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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">As doen&#231;as da vulva s&#227;o comuns na popula&#231;&#227;o em geral&#44; embora sua verdadeira import&#226;ncia e frequ&#234;ncia sejam frequentemente subestimadas&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> A maioria das doen&#231;as da vulva tem impacto acentuadamente negativo na qualidade de vida das pacientes&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#44;3</span></a> Seja por desconhecimento ou vergonha&#44; a vulva &#233; uma &#225;rea do corpo geralmente negligenciada tanto por pacientes quanto por profissionais&#46; Al&#233;m disso&#44; as doen&#231;as da vulva geralmente est&#227;o associadas a atrasos significativos no diagn&#243;stico&#44; pois pacientes com sintomas vulvares comumente levam muito tempo para consultar um m&#233;dico&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Embora em geral os ginecologistas sejam os primeiros especialistas a atender pacientes com sintomas vulvovaginais&#44; eles geralmente recebem pouco treinamento no manejo de doen&#231;as dermatol&#243;gicas da vulva&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Os dermatologistas s&#227;o especialistas na avalia&#231;&#227;o e tratamento da pele e das membranas mucosas&#44; incluindo a regi&#227;o genital&#46; No entanto&#44; a vulva &#233; uma &#225;rea muitas vezes negligenciada pelos dermatologistas&#46; Os motivos mais comuns para isso incluem falta de treinamento&#44; desconforto durante a entrevista cl&#237;nica e falta de conhecimento dos exames complementares comumente utilizados em doen&#231;as vulvares&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Em pesquisa realizada nos Estados Unidos da Am&#233;rica do Norte que objetivou avaliar compet&#234;ncias no manejo de doen&#231;as da vulva entre estudantes de medicina e residentes de dermatologia e ginecologia&#44; apenas 19&#37; dos estudantes avaliados relataram ter recebido treinamento espec&#237;fico durante a resid&#234;ncia&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Embora tenha havido interesse crescente entre os dermatologistas no estudo da vulva nos &#250;ltimos anos<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> &#8211; particularmente entre os dermatologistas do Reino Unido&#44; um dos principais pa&#237;ses a desenvolver unidades espec&#237;ficas dedicadas ao tratamento de doen&#231;as da vulva &#8211;&#44; h&#225; atualmente poucos estudos cient&#237;ficos sobre o assunto&#46; Assim&#44; o objetivo deste estudo &#233; descrever a experi&#234;ncia dos autores como dermatologistas no manejo de consultas de dermatoses da vulva&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Materiais e m&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Estudo observacional retrospectivo foi realizado durante um per&#237;odo de cinco anos no hospital Viamed Santa Angela de la Cruz&#44; em Sevilha&#44; sul da Espanha&#46; Entre maio de 2015 e maio de 2020&#59; todas as pacientes que visitaram a unidade vulvar foram inclu&#237;das no estudo&#46; A coleta de dados foi realizada por especialista em dermatologia&#46; Os dados foram obtidos da hist&#243;ria cl&#237;nica de cada paciente&#46; As seguintes vari&#225;veis foram coletadas para an&#225;lise&#58; idade das pacientes&#44; sintomas&#44; tempo de evolu&#231;&#227;o&#44; diagn&#243;sticos principais e secund&#225;rios&#44; exames complementares e tratamentos utilizados&#46; O estudo foi aprovado pelo comit&#234; de &#233;tica do hospital&#44; e um documento de informa&#231;&#245;es sobre o estudo foi fornecido &#224;s pacientes interessadas em participar do mesmo&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Foi realizada an&#225;lise descritiva utilizando medidas de tend&#234;ncia central e dispers&#227;o para vari&#225;veis quantitativas e distribui&#231;&#227;o de frequ&#234;ncia para vari&#225;veis qualitativas&#46; Para a an&#225;lise estat&#237;stica&#44; utilizou&#8208;se o teste estat&#237;stico de qui&#8208;quadrado&#44; ou teste exato de Fisher&#44; se as frequ&#234;ncias esperadas fossem<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5&#44; para comparar as vari&#225;veis qualitativas&#46; O teste U de Mann&#8208;Whitney foi utilizado para comparar as vari&#225;veis quantitativas&#46; O n&#237;vel de signific&#226;ncia estat&#237;stica foi estabelecido em &#945;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; As an&#225;lises estat&#237;sticas foram realizadas com o software SPSS vers&#227;o 25&#46;0 para Apple macOS &#40;IBM Corporation&#44; Armonk&#44; NY&#44; EUA&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cento e quarenta e oito mulheres foram estudadas na cl&#237;nica da vulva durante per&#237;odo de cinco anos&#46; A idade