What is your diagnosis?
Case for diagnosis. Subcutaneous nodules in the plantar region
Diego Henrique Morais Silva
, Isaura Azevedo Fasciani, Neusa Yuriko Sakai Valente, Bethânia Cabral Cavalli Swiczar
Corresponding author
Department of Dermatology, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
Read
6151
Timeswas read the article
2947
Total PDF
3204
Total HTML
Share statistics
array:24 [ "pii" => "S0365059620301689" "issn" => "03650596" "doi" => "10.1016/j.abd.2020.02.006" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "223" "copyright" => "Sociedade Brasileira de Dermatologia" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "pt" => array:19 [ "pii" => "S2666275220302447" "issn" => "26662752" "doi" => "10.1016/j.abdp.2020.07.003" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "223" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "pt" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Qual o seu diagnóstico?</span>" "titulo" => "Caso para diagnóstico. Nódulos subcutâneos em região plantar" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "649" "paginaFinal" => "651" ] ] "contieneResumen" => array:1 [ "pt" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 146840 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Granuloma com necrose central circundada por células epitelioides em paliçada (Hematoxilina & eosina, 100×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diego Henrique Morais Silva, Isaura Azevedo Fasciani, Neusa Yuriko Sakai Valente, Bethânia Cabral Cavalli Swiczar" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Diego Henrique Morais" "apellidos" => "Silva" ] 1 => array:2 [ "nombre" => "Isaura Azevedo" "apellidos" => "Fasciani" ] 2 => array:2 [ "nombre" => "Neusa Yuriko Sakai" "apellidos" => "Valente" ] 3 => array:2 [ "nombre" => "Bethânia Cabral Cavalli" "apellidos" => "Swiczar" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059620301689" "doi" => "10.1016/j.abd.2020.02.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301689?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220302447?idApp=UINPBA00008Z" "url" => "/26662752/0000009500000005/v1_202010040634/S2666275220302447/v1_202010040634/pt/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S0365059620301690" "issn" => "03650596" "doi" => "10.1016/j.abd.2019.12.007" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "224" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">What is your diagnosis?</span>" "titulo" => "Case for diagnosis. Infiltrated areas on the trunk" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "652" "paginaFinal" => "654" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 681 "Ancho" => 905 "Tamanyo" => 103991 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous plaques on the trunk.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Larissa Daniele Machado Góes, Juliana Alves Scrignoli, Patrícia Morais, Carolina Talhari" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Larissa Daniele Machado" "apellidos" => "Góes" ] 1 => array:2 [ "nombre" => "Juliana Alves" "apellidos" => "Scrignoli" ] 2 => array:2 [ "nombre" => "Patrícia" "apellidos" => "Morais" ] 3 => array:2 [ "nombre" => "Carolina" "apellidos" => "Talhari" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220302459" "doi" => "10.1016/j.abdp.2020.07.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220302459?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301690?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000005/v2_202011080908/S0365059620301690/v2_202011080908/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0365059620301793" "issn" => "03650596" "doi" => "10.1016/j.abd.2020.03.007" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "234" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Images in Dermatology</span>" "titulo" => "Multisystemic fusariosis with fulminant evolution" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "645" "paginaFinal" => "648" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 723 "Ancho" => 905 "Tamanyo" => 128841 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Fusariosis, histopathology of skin lesions (Grocott-Gomori, ×40). Septate hyphae and intravascular conidiophores are evident.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nelson Turra, Agustina Acosta, Andrea Incoronato, Pilar Beltramo" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Nelson" "apellidos" => "Turra" ] 1 => array:2 [ "nombre" => "Agustina" "apellidos" => "Acosta" ] 2 => array:2 [ "nombre" => "Andrea" "apellidos" => "Incoronato" ] 3 => array:2 [ "nombre" => "Pilar" "apellidos" => "Beltramo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220302551" "doi" => "10.1016/j.abdp.2020.03.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220302551?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301793?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000005/v2_202011080908/S0365059620301793/v2_202011080908/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">What is your diagnosis?