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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Prurigo nodularis &#40;PN&#41; is a chronic&#44; difficult-to-treat pruriginous disease that can have a significant impact on a patient&#8217;s quality of life&#46; It is a neurodermatitis in which the itch-scratch cycle perpetuates the nodular lesions&#46; The cause is unknown&#44; but the condition is associated with other skin diseases &#40;mainly atopic dermatitis&#41;&#44; systemic diseases &#40;liver and renal failure and infections&#41;&#44; neurologic and psychiatric disorders&#44; and neoplasms&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Larson et al<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> recently published the findings of the largest study to date on the association between PN and neoplasms&#46; They included 695 diagnosed patients &#40;51&#46;6&#37; women&#41; between the ages of 40 and 69 years&#44; comparing them to more than 2 million individuals with similar characteristics&#46; The authors found that 17&#46;8&#37; of the patients with PN had some type of neoplasm and that malignancy was 4-fold more likely among those with PN than in the control individuals &#40;odds ratio &#91;OR&#93;&#44; 4&#46;54&#59; 95&#37; CI&#44; 3&#46;74&#8211;5&#46;52&#41;&#46; Skin tumors were the most common type of neoplasm &#40;in 47&#37;&#41;&#59; the majority were basal cell carcinoma&#44; followed in frequency by squamous cell carcinoma and melanoma&#46; Solid organ tumors &#40;in 32&#37; of the patients&#41; were mainly genital &#40;in women&#41;&#44; in the lung&#44; or in the digestive tract&#46; Blood neoplasms were found in 21&#37; &#40;mainly non-Hodgkin lymphoma&#44; multiple myeloma&#44; or primary cutaneous lymphoma&#41;&#46; The patients with PN had significantly higher risk for skin cancer &#40;OR&#44; 10&#46;94&#59; 95&#37; CI&#44; 8&#46;01&#8211;14&#46;96&#41;&#44; primary cutaneous lymphoma &#40;OR&#44; 24&#46;82&#59; 95&#37; CI&#44; 7&#46;96&#8211;77&#46;46&#41;&#44; and female genital neoplasia &#40;OR&#44; 11&#46;00&#59; 95&#37; CI&#44; 4&#46;90&#8211;24&#46;68&#41;&#44; among other malignant tumors&#46; The pathophysiologic mechanism for the association between neoplasia and PN is unknown&#44; but it may be related to a proinflammatory state&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Given the strong association between PN and tumors in patients in the aforementioned study&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> a high index of suspicion is recommended&#46; Also recommended is careful examination of skin and mucosal tissues and additional tests &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; following a multidisciplinary approach&#59; screening for neoplasms according to sex and age should be included&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">There is limited evidence available on the treatment of PN given that fewer than 10 clinical trials have been published&#44; and most are small&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Good outcomes have been described after treatment with topical corticosteroids and calcineurin inhibitors&#44; phototherapy&#44; thalidomide &#40;though its safety profile is poor&#41;&#44; antiepileptics or anticonvulsives &#40;pregabalin&#44; gabapentin&#44; or amitriptyline&#41;&#44; ciclosporin&#44; and methotrexate&#46; A recent retrospective study of 39 patients with refractory PN showed an objectively measured response to methotrexate in 90&#37; at 3 and 12 months&#44; and complete resolution was observed at 12 months in 57&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; 12&#37; of the patients had to stop treatment due to such adverse effects as transaminitis&#44; pneumonitis&#44; or gastrointestinal symptoms&#44; among other events&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In our patients&#44; we have also observed good responses to treatment with methotrexate and pregabalin&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Emerging therapies include neurokinin 1 receptor antagonists such as aprepitant and serlopitant&#44; the focus of an as-yet unpublished phase-3 trial&#59; interleukin-31 inhibitors such as nemolizumab&#44; currently being studied in a phase-2 trial&#59; and opioid receptor agonists&#47;antagonists such as nalbuphine&#46; There is also the interleukin-4 inhibitor dupilumab&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">PN may be associated with neoplasms&#46; A high index of clinical suspicion is necessary so that appropriate additional screening tests can be ordered&#46; Treatment is complex&#44; and clinical evidence is still limited&#46;</p></span>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Chest radiograph if lymphoma is suspected<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Skin biopsy<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#8239;&#43;&#8239;negative direct immunofluorescence<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">Multidisciplinary management</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">Consult other specialists to screen for digestive&#44; genital&#44; or other neoplasms&#44; as appropriate according to sex and age&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Consider consulting a psychiatrist and&#47;or a psychologist&#46;&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
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                  \t\t\t\t">Treatments</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">First line&#58; Start with topical corticosteroid or calcineurin inhibitors and&#47;or phototherapy&#46;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Second line&#58; Add gabapentin or pregabalin&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Third line&#58; Evaluate the need for antidepressants &#40;paroxetine or mirtazapine&#41;&#46;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&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">Fourth line&#58; Consider immunosuppressants &#40;ciclosporin or methotrexate&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Fifth line&#58; Consider duplimab&#44; aprepitant&#44; serlopitant&#44; or opioid receptor antagonists&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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RF-Prurigo Nodularis: Associations With Neoplasms, Recommendations for Additional Testing, and Novel Treatments
FR-Prurigo nodular: asociación con neoplasias, pruebas complementarias y nuevos tratamientos
L. Serra-García, D. Morgado-Carrasco
Autor para correspondencia
danielmorgado@yahoo.com.ar

Corresponding author.