m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177; desvio padr&#227;o &#40;DP&#41; era de 43&#44;24<span class="elsevierStyleHsp" style=""></span>&#177; 15&#44;15 anos&#44; com as idades das pacientes variando de 4 meses a 80 anos&#46; As pacientes foram divididas por idade com a seguinte distribui&#231;&#227;o&#58; &#60;<span class="elsevierStyleHsp" style=""></span>18 anos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#59; 6&#44;8&#37;&#41;&#44; entre 18 e 40 anos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#59; 33&#44;8&#37;&#41;&#44; entre 40 e 60 anos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&#59; 45&#44;9&#37;&#41;&#44; e<span class="elsevierStyleHsp" style=""></span>&#62; 60 anos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#59; 13&#44;5&#37;&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">O diagn&#243;stico prim&#225;rio mais frequente foi l&#237;quen escleroso &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>62&#59; 41&#44;9&#37;&#41;&#44; seguido de eczema irritativo da vulva &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#59; 14&#44;9&#37;&#41; e l&#237;quen simples cr&#244;nico &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#59; 10&#44;1&#37;&#41;&#46; Quatorze &#40;9&#44;5&#37;&#41; pacientes tamb&#233;m apresentavam outra dermatose concomitante no momento da consulta&#46; A evolu&#231;&#227;o das diferentes doen&#231;as prim&#225;rias foi a seguinte&#58; menos de um ano &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41&#59; 27&#44;7&#37;&#41;&#44; entre dois e cinco anos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>79&#59; 53&#44;4&#37;&#41; e mais de cinco anos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#59; 18&#44;9&#37;&#41;&#46; Cento e vinte e quatro pacientes &#40;83&#44;8&#37;&#41; relataram prurido anogenital&#44; 98 &#40;66&#44;2&#37;&#41; dor e 68 &#40;45&#44;9&#37;&#41; dispareunia&#46; Alguns exames complementares foram realizados em 36 &#40;22&#44;3&#37;&#41; casos&#44; dos quais 14 &#40;9&#44;5&#37;&#41; tiveram amostra microbiol&#243;gica coletada&#44; e em 22 &#40;14&#44;9&#37;&#41; foi realizada bi&#243;psia de pele&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">O tratamento mais prescrito foi o corticoide t&#243;pico ultrapotente &#40;propionato de clobetasol&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>61&#59; 41&#44;2&#37;&#41;&#44; e o tratamento adjuvante mais prescrito foi o gel t&#243;pico de cetoconazol &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>42&#59; 28&#44;4&#37;&#41;&#46; Em 34 &#40;23&#37;&#41; mulheres foi indicada fisioterapia do assoalho p&#233;lvico para desconforto vulvar&#59; em 23&#44; &#40;15&#44;5&#37;&#41; anti&#8208;histam&#237;nicos&#59; e em 15&#44; &#40;10&#44;1&#37;&#41; f&#243;rmula com 0&#44;5&#37; de triancinolona&#46; Em oito casos &#40;5&#44;4&#37;&#41; foram prescritos inibidores de calcineurina&#46; Outros tratamentos prescritos foram crioterapia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#59; 2&#44;7&#37;&#41;&#44; antif&#250;ngicos t&#243;picos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#59; 10&#44;1&#37;&#41;&#44; antibi&#243;ticos t&#243;picos e&#47;ou orais &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#59; 4&#44;7&#37;&#41;&#44; dilatadores vaginais &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#59; 0&#44;7&#37;&#41;&#44; imiquimod t&#243;pico &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#59; 1&#44;4&#37;&#41;&#44; gabapentina t&#243;pica &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#59; 0&#44;7&#37;&#41;&#44; diltiazem t&#243;pico &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#59; 0&#44;7&#37;&#41;&#44; antivirais &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#59; 2&#44;7&#37;&#41; e cirurgia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#59; 1&#44;4&#37;&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A an&#225;lise detalhada dos diferentes diagn&#243;sticos observados est&#225; mostrada na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a> e na <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46; As diferentes caracter&#237;sticas das doen&#231;as mais relevantes identificadas durante este estudo s&#227;o mostradas nas <a class="elsevierStyleCrossRefs" href="#tbl0010">tabelas 2 e 3</a>&#46; A <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> mostra a propor&#231;&#227;o de dor&#44; prurido e dispareunia que representam as principais doen&#231;as identificadas neste trabalho&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas das pacientes s&#227;o descritas com base nos diagn&#243;sticos mais relevantes&#46; Foi realizada uma an&#225;lise comparativa entre as pacientes que apresentavam l&#237;quen escleroso <span class="elsevierStyleItalic">versus</span> as