</span>" "titulo" => "Case for diagnosis. Subcutaneous nodules in the plantar region" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "649" "paginaFinal" => "651" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Diego Henrique Morais Silva, Isaura Azevedo Fasciani, Neusa Yuriko Sakai Valente, Bethânia Cabral Cavalli Swiczar" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Diego Henrique Morais" "apellidos" => "Silva" "email" => array:1 [ 0 => "dhenriquems@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Isaura Azevedo" "apellidos" => "Fasciani" ] 2 => array:2 [ "nombre" => "Neusa Yuriko Sakai" "apellidos" => "Valente" ] 3 => array:2 [ "nombre" => "Bethânia Cabral Cavalli" "apellidos" => "Swiczar" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 204790 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Granuloma with central necrosis surrounded by a palisade of epithelioid cells (Hematoxylin & eosin, ×100).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 60-year-old caucasian woman was referred to the dermatology outpatient clinic by the rheumatology service, where she was followed-up due to a 20-year history of rheumatoid arthritis. The patient reported a two-year history of painful nodules on the soles of her feet, with slow growth, which hindered walking (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The ultrasound report showed nonspecific nodules in the subcutaneous tissue. The appearance of the nodules was accompanied by a progressive worsening of joint symptoms. One of the nodules was excised (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec9005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect9015">What is your diagnosis?</span><p id="par0010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">a)</span></span><p id="par0015" class="elsevierStylePara elsevierViewall">Fibroma</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">b)</span></span><p id="par0020" class="elsevierStylePara elsevierViewall">Rheumatoid nodule</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">c)</span></span><p id="par0025" class="elsevierStylePara elsevierViewall">Lipoma</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">d)</span></span><p id="par0030" class="elsevierStylePara elsevierViewall">Calcinosis</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Rheumatoid arthritis is a systemic inflammatory disease, primarily articular, that affects about 0.8% of the world population.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Among the cutaneous manifestations of rheumatoid arthritis, rheumatoid nodules are the most common, being observed in approximately 30% of these patients. They typically consist of subcutaneous, painless nodules located in extensor and repetitive trauma regions such as the back of the hands, ankles, knees, elbows, and the occipital region.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Rheumatoid nodules are more common in men, especially Caucasians.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Plantar involvement is rare and seldom described in the literature; it is generally observed in the context of multiple lesions in other locations.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are a variety of differential diagnoses, including subcutaneous granuloma annulare, calcinosis, lipoma, and gouty tophi; however, the history of rheumatoid arthritis, especially in a context of exacerbation of the articular condition, favors the clinical diagnosis of rheumatoid nodule. In doubtful cases, the definitive diagnosis is established by histopathological findings of a granulomatous process characterized by a focus of fibrinoid necrosis surrounded by a palisade of histiocytes.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Most patients have asymptomatic nodules and do not require treatment; however, when these nodules become painful, infected, or ulcerated, treatment is imperative.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,2,4</span></a> The intralesional application of corticosteroids to reduce the size of the nodules is the treatment of choice in most symptomatic cases. Surgical resection is generally not necessary, except in cases of nerve compression or those with range of joint movement limitation.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">After excision and confirmation of the diagnosis of rheumatoid nodule, the patient is currently being followed-up by the rheumatology team, with improvement of joint symptoms after the introduction of certolizumab, which inhibits tumor necrosis factor-α (TNF-α). As the joint symptoms were controlled, the patient presented an improvement in symptoms and a reduction in the dimensions of the plantar nodules.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors' contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Diego Henrique Morais Silva: Conception and planning of the study; elaboration and writing of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Isaura Azevedo Fasciani: Conception and planning of the study; critical review of the literature.