some publications describe the use of photodynamic therapy &#40;PDT&#41; as second-line treatment in refractory cases&#44; with variable results&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe our experience in the treatment with PDT of 4 patients with NL&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><p id="par0020" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the clinical characteristics of the 4 patients treated in our department using PDT&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The 4 patients were women&#44; aged 21&#44; 22&#44; 31&#44; and 61 years&#46; All had DM&#59; the first 3 had type-1 DM and the last had type-2 DM&#46; All had received at least 2 prior treatments&#44; with minimal or no response&#46; These treatments included topical corticosteroids&#44; topical calcineurin inhibitors&#44; topical calcitriol&#44; pentoxifylline&#44; acetylsalicylic acid&#44; pulsed dye laser&#44; and cryotherapy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The time from diagnosis to start of PDT was 2&#44; 8&#44; 72&#44; and 120 months&#44; respectively&#46; The first 2 cases were treated with methyl aminolevulinate &#40;MAL&#59; Metvix&#174;&#44; Galderma&#44; Lausanne&#44; Switzerland&#41;&#46; Cases 3 and 4 combined MAL and 5-aminolevulinic acid &#40;BF-200 ALA&#59; Ameluz&#174;&#44; Biofrontera&#44; Leverkusen&#44; Germany&#41;&#46; The photosensitizing agent was incubated for 3 hours in the case of MAL&#44; and 2&#8239;hours and 30&#8239;minutes in the case of BF-200 ALA&#44; in accordance with the protocol that we follow in our hospital&#46; The illumination used was red visible light &#40;Aktilite&#174; CL128&#44; Galderma&#44; Lausanne&#44; Switzerland&#41;&#44; with a peak wavelength of 630&#8239;nm and total energy of 37&#8239;J&#47;cm<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; for a period of 9&#8239;minutes 50&#8239;seconds&#46; Anesthesia was not needed in any of the cases owing to the good tolerance of the technique&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Two sessions with an interval of 2 weeks between sessions were initially indicated&#46; The lesions were then re-evaluated&#44; and a new cycle of treatment was indicated if the effect obtained was insufficient&#46; The mean total number of sessions per patients was 11&#46;3 &#40;interval&#44; 6&#8211;18&#41;&#46; Each of the lesions received an average of 3&#46;2 sessions &#40;interval&#44; 1&#8211;5&#41;&#46; The fluorescence observed with the Wood light was low intensity&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a> show the appearance of the lesions at the start and after treatment&#46; The plaques&#44; with raised violaceous edges&#44; resolved completely&#59; only residual atrophic skin persisted&#46; No signs of active disease were therefore visible after completion of the treatment&#46; Also noteworthy is the rapid improvement of the symptoms after starting treatment&#46; Specifically&#44; the patient in case 1 suffered intense dysesthesia&#44; for which she had been studied in a neurophysiology department&#46; After start of treatment and from the first sessions&#44; the patient presented a considerable improvement in symptoms and became completely asymptomatic&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Subsequently&#44; during follow-up&#44; cases 1&#44; 2&#44; and 3 presented new NL plaques&#44; some of which were distant from the original plaques&#46; Due to the chronic course of the disease&#44; it is difficult to distinguish whether this is persistence or the appearance of new lesions&#46; Nevertheless&#44; the new lesions continue to respond well to treatment with PDT&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Photodynamic therapy is a technique approved for the treatment of actinic keratosis&#44; superficial basal cell carcinoma&#44; and Bowen disease&#46; Its use is increasingly frequent off data sheet in infectious and inflammatory diseases&#46; One of these new indications may be treatment of NL&#46; Its immune-modulating effect&#44; the product of modified cytokine expression &#40;IL1-&#946;&#44; IL-2&#44; and TNF-&#945;&#41; and immune specific response induction&#44; may explain the response of the NL lesions to PDT<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In this regard&#44; several articles have been published on single cases satisfactorily treated with conventional PDT&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> Nevertheless&#44; the first publications of case series treated with PDT showed more discreet results&#44; such as the study by Berking et al&#46;&#44; in which they retrospectively analyzed 18 cases of patients with NL treated with PDT with MAL&#44; and in which they obtained an overall response rate of 39&#37;&#44; with a single case of complete response and more than 60&#37; of nonresponding patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">More recently&#44; the Kaae group published a series of 65 patients with NL treated with conventional PDT and natural daylight PDT with MAL&#46; In their article&#44; those authors place particular emphasis on the need to perform prior superficial curettage of the lesions&#44; as this would increase levels of protoporphyrin IX and&#44; thus&#44; increase the efficacy of the PDT&#46; The percentage of complete responses obtained was 66&#37;&#44; with 90&#37; partial responses and with no statistically significant differences between conventional PDT and natural daylight PDT&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Our results are closer to those of this second study&#46; Nevertheless&#44; we have no experience in prior curettage of the lesions or in the use of natural daylight in the treatment of NL&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">With regard to predictive factors of response to PDT in NL&#44; those authors found no statistically significant differences between response and age&#44; sex&#44; duration&#44; and number of lesions&#46; DM was not a predictive factor&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Due to the chronic course of