que apresentavam outras dermatoses da vulva&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">L&#237;quen escleroso</span><p id="par0055" class="elsevierStylePara elsevierViewall">Ao todo&#44; 62 pacientes com l&#237;quen escleroso foram estudadas&#59; as pacientes tinham m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177; DP de idade de 46&#44;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;35 anos &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46; A evolu&#231;&#227;o foi menos de um ano em 13 &#40;21&#37;&#41; pacientes&#44; entre dois e cinco anos em 34 &#40;54&#44;8&#37;&#41; e mais de cinco anos em 15 &#40;24&#44;2&#37;&#41;&#46; Uma segunda dermatose concomitante foi registrada em sete pacientes&#59; o vitiligo foi a mais frequente &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#59; 3&#44;2&#37;&#41;&#46; Em geral&#44; 55 &#40;88&#44;7&#37;&#41; pacientes apresentavam prurido&#44; 38 &#40;61&#44;3&#37;&#41; dor e 27 &#40;43&#44;5&#37;&#41; dispareunia&#46; A bi&#243;psia de pele foi realizada em nove &#40;14&#44;5&#37;&#41; casos&#44; e amostras microbiol&#243;gicas foram obtidas em quatro &#40;6&#44;5&#37;&#41;&#46; Bi&#243;psias de pele foram realizadas para confirmar o diagn&#243;stico de l&#237;quen escleroso em casos clinicamente duvidosos&#44; em casos resistentes a esteroides &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41; e em les&#245;es ulceradas ou hipercerat&#243;ticas para descartar neoplasia maligna &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">figs&#46; 5 e 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">O tratamento mais frequente foi corticoide t&#243;pico ultrapotente &#40;propionato de clobetasol&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#59; 72&#44;6&#37;&#41;&#44; com gel t&#243;pico de cetoconazol a 2&#37; servindo como terapia adjuvante em 25 &#40;40&#44;3&#37;&#41; casos&#46; Em oito &#40;12&#44;95&#37;&#41; pacientes foi utilizada f&#243;rmula com 0&#44;5&#37; de triancinolona gel&#46; Em nove &#40;14&#44;5&#37;&#41; mulheres&#44; os anti&#8208;histam&#237;nicos tamb&#233;m foram indicados para o prurido&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Foi realizada uma an&#225;lise comparativa entre as pacientes com l&#237;quen escleroso e o restante das pacientes inclu&#237;das no estudo&#46; Foram encontradas diferen&#231;as estatisticamente significativas em rela&#231;&#227;o a idade e alguns dos tratamentos prescritos &#40;corticosteroides t&#243;picos ultrapotentes&#44; inibidores de calcineurina&#44; fisioterapia do assoalho p&#233;lvico e gel t&#243;pico de cetoconazol&#41;&#46; N&#227;o foram encontradas diferen&#231;as no tempo de evolu&#231;&#227;o da doen&#231;a ou nos sintomas&#46; A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> mostra as caracter&#237;sticas das pacientes com l&#237;quen escleroso e apresenta uma an&#225;lise comparativa com os demais casos&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Eczema irritativo da vulva</span><p id="par0070" class="elsevierStylePara elsevierViewall">Vinte e duas pacientes com eczema irritativo da vulva foram avaliadas &#40;<a class="elsevierStyleCrossRef" href="#fig0035">fig&#46; 7</a>&#41;&#59; tinham m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 38&#44;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;41 anos &#8211; a mais nova era uma crian&#231;a de 4 meses&#46; A evolu&#231;&#227;o era menos de um ano em cinco &#40;22&#44;7&#37;&#41; pacientes&#44; de dois a cinco anos em 15 &#40;68&#44;2&#37;&#41; e mais de cinco anos em duas pacientes &#40;9&#44;1&#37;&#41;&#46; Em uma &#250;nica paciente &#40;a referida paciente de 4 meses de idade&#41; foi registrada uma dermatose concomitante&#58; intertrigo por c&#226;ndida&#46; Ao todo&#44; 19 &#40;86&#44;4&#37;&#41; pacientes apresentavam prurido&#44; 19 &#40;86&#44;4&#37;&#41; dor e 12 &#40;54&#44;5&#37;&#41; dispareunia&#46; Bi&#243;psia de pele foi realizada em apenas dois &#40;9&#44;1&#37;&#41; casos&#44; e amostras microbiol&#243;gicas foram coletadas em tr&#234;s &#40;13&#44;6&#37;&#41;&#59; corticoide t&#243;pico ultrapotente foi indicado para quatro &#40;18&#44;2&#41; pacientes&#44; fisioterapia do assoalho p&#233;lvico para cinco &#40;22&#44;7&#37;&#41; e formula&#231;&#227;o com triancinolona 0&#44;5&#37; para uma paciente &#40;4&#44;5&#37;&#41;&#59; como terapia adjuvante&#44; anti&#8208;histam&#237;nicos foram indicados em cinco &#40;22&#44;7&#37;&#41; casos&#44; e gel t&#243;pico de cetoconazol a 2&#37; em cinco &#40;22&#44;7&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Entre os produtos para uso nas dermatoses&#44; foi observada grande variedade de cremes para uso &#237;ntimo e geral&#59; os mais frequentes foram blastoestimulina e uso de len&#231;os &#237;ntimos para