Departamento de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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    "cabecera" => "<span class="elsevierStyleTextfn">Resident&#8217;s Forum</span>"
    "titulo" => "RF-Prurigo Nodularis&#58; Associations With Neoplasms&#44; Recommendations for Additional Testing&#44; and Novel Treatments"
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    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "L&#46; Serra-Garc&#237;a, D&#46; Morgado-Carrasco"
        "autores" => array:2 [
          0 => array:2 [
            "nombre" => "L&#46;"
            "apellidos" => "Serra-Garc&#237;a"
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          1 => array:4 [
            "nombre" => "D&#46;"
            "apellidos" => "Morgado-Carrasco"
            "email" => array:1 [
              0 => "danielmorgado@yahoo.com.ar"
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        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Departamento de Dermatolog&#237;a&#44; Hospital Cl&#237;nic de Barcelona&#44; Universitat de Barcelona&#44; Barcelona&#44; Spain"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "FR-Prurigo nodular&#58; asociaci&#243;n con neoplasias&#44; pruebas complementarias y nuevos tratamientos"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Prurigo nodularis &#40;PN&#41; is a chronic&#44; difficult-to-treat pruriginous disease that can have a significant impact on a patient&#8217;s quality of life&#46; It is a neurodermatitis in which the itch-scratch cycle perpetuates the nodular lesions&#46; The cause is unknown&#44; but the condition is associated with other skin diseases &#40;mainly atopic dermatitis&#41;&#44; systemic diseases &#40;liver and renal failure and infections&#41;&#44; neurologic and psychiatric disorders&#44; and neoplasms&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Larson et al<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> recently published the findings of the largest study to date on the association between PN and neoplasms&#46; They included 695 diagnosed patients &#40;51&#46;6&#37; women&#41; between the ages of 40 and 69 years&#44; comparing them to more than 2 million individuals with similar characteristics&#46; The authors found that 17&#46;8&#37; of the patients with PN had some type of neoplasm and that malignancy was 4-fold more likely among those with PN than in the control individuals &#40;odds ratio &#91;OR&#93;&#44; 4&#46;54&#59; 95&#37; CI&#44; 3&#46;74&#8211;5&#46;52&#41;&#46; Skin tumors were the most common type of neoplasm &#40;in 47&#37;&#41;&#59; the majority were basal cell carcinoma&#44; followed in frequency by squamous cell carcinoma and melanoma&#46; Solid organ tumors &#40;in 32&#37; of the patients&#41; were mainly genital &#40;in women&#41;&#44; in the lung&#44; or in the digestive tract&#46; Blood neoplasms were found in 21&#37; &#40;mainly non-Hodgkin lymphoma&#44; multiple myeloma&#44; or primary cutaneous lymphoma&#41;&#46; The patients with PN had significantly higher risk for skin cancer &#40;OR&#44; 10&#46;94&#59; 95&#37; CI&#44; 8&#46;01&#8211;14&#46;96&#41;&#44; primary cutaneous lymphoma &#40;OR&#44; 24&#46;82&#59; 95&#37; CI&#44; 7&#46;96&#8211;77&#46;46&#41;&#44; and female genital neoplasia &#40;OR&#44; 11&#46;00&#59; 95&#37; CI&#44; 4&#46;90&#8211;24&#46;68&#41;&#44; among other malignant tumors&#46; The pathophysiologic mechanism for the association between neoplasia and PN is unknown&#44; but it may be related to a proinflammatory state&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Given the strong association between PN and tumors in patients in the aforementioned study&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> a high index of suspicion is recommended&#46; Also recommended is careful examination of skin and mucosal tissues and additional tests &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; following a multidisciplinary approach&#59; screening for neoplasms according to sex and age should be included&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">There is limited evidence available on the treatment of PN given that fewer than 10 clinical trials have been published&#44; and most are small&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Good outcomes have been described after treatment with topical corticosteroids and calcineurin inhibitors&#44; phototherapy&#44; thalidomide &#40;though its safety profile is poor&#41;&#44; antiepileptics or anticonvulsives &#40;pregabalin&#44; gabapentin&#44; or amitriptyline&#41;&#44; ciclosporin&#44; and methotrexate&#46; A recent retrospective study of 39 patients with refractory PN showed an objectively measured response to methotrexate in 90&#37; at 3 and 12 months&#44; and complete resolution was observed at 12 months in 57&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; 12&#37; of the patients had to stop treatment due to such adverse effects as transaminitis&#44; pneumonitis&#44; or gastrointestinal symptoms&#44; among other events&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In our patients&#44; we have also observed good responses to treatment with methotrexate and pregabalin&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Emerging therapies include neurokinin 1 receptor antagonists such as aprepitant and serlopitant&#44; the focus of an as-yet unpublished phase-3 trial&#59; interleukin-31 inhibitors such as nemolizumab&#44; currently being studied in a phase-2 trial&#59; and opioid receptor agonists&#47;antagonists such as nalbuphine&#46; There is also the interleukin-4 inhibitor dupilumab&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">PN may be associated with neoplasms&#46; A high index of clinical suspicion is necessary so that appropriate additional screening tests can be ordered&#46; Treatment is complex&#44; and clinical evidence is still limited&#46;</p></span>"
    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2019-07-30"
    "fechaAceptado" => "2019-08-07"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1395165"
          "palabras" => array:6 [
            0 => "Prurigo nodularis"
            1 => "Malignant neoplasms"
            2 => "Tumors"
            3 => "Pruritus"
            4 => "Methotrexate"