the disease&#44; the appearance of new lesions during follow-up is frequent&#46; In these cases&#44; new treatment cycles may be indicated&#46; Our impression is that the patients who respond well initially continue to do so with the new sessions&#46; We have not considered maintenance treatment in any of the cases&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report 4 patients with NL&#44; treated with conventional PDT with a complete response&#46; The latest publications situate PDT as one of the most effective treatments&#44; with response rates of between 39&#37; and 90&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8</span></a> Long periods of treatment are frequently required to obtain definitive results&#46; Because pain may be a limiting factor&#44; some publications support the use of natural daylight PDT with similar results to those of conventional PDT&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Due to the low levels of evidence of existing published studies&#44; prospective randomized&#44; controlled prospective studies are required to try to define the real potential of this technique&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">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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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Necrobiosis lipoidica is a rare chronic granulomatous disease&#46; Multiple treatment approaches are available&#44; but results are generally minimal and inconsistent&#46; Some publications report variable results with photodynamic therapy &#40;PDT&#41; as a second line of treatment for refractory cases&#46; We report 4 cases of necrobiosis lipoidica treated satisfactorily with conventional PDT using methyl aminolevulinate or 5-aminolevulinic acid BF-200 as the photosensitizing agent&#46; All 4 patients were women with diabetes mellitus who had undergone treatment at least twice in the past&#44; with little improvement&#46; The lesions resolved completely with PDT&#44; leaving only residual atrophy after a mean of 3&#46;2 sessions per lesion&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La necrobiosis lipoidica &#40;NL&#41; es una enfermedad granulomatosa cr&#243;nica poco frecuente para la que existen multitud de tratamientos disponibles&#46; No obstante&#44; estos ofrecen habitualmente m&#237;nimos e inconsistentes resultados&#46; En algunas publicaciones se describe el tratamiento con terapia fotodin&#225;mica &#40;TFD&#41; como tratamiento de segunda l&#237;nea en casos refractarios&#44; con resultados variables&#46; Comunicamos cuatro casos de NL tratados satisfactoriamente con TFD convencional con MAL y BF-200 ALA&#46; Las cuatro pacientes eran mujeres afectas de diabetes mellitus y todas hab&#237;an recibido al menos 2 tratamientos previos con escaso resultado&#46; Tras una media de 3&#44;2 sesiones de TFD por lesi&#243;n&#44; las cuatro pacientes presentaron una resoluci&#243;n completa de las lesiones&#44; persistiendo &#250;nicamente atrofia residual&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; A 21-year-old woman with DM1 and necrobiosis lipoidica with a long time since onset &#40;72 months&#41;&#46; Appearance of the lesions at the start &#40;A and B&#41; and after completing treatment with conventional PDT with MAL &#40;C and D&#41;&#46; gr1&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#44; ASA indicates acetylsalicylic acid&#59; BF-200 ALA&#44; 5-aminolevulinic acid&#59; DM1&#44; type 1 diabetes mellitus&#59; DM2&#44; type 2 diabetes mellitus&#59; MAL&#44; methyl-aminolevulinate&#59; PDL&#44; pulsed dye laser&#46;</p>"
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                  <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="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; of Sessions&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Response&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-Up Time&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1&#44; Graves-Basedow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pentoxifylline&#44; ASA&#44; clobetasol&#44; tacrolimus&#44; calcitriol&#44; PDL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pentoxifylline&#44; clobetasol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clobetasol&#44; pimecrolimus&#44; PDL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAL&#44; BF-200 ALA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM2&#44; leiomyosarcoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clobetasol&#44; cryotherapy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">MAL&#44; BF-200 ALA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical Characteristics of Patients Treated With Photodynamic Therapy&#58; Age&#44; Medical History&#44; Time Since Onset of the Disease&#44; Treatments Previously Received&#44; Number of Sessions Administered&#44; Photosensitizing Agent Administered&#44; Response Observed&#44; and Follow-up Time From End of Treatment&#46;</p>"
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                      "titulo" => "Updated results of 100 patients on clinical features and therapeutic options in necrobiosis lipoidica in a retrospective multicentre study"
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                        0 => array:2 [
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                            0 => "C&#46; Erfurt-Berge"
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                            2 => "K&#46; Schwede"
                            3 => "A&#46;T&#46; Seitz"
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                      "titulo" => "Update on clinical and laboratory features in necrobiosis lipoidica&#58; A retrospective multicentre study of 52 patients"
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                      "titulo" => "Necrobiosis lipo&#237;dica&#46; Estudio descriptivo de 35 pacientes"
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                            1 => "S&#46; G&#243;mez-Armayones"
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