higiene&#46; Em um caso&#44; a dermatose foi relacionada ao uso de tintura de cabelo em paciente com diagn&#243;stico pr&#233;vio de alergia &#224; p&#8208;fenilenodiamina&#59; esse representa o &#250;nico caso de dermatite al&#233;rgica de contato em toda a presente s&#233;rie&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">L&#237;quen simples cr&#244;nico</span><p id="par0080" class="elsevierStylePara elsevierViewall">Quinze pacientes com l&#237;quen simples cr&#244;nico foram estudadas&#59; tinham m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 41&#44;51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;00 anos&#46; A evolu&#231;&#227;o mais frequente foi menos de um ano em sete &#40;46&#44;7&#37;&#41; pacientes&#46; Dermatose concomitante&#44; intertrigo por c&#226;ndida&#44; foi registrada em uma &#250;nica paciente&#46; Todas as pacientes apresentavam prurido &#40;100&#44;0&#37;&#41;&#44; bem como dor &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#59; 66&#44;7&#37;&#41; e dispareunia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#59; 46&#44;7&#37;&#41;&#46; Em nenhum caso foi realizada bi&#243;psia de pele&#44; e amostras microbiol&#243;gicas foram obtidas em um &#250;nico caso&#46; O uso de corticoide t&#243;pico ultrapotente foi indicado em sete &#40;46&#44;7&#37;&#41; pacientes&#44; fisioterapia do assoalho p&#233;lvico em duas &#40;13&#44;3&#37;&#41; e f&#243;rmula contendo 0&#44;5&#37; de triancinolona em dois casos &#40;13&#44;3&#37;&#41;&#46; Como terapia adjuvante&#44; anti&#8208;histam&#237;nicos foram indicados em seis &#40;40&#37;&#41; casos e gel t&#243;pico de cetoconazol em seis &#40;40&#37;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Hidradenite supurativa</span><p id="par0085" class="elsevierStylePara elsevierViewall">Foram observadas seis mulheres com hidradenite supurativa&#44; com m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 45&#44;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;69 anos &#40;<a class="elsevierStyleCrossRef" href="#fig0040">fig&#46; 8</a>&#41;&#46; A evolu&#231;&#227;o foi menos de um ano em uma &#40;16&#44;7&#37;&#41; paciente&#44; entre dois e cinco anos em tr&#234;s &#40;50&#37;&#41; e mais de cinco anos em duas pacientes &#40;33&#44;3&#37;&#41;&#46; Quatro &#40;66&#44;7&#37;&#41; pacientes apresentavam prurido&#44; cinco &#40;83&#44;3&#37;&#41; apresentavam dor e sete dispareunia &#40;50&#37;&#41;&#46; Em nenhum caso foram realizadas bi&#243;psias de pele ou coletadas amostras microbiol&#243;gicas&#46; Antibi&#243;ticos t&#243;picos e&#47;ou orais foram prescritos para tr&#234;s pacientes&#46; A fisioterapia do assoalho p&#233;lvico foi indicada para uma paciente&#46; Como terapia adjuvante&#44; gel t&#243;pico de cetoconazol a 2&#37; foi indicado em um caso&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">L&#237;quen plano</span><p id="par0090" class="elsevierStylePara elsevierViewall">Foram avaliadas seis pacientes com l&#237;quen plano vulvar&#44; com m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 56&#44;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;22 anos&#46; O tempo de evolu&#231;&#227;o mais frequente foi de dois a cinco anos em cinco &#40;83&#44;3&#37;&#41; pacientes&#46; Cinco &#40;83&#44;3&#37;&#41; pacientes apresentavam prurido&#44; cinco &#40;83&#44;3&#37;&#41; dor e quatro &#40;66&#44;7&#37;&#41; dispareunia&#46; A bi&#243;psia de pele foi realizada em cinco &#40;83&#44;3&#37;&#41; casos&#44; e amostras microbiol&#243;gicas foram obtidas de uma &#250;nica paciente&#46; Corticoide t&#243;pico ultrapotente foi indicado em quatro &#40;66&#44;7&#37;&#41; pacientes&#59; triancinolona 0&#44;5&#37; foi prescrita para quatro &#40;66&#44;7&#37;&#41; pacientes&#44; e fisioterapia do assoalho p&#233;lvico foi indicada em tr&#234;s pacientes &#40;50&#37;&#41;&#46; Como terapia adjuvante&#44; gel t&#243;pico de cetoconazol a 2&#37; foi indicado para uma &#250;nica paciente&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">S&#237;ndromes de dor vulvar</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Vestibulodinia provocada secund&#225;ria</span><p id="par0095" class="elsevierStylePara elsevierViewall">Oito pacientes compareceram &#224;s consultas por dor vulvar inespec&#237;fica&#44; seis das quais foram diagnosticadas com vestibulodinia provocada secund&#225;ria&#44; com m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 44&#44;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;48 anos&#46; A evolu&#231;&#227;o era de menos de um ano em uma &#40;16&#44;7&#37;&#41; paciente&#44; entre dois e cinco anos em tr&#234;s &#40;50&#37;&#41; e mais de cinco anos em duas pacientes &#40;33&#44;3&#37;&#41;&#46; A candid&#237;ase vulvovaginal&#44; como concomitante&#44; foi registrada em uma &#250;nica