            5 => "Dupilumab"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Serra-Garc&#237;a L&#44; Morgado-Carrasco D&#46; FR-Prurigo nodular&#58; asociaci&#243;n con neoplasias&#44; pruebas complementarias y nuevos tratamientos&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;663&#8211;664&#46;</p>"
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        "fuente" => "Sources&#58; St&#228;nder et al<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and Larson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; PN&#44; prurigo nodularis&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Associated neoplasms</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">Skin cancer &#40;basal cell carcinoma&#44; squamous cell carcinoma&#44; and melanoma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Solid-organ malignancies &#40;female genitalia&#44; breast&#44; lung&#44; digestive system&#44; head and neck&#44; endocrine glands&#44; urinary tract&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Hematologic neoplasms &#40;non-Hodgkin lymphoma&#44; multiple myeloma&#44; primary cutaneous lymphomas&#44; lymphocytic leukemia&#44; myeloid leukemia&#44; Hodgkin lymphoma&#41;&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">Physical examination&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">Look for signs of atopic dermatitis&#44; bullous pemphigoid&#44; skin cancer&#44; and primary cutaneous lymphoma&#46;&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 " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tests</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 blood count&#44; erythrocyte sedimentation rate&#44; and ferritin level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Creatinine level and liver-function tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Blood sugar and thyroid function tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Serology for human immunodeficiency virus infection and hepatitis B and C virus infections<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Chest radiograph if lymphoma is suspected<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Skin biopsy<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#8239;&#43;&#8239;negative direct immunofluorescence<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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 " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multidisciplinary management</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">Consult other specialists to screen for digestive&#44; genital&#44; or other neoplasms&#44; as appropriate according to sex and age&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Consider consulting a psychiatrist and&#47;or a psychologist&#46;&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 " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatments</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">First line&#58; Start with topical corticosteroid or calcineurin inhibitors and&#47;or phototherapy&#46;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Second line&#58; Add gabapentin or pregabalin&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Third line&#58; Evaluate the need for antidepressants &#40;paroxetine or mirtazapine&#41;&#46;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Fourth line&#58; Consider immunosuppressants &#40;ciclosporin or methotrexate&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Fifth line&#58; Consider duplimab&#44; aprepitant&#44; serlopitant&#44; or opioid receptor antagonists&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">If autoimmune bullous disease is suspected</p>"
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            2 => array:3 [
              "identificador" => "tblfn0015"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Consider intralesional corticosteroids in patients with few lesions or isolated nodules that are refractory to treatment&#46;</p>"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Especially in patients with mood disorders or other psychological problems&#46; Consider mirtazapine for patients with sleep disorders&#46;</p>"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Management of PN&#58; Associated Neoplasms&#44; Physical Examination&#44; Recommended Additional Tests&#44; and Treatments</p>"
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "H&#46;F&#46; St&#228;nder"
                            1 => "S&#46; Elmariah"
                            2 => "C&#46; Zeidler"
                            3 => "M&#46; Spellman"
                            4 => "S&#46; St&#228;nder"
                          ]
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                      "doi" => "10.1016/j.jaad.2019.07.022"
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                        "fecha" => "2019"
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              "etiqueta" => "2"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between prurigo nodularis and malignancy in middle-aged adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "V&#46;A&#46; Larson"
                            1 => "O&#46; Tang"
                            2 => "S&#46; Stander"
                            3 => "L&#46;S&#46; Miller"
                            4 => "S&#46; Kang"
                            5 => "S&#46;G&#46; Kwatra"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2019.03.083"
                      "Revista" => array:2 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2019"
                      ]
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              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A systematic review of evidence-based treatments for prurigo nodularis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;A&#46; Qureshi"
                            1 => "L&#46;E&#46; Abate"
                            2 => "G&#46; Yosipovitch"
                            3 => "A&#46;J&#46; Friedman"
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                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2018.09.020"
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                        "volumen" => "80"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30261199"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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ISSN: 15782190
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