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Neusa Yuriko Sakai Valente: Conception and planning of the study; obtaining, analyzing, and interpreting the data; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Bethânia Cabral Cavalli Swiczar: Effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1410360" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1290409" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 3 => array:2 [ "identificador" => "sec9005" "titulo" => "What is your diagnosis?" ] 4 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors' contributions" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-18" "fechaAceptado" => "2020-02-09" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1290409" "palabras" => array:3 [ 0 => "Arthritis, rheumatoid" 1 => "Granuloma" 2 => "Rheumatoid nodule" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors report a case of mobile and painful nodules on the bilateral plantar surface of a female patient referred by the rheumatology service, where she was being followed-up for rheumatoid arthritis. A nodule excision was performed for differential diagnosis and symptom relief; the histopathological analysis was compatible with a rheumatoid nodule. Although rheumatoid nodules are a common manifestation of rheumatoid arthritis, exclusive plantar involvement is seldom described in the literature.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Silva DHM, Fasciani IA, Valente NYS, Swiczar BCC. Case for diagnosis. Subcutaneous nodules in the plantar region. An Bras Dermatol. 2020;95:649–51.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1354 "Ancho" => 905 "Tamanyo" => 113897 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nodules on the left plantar surface.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 809 "Ancho" => 905 "Tamanyo" => 84839 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Detail of nodules in pressure areas of the plantar region.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 204790 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Granuloma with central necrosis surrounded by a palisade of epithelioid cells (Hematoxylin & eosin, ×100).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rheumatoid arthritis in dermatology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Halta" 1 => "A. Kavanaugh" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Dermatol" "fecha" => "2006" "volumen" => "24" "paginaInicial" => "430" "paginaFinal" => "437" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skin signs of rheumatoid arthritis and its therapy-induced cutaneous side effects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y. Xue" 1 => "J.M. Cohen" 2 => "N.A. Wright" 3 => "J.F. Merola" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Clin Dermatol" "fecha" => "2016" "volumen" => "17" "paginaInicial" => "147" "paginaFinal" => "162" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Soft tissue swellings in the foot: Rheumatoid nodulosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "W. McMurrich" 1 => "C. Thomson" 2 => "N.D. McKay" 3 => "E. McRorie" 4 => "D. Salter" 5 => "J. McKinley" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Foot (Edinb)" "fecha" => "2014" "volumen" => "24" "paginaInicial" => "37" "paginaFinal" => "41" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rheumatoid nodules" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.S. Tilstra" 1 => "D.W. Lienesch" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatol Clin" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "361" "paginaFinal" => "371" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000005/v2_202011080908/S0365059620301689/v2_202011080908/en/main.assets" "Apartado" => array:4 [ "identificador" => "80633" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "What is your Diagnosis?" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000005/v2_202011080908/S0365059620301689/v2_202011080908/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301689?idApp=UINPBA00008Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 7 | 23 |
| 2024 October | 100 | 76 | 176 |
| 2024 September | 157 | 75 | 232 |
| 2024 August | 148 | 95 | 243 |
| 2024 July | 146 | 124 | 270 |
| 2024 June | 106 | 70 | 176 |
| 2024 May | 76 | 75 | 151 |
| 2024 April | 104 | 86 | 190 |
| 2024 March | 82 | 68 | 150 |
| 2024 February | 105 | 81 | 186 |
| 2024 January | 71 | 50 | 121 |
| 2023 December | 62 | 75 | 137 |
| 2023 November | 80 | 64 | 144 |
| 2023 October | 83 | 89 | 172 |
| 2023 September | 78 | 68 | 146 |
| 2023 August | 73 | 41 | 114 |
| 2023 July | 58 | 26 | 84 |
| 2023 June | 81 | 49 | 130 |
| 2023 May | 73 | 27 | 100 |
| 2023 April | 61 | 16 | 77 |
| 2023 March | 55 | 47 | 102 |
| 2023 February | 42 | 40 | 82 |
| 2023 January | 35 | 39 | 74 |
| 2022 December | 54 | 23 | 77 |
| 2022 November | 60 | 56 | 116 |
| 2022 October | 58 | 52 | 110 |
| 2022 September | 52 | 60 | 112 |
| 2022 August | 47 | 43 | 90 |
| 2022 July | 40 | 42 | 82 |
| 2022 June | 52 | 54 | 106 |
| 2022 May | 31 | 51 | 82 |
| 2022 April | 29 | 47 | 76 |
| 2022 March | 43 | 52 | 95 |
| 2022 February | 27 | 48 | 75 |
| 2022 January | 39 | 81 | 120 |
| 2021 December | 35 | 61 | 96 |
| 2021 November | 37 | 55 | 92 |
| 2021 October | 52 | 83 | 135 |
| 2021 September | 32 | 39 | 71 |
| 2021 August | 37 | 59 | 96 |
| 2021 July | 47 | 52 | 99 |
| 2021 June | 39 | 49 | 88 |
| 2021 May | 47 | 110 | 157 |
| 2021 April | 104 | 263 | 367 |
| 2021 March | 75 | 66 | 141 |
| 2021 February | 35 | 23 | 58 |
| 2021 January | 40 | 23 | 63 |
| 2020 December | 32 | 14 | 46 |
| 2020 November | 83 | 10 | 93 |
| 2020 October | 28 | 8 | 36 |
| 2020 September | 20 | 10 | 30 |
| 2020 August | 10 | 9 | 19 |
| 2020 July | 24 | 13 | 37 |
| 2020 June | 3 | 3 | 6 |
Show all