paciente&#46; Cinco &#40;83&#44;3&#37;&#41; pacientes apresentavam prurido&#44; cinco &#40;83&#44;3&#37;&#41; dor e quatro dispareunia &#40;66&#44;7&#37;&#41;&#59; as outras duas pacientes n&#227;o tinham rela&#231;&#245;es sexuais&#44; de modo que n&#227;o foi poss&#237;vel avaliar a presen&#231;a ou aus&#234;ncia de dispareunia&#46; Em nenhum caso foi realizada bi&#243;psia de pele&#44; e amostras microbiol&#243;gicas foram obtidas em apenas um caso&#46; Dentre os tratamentos&#44; a fisioterapia do assoalho p&#233;lvico foi indicada em cinco casos&#44; gabapentina t&#243;pica em um caso e cirurgia em um caso&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Vulvod&#237;nia</span><p id="par0105" class="elsevierStylePara elsevierViewall">Duas pacientes foram &#224; consulta por vulvod&#237;nia com m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 30&#44;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;5 anos&#46; Ambas as pacientes apresentavam tempo de evolu&#231;&#227;o da doen&#231;a maior que cinco anos&#46; Em nenhum caso foram realizadas bi&#243;psias de pele ou coletadas amostras microbiol&#243;gicas&#46; Quanto ao tratamento&#44; foi indicada fisioterapia do assoalho p&#233;lvico em uma paciente e psicoterapia em outra&#46;</p></span></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discuss&#227;o</span><p id="par0110" class="elsevierStylePara elsevierViewall">O presente estudo mostra a experi&#234;ncia de cinco anos dos autores como dermatologistas no manejo de consultas espec&#237;ficas relacionadas a doen&#231;as da vulva&#46; Em todos os momentos&#44; essas consultas foram organizadas em estreita colabora&#231;&#227;o e com constante comunica&#231;&#227;o entre os v&#225;rios membros da equipe do servi&#231;o de ginecologia do hospital&#46; Ao todo&#44; 148 mulheres foram avaliadas&#59; as que compareceram &#224; consulta tinham maior probabilidade de ter entre 40 e 60 anos&#44; e o diagn&#243;stico mais frequente foi o de l&#237;quen escleroso&#46; Esse diagn&#243;stico foi seguido por eczema irritativo e l&#237;quen simples cr&#244;nico&#44; como em outras s&#233;ries&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8&#8211;10</span></a> A pr&#225;tica cl&#237;nica dos autores tem verificado aumento no n&#250;mero de pacientes atendidas a cada ano&#44; especialmente nos &#250;ltimos dois anos&#46; De fato&#44; no per&#237;odo de 2018 a 2020&#44; 89&#44;2&#37; das mulheres desta s&#233;rie compareceram &#224; consulta pela primeira vez&#46; Por um lado&#44; esses dados refletem o aumento do conhecimento e das preocupa&#231;&#245;es das pacientes em rela&#231;&#227;o &#224; vulva e suas diferentes altera&#231;&#245;es&#59; por outro lado&#44; os dados tamb&#233;m representam um aumento na procura por um especialista em dermatologia que possa atuar como m&#233;dico de refer&#234;ncia no diagn&#243;stico e tratamento de doen&#231;as da vulva&#46; Essa necessidade provavelmente surgiu tamb&#233;m pelo contato direto e pr&#243;ximo com outros especialistas como ginecologistas&#44; urologistas e m&#233;dicos generalistas no hospital&#44; o que &#233; alcan&#231;ado por meio de reuni&#245;es e sess&#245;es cl&#237;nicas bimestrais&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Pacientes com doen&#231;as da vulva costumam demorar muito para procurar atendimento m&#233;dico&#44; principalmente por causa da ansiedade e do constrangimento&#46; Al&#233;m disso&#44; essa demora em ir ao m&#233;dico faz com que muitas pacientes utilizem rem&#233;dios caseiros como tratamento&#44; o que est&#225; frequentemente associado ao agravamento dos sintomas&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Mais da metade das pacientes no presente estudo &#40;54&#44;8&#37;&#41; levaram entre dois e cinco anos para buscar consulta m&#233;dica&#46; Considerando que muitas das doen&#231;as t&#234;m impacto muito negativo na qualidade de vida das pacientes&#44; e que algumas dessas doen&#231;as s&#227;o pr&#233;&#8208;neopl&#225;sicas&#44; &#233; essencial evitar esse atraso no diagn&#243;stico&#44; promovendo o atendimento m&#233;dico precoce &#224;s pacientes com sintomas na regi&#227;o da vulva&#44; facilitando assim o diagn&#243;stico precoce&#46; Estima&#8208;se que aproximadamente uma em cada seis mulheres experimentar&#225; desconforto vulvovaginal n&#227;o diagnosticado ou n&#227;o tratado durante a vida&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">A doen&#231;a mais frequentemente identificada em nossa s&#233;rie foi o l&#237;quen escleroso&#44; doen&#231;a inflamat&#243;ria cr&#244;nica que acomete principalmente a regi&#227;o anogenital&#46; Ela afeta mais frequentemente as mulheres na pr&#233;&#8208;puberdade e na p&#243;s&#8208;menopausa&#44; e sua etiologia &#233; influenciada por fatores gen&#233;ticos