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This is a cross section of the reticular dermis demonstrating ink between the collagen fibers, without bolus formation</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest Nogueira’s et al. recent case report.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This is an important contribution to the limited evidence about the safety of drug delivery techniques.</p><p id="par0010" class="elsevierStylePara elsevierViewall">As an experienced and enthusiastic user of the MMP® technique, I have a few considerations:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1)</span><p id="par0015" class="elsevierStylePara elsevierViewall">Although evidence derived from case reports is considered low, nevertheless it is important to raise questions in different scenarios.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Changes in liver enzyme levels are common in clinical practice and can be caused by many factors including physical activity, use of drugs (e.g., acetaminophen) or alcohol, and viral infections.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3)</span><p id="par0025" class="elsevierStylePara elsevierViewall">MMP® is a drug delivery technique that uses microneedles and dermo pigmentation equipment. Tattoos are unequivocal evidence of injection and absorption. The main advantages of this technique are the uniform drug distribution in the dermis, without bolus formation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and increased substance dispersion due to shear stress and turbulent whirling<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> caused by Newton’s law of attrition.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Drug absorption delivered through MMP® occurs predominantly through the lymphatic channels of the skin<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and not the subjacent blood vessels.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5)</span><p id="par0035" class="elsevierStylePara elsevierViewall">MMP® is the only drug delivery technique with published protocols that allow the quantification of the drug density injected in the dermis,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> offering safety parameters to the dermatologist.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6)</span><p id="par0040" class="elsevierStylePara elsevierViewall">Since the procedure was done in an ophiasis region (423 cm<span class="elsevierStyleSup">2</span>), using a saline solution (estimated density 1.000.000 µg/mL) and the medication contained 25 mg/mL of the active ingredient, based on published protocols we calculate that 390.907 µg (0.390907 mg) of the methotrexate solution was injected in the dermis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> (Video 1), which corresponds to 9.8 mg of methotrexate.</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Considering the aforementioned facts, and the lack of other reports of possible drug toxicity related to methotrexate MMP® drug delivery, we must consider an alternative hypothesis for the findings described by Nogueira et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is possible that this patient’s mild transient increase in transaminases may have occurred by chance or have been caused by other factors unrelated to methotrexate MMP® drug delivery?</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">TRADERM, a company that commercializes tattoo supplies.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Samir Arbache: Conceptualization; data curation; writing-original draft; and writing-review and editing.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Sergio Henrique Hirata: Conceptualization; data curation; writing-original draft; and writing-review and editing.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">MMP®, a registered trademark in Brazil, the United States, and Europe, grants free use exclusively to dermatologists who are members of the Brazilian Society of Dermatology and equivalent associations in the world. Dr. Arbache owns the company that commercializes the supplies used for MMP and is part of a team of professionals who train Brazilian dermatologists in to use of this technique.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:2 [ "identificador" => "xack720586" "titulo" => "Acknowledgments" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-05-05" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the DermoCentro Clinic, São José dos Campos, SP, Brazil.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0080" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0025" ] ] ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1315 "Ancho" => 1675 "Tamanyo" => 438940 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Drug delivery with MMP® technique. 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"autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.L. Nogueira" 1 => "R.R. Bonamigo" 2 => "R. Heck" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.abd.2021.01.013" "Revista" => array:6 [ "tituloSerie" => "An Bras Dermatol." "fecha" => "2023" "volumen" => "98" "paginaInicial" => "390" "paginaFinal" => "391" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/36581558" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Liver enzyme alteration: a guide for clinicians" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E.G. Giannini" 1 => "R. Testa" 2 => "V. Savarino" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1503/cmaj.1040752" "Revista" => array:6 [ "tituloSerie" => "Cmaj." "fecha" => "2005" "volumen" => "172" "paginaInicial" => "367" "paginaFinal" => "379" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15684121" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of idiopathic guttate hypomelanosis with a tattoo device versus a handheld needle" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Arbache" 1 => "M.T. de Mendonca" 2 => "S.T. Arbache" 3 => "S.H. Hirata" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jdin.2021.01.005" "Revista" => array:6 [ "tituloSerie" => "JAAD Int." 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"autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Arbache" 1 => "E. da Costa Mattos" 2 => "M.F. Diniz" 3 => "P.Y.A. Paiva" 4 => "D. Roth" 5 => "S.T. Arbache" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ijd.14408" "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol." "fecha" => "2019" "volumen" => "58" "paginaInicial" => "750" "paginaFinal" => "755" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30828798" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack720586" "titulo" => "Acknowledgments" "texto" => "<p id="par0070" class="elsevierStylePara elsevierViewall">Dr. Nilceo Michalany for microphotography documentation. Dr. Sergio Hirata, advisor of my doctoral thesis.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009900000001/v1_202401040817/S036505962300212X/v1_202401040817/en/main.assets" "Apartado" => array:4 [ "identificador" => "96905" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Correspondences" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009900000001/v1_202401040817/S036505962300212X/v1_202401040817/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S036505962300212X?idApp=UINPBA00008Z" ]
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