e autoimunes&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Sua verdadeira preval&#234;ncia &#233; desconhecida e varia dependendo se a mesma &#233; avaliada por especialistas em ginecologia ou dermatologia&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> Entretanto&#44; sua incid&#234;ncia parece estar aumentando&#44; e &#233; um dos diagn&#243;sticos mais frequentes nas consultas relacionadas a doen&#231;as vulvares&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> embora isso tamb&#233;m possa ser resultado do aumento das consultas e do n&#250;mero de diagn&#243;sticos&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">No presente estudo&#44; o l&#237;quen escleroso representou 41&#44;9&#37; do total de doen&#231;as identificadas&#44; tornando&#8208;se a doen&#231;a mais frequentemente identificada&#44; similar ao relatado em outros estudos&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8&#8211;10</span></a> Eczema irritativo e l&#237;quen simples cr&#244;nico s&#227;o dermatoses comuns que frequentemente afetam a vulva na popula&#231;&#227;o geral&#46; Entre as causas de ambas as dermatoses&#44; &#233; importante investigar todos os produtos que foram aplicados topicamente na vulva&#59; os m&#233;dicos tamb&#233;m devem perguntar sobre h&#225;bitos de higiene &#237;ntima e perguntar se a paciente est&#225; apresentando algum tipo de incontin&#234;ncia&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Nos casos em que n&#227;o houver melhora&#44; seria conveniente realizar testes epicut&#226;neos para descartar etiologia al&#233;rgica&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Assim como o l&#237;quen escleroso&#44; essas dermatoses representam importante causa de consulta&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Foi detectado um &#250;nico caso de dermatite al&#233;rgica de contato em paciente j&#225; diagnosticada com alergia de contato a p&#8208;fenilenodiamina&#46; A demora no diagn&#243;stico dessa paciente foi de quase seis meses&#44; pois ela n&#227;o associou o uso de tintura nos pelos da regi&#227;o genital com o desconforto que apresentava e n&#227;o comentou sobre isso durante a consulta&#46; Com esse caso espec&#237;fico&#44; os autores querem destacar a import&#226;ncia de obter hist&#243;rico m&#233;dico exaustivo&#44; essencial para o diagn&#243;stico de doen&#231;as cut&#226;neas da vulva&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Em conjunto&#44; as doen&#231;as inflamat&#243;rias&#44; incluindo l&#237;quen escleroso&#44; eczema vulvar&#44; l&#237;quen simples cr&#244;nico e l&#237;quen plano&#44; representaram 71&#37; do total da s&#233;rie&#46; Por outro lado&#44; oito pacientes da s&#233;rie &#40;5&#44;4&#37;&#41; procuraram a consulta por s&#237;ndromes de dor vulvar&#44; incluindo vulvod&#237;nia e vestibulod&#237;nia&#46; Atualmente&#44; a preval&#234;ncia dessa condi&#231;&#227;o &#233; desconhecida na Espanha&#44; tanto pela falta de consultas espec&#237;ficas das pacientes quanto pela falta de treinamento dos especialistas que as atendem&#46; Vulvod&#237;nia &#233; um dist&#250;rbio de dor vulvar que ocorre frequentemente&#44; mas raramente &#233; reconhecido e &#233; definido como dor espont&#226;nea ou provocada na &#225;rea vulvar com dura&#231;&#227;o maior que tr&#234;s meses de evolu&#231;&#227;o&#44; sem causa estabelecida&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#44;13</span></a> Embora sua etiologia seja multifatorial&#44; parece que a disfun&#231;&#227;o muscular do assoalho p&#233;lvico &#233; fator chave&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> Quando a dor vulvar &#233; limitada ao vest&#237;bulo e geralmente &#233; desencadeada por fric&#231;&#227;o&#44; ela &#233; chamada de vestibulodinia provocada secund&#225;ria&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> Na presente s&#233;rie&#44; seis das oito pacientes com dor vulvar foram diagnosticadas com vestibulod&#237;nia&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Onze pacientes &#40;7&#44;4&#37;&#41; buscaram consulta por causa infecciosa&#46; Ao contr&#225;rio do presente estudo&#44; outros autores afirmaram que as doen&#231;as da vulva mais frequentes em consultas m&#233;dicas s&#227;o infec&#231;&#245;es f&#250;ngicas e bacterianas&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> Embora seja poss&#237;vel que as causas mais frequentes de doen&#231;as da vulva sejam infec&#231;&#245;es&#44; a maioria &#233; tratada por m&#233;dicos da aten&#231;&#227;o prim&#225;ria ou encaminhadas a ginecologistas&#44; e esses geralmente n&#227;o realizam consultas espec&#237;ficas da vulva&#46; De fato&#44; outros estudos semelhantes ao presente trabalho&#44; realizados por dermatologistas&#44; relataram percentual semelhante de infec&#231;&#245;es&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8&#44;9</span></a> Da mesma maneira&#44; as v&#225;rias doen&#231;as inflamat&#243;rias que afetam a vulva &#8211; e que foram t&#227;o prevalentes nas consultas &#8211; inclu&#237;ram dermatite at&#243;pica&#44; psor&#237;ase ou hidradenite supurativa &#40;<a class="elsevierStyleCrossRef" href="#fig0040">fig&#46; 8</a>&#41;&#46; Essas doen&#231;as geralmente n&#227;o s&#227;o observadas durante as consultas&#44; pois os dermatologistas ou outros especialistas est&#227;o familiarizados com seu tratamento e geralmente n&#227;o encaminham as pacientes para outros especialistas&#46; Isso explicaria por que o l&#237;quen escleroso&#44; doen&#231;a espec&#237;fica da vulva&#44; &#233; a mais frequentemente diagnosticada&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Em decorr&#234;ncia de caracter&#237;sticas anat&#244;micas particulares da vulva&#44; as doen&#231;as dessa regi&#227;o s&#227;o tratadas de modo diferente de outras &#225;reas da pele&#46; Em doen&#231;as inflamat&#243;rias&#44; o uso de corticosteroides t&#243;picos ultrapotentes &#233; essencial&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Esses agentes s&#227;o conhecidos por melhorar muito os sintomas e&#44; al&#233;m disso&#44; em algumas doen&#231;as&#44; como o l&#237;quen escleroso&#44; parecem reduzir o risco de progress&#227;o para carcinoma de c&#233;lulas escamosas da vulva&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#44;17</span></a> De fato&#44; foi o tratamento mais frequentemente prescrito na presente s&#233;rie&#46; Uma segunda op&#231;&#227;o comum para tratar doen&#231;as inflamat&#243;rias da vulva&#44; e tamb&#233;m de acordo com as diretrizes atuais&#44; inclui os inibidores de calcineurina&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18&#44;19</span></a> &#201; de opini&#227;o dos autores que sua efic&#225;cia &#233; um pouco limitada por seus efeitos colaterais frequentes de dor e ard&#234;ncia ap&#243;s a aplica&#231;&#227;o&#46; Por essa raz&#227;o&#44; no presente estudo&#44; esses agentes foram prescritos apenas para 5&#44;4&#37; das pacientes&#46; Em muitas ocasi&#245;es&#44; as pacientes n&#227;o toleravam os cremes ou prepara&#231;&#245;es comerciais que s&#227;o distribu&#237;dos na farm&#225;cia em raz&#227;o de sua intoler&#226;ncia &#224; f&#243;rmula ou a seus excipientes&#46; Portanto&#44; a formula&#231;&#227;o de corticosteroides ultrapotentes e potentes&#44; como a triancinolona&#44; &#233; essencial em fun&#231;&#227;o de sua toler&#226;ncia para aplica&#231;&#227;o na &#225;rea genital&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Deve&#8208;se destacar o trabalho multidisciplinar na presente pr&#225;tica&#44; pois os autores n&#227;o trabalharam apenas com a ginecologia&#44; mas integraram uma unidade espec&#237;fica do assoalho p&#233;lvico&#44; contaram com a colabora&#231;&#227;o de especialistas em psicolog&#237;a e sexologia&#46; Quase 100&#37; das pacientes atendidas relataram dor vulvar relacionada aos surtos de sua doen&#231;a espec&#237;fica&#44; ou mesmo nos per&#237;odos entre surtos&#44; representando parte das s&#237;ndromes de dor vulvar secund&#225;ria&#46; Em geral&#44; a dor vulvar pode afetar at&#233; 20&#37; das mulheres em algum momento de suas vidas&#44; e sabe&#8208;se que a maioria dos casos est&#225; associada a dist&#250;rbios do assoalho p&#233;lvico&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">A fisioterapia do assoalho p&#233;lvico &#233; uma disciplina relativamente nova que vem ganhando relev&#226;ncia na &#250;ltima d&#233;cada&#44; n&#227;o apenas por sua efic&#225;cia como tratamento para mulheres com dor vulvar prim&#225;ria ou secund&#225;ria&#44; mas tamb&#233;m por auxiliar na preven&#231;&#227;o e manuten&#231;&#227;o da sa&#250;de do assoalho p&#233;lvico durante a gravidez&#44; p&#243;s&#8208;parto e climat&#233;rio&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14&#44;20</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">A grande maioria das pacientes atendidas no servi&#231;o dos autores relatou dor ou desconforto vulvar&#46; A fisioterapia do assoalho p&#233;lvico possibilita a avalia&#231;&#227;o desses processos e o diagn&#243;stico precoce e tratamento de poss&#237;veis vulvod&#237;nias secund&#225;rias e disfun&#231;&#245;es musculares p&#233;lvicas&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Infelizmente&#44; na Espanha&#44; nem o sistema p&#250;blico de sa&#250;de nem as seguradoras de sa&#250;de normalmente cobrem esse tipo de assist&#234;ncia&#46; Assim&#44; embora seja recomendado que uma grande porcentagem de pacientes compare&#231;a para avalia&#231;&#227;o&#44; as limita&#231;&#245;es econ&#244;micas e a falta de informa&#231;&#227;o sobre essa especialidade fazem com que apenas uma pequena porcentagem compare&#231;a &#40;23&#37; do total&#41;&#44; com melhoras evidentes em todos elas&#46; Algo semelhante ocorreu com a psicoterapia e a sexologia&#46; Uma grande porcentagem de mulheres &#40;45&#44;9&#37;&#41; relatou dor ou desconforto na rela&#231;&#227;o sexual&#44; mas apenas duas pacientes foram &#224;s consultas com especialistas em psicologia e sexologia&#46; Motivos financeiros&#44; vergonha e o fato de que a consulta com psic&#243;logo&#47;sex&#243;logo &#233; considerada tabu social foram os principais motivos citados para que as pacientes se abstivessem da consulta&#46; Os autores consideram que a partir de estudos de base como esse&#44; estudos futuros possam avaliar como a fisioterapia e a psicoterapia do assoalho p&#233;lvico influenciam a qualidade de vida de pacientes com doen&#231;as da vulva&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">O presente estudo tem algumas limita&#231;&#245;es&#46; Por um lado&#44; apresentou as v&#225;rias limita&#231;&#245;es associadas aos estudos retrospectivos&#46; Por outro lado&#44; o n&#250;mero limitado de pacientes&#44; bem como o fato de que determinadas doen&#231;as como as de causa infecciosa&#44; costumam ser atendidas na aten&#231;&#227;o prim&#225;ria&#59; portanto&#44; esses casos n&#227;o foram inclu&#237;dos no presente estudo&#46; Al&#233;m disso&#44; n&#227;o foram coletados dados sobre a resposta e&#47;ou satisfa&#231;&#227;o das pacientes aos diferentes tratamentos&#46; Por fim&#44; o fato de todas as pacientes serem oriundas de um &#250;nico hospital privado limitou a possibilidade de obter&#8208;se conclus&#245;es relevantes&#44; pois&#44; quando comparado ao sistema p&#250;blico de sa&#250;de&#44; &#233; acentuadamente mais f&#225;cil consultar um dermatologista e outras especialidades m&#233;dicas e servi&#231;os de sa&#250;de relacionados&#46; Por outro lado&#44; h&#225; diferentes limita&#231;&#245;es socioecon&#244;micas associadas ao acesso &#224; sa&#250;de privada e &#224;s diferentes coberturas de seguros de sa&#250;de&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclus&#227;o</span><p id="par0170" class="elsevierStylePara elsevierViewall">Apresentamos a experi&#234;ncia dos autores ap&#243;s cinco anos de realiza&#231;&#227;o de consultas espec&#237;ficas de vulva&#46; As doen&#231;as da vulva s&#227;o frequentes e comumente associadas a alta morbidade&#46; Assim&#44; &#233; fundamental que essas pacientes sejam avaliadas em unidades espec&#237;ficas que garantam assist&#234;ncia integral&#46; Tamb&#233;m &#233; necess&#225;rio que essas unidades incluam outros especialistas com experi&#234;ncia na &#225;rea&#44; como ginecologistas&#44; urologistas&#44; fisioterapeutas e psic&#243;logos&#44; que possam garantir abordagem multidisciplinar no atendimento &#224;s pacientes com sintomas vulvovaginais&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Suporte financeiro</span><p id="par0175" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Contribui&#231;&#227;o dos autores</span><p id="par0180" class="elsevierStylePara elsevierViewall">Fernando Garc&#237;a&#8208;Souto&#58; Elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; an&#225;lise estat&#237;stica&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Ana Isabel Lorente&#8208;Lavirgen&#58; Concep&#231;&#227;o e planeamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Francisco Manuel Ildefonso Mendon&#231;a&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Manuel Garc&#237;a&#8208;de&#8208;Lomas&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Mariana Viktoria Hoffner&#8208;Zuchelli&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Desiree Rodriguez&#8208;Ojeda&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Elena Pozo&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Jos&#233; Bernab&#233;u&#8208;Wittel&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflito de interesses</span><p id="par0220" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">As doen&#231;as da vulva s&#227;o comuns na popula&#231;&#227;o em geral e t&#234;m impacto negativo na qualidade de vida&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descrever a experi&#234;ncia dos autores como dermatologistas na conduta de consultas de dermatose da vulva&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Foi realizado um estudo observacional retrospectivo com pacientes que compareceram a consultas para les&#245;es na vulva durante um per&#237;odo de cinco anos&#46; As informa&#231;&#245;es cl&#237;nicas foram obtidas dos prontu&#225;rios dos pacientes&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Foram estudadas 148 mulheres&#46; A m&#233;dia de idade foi de 43&#44;24 anos &#40;desvio padr&#227;o&#58; 15&#44;15 anos&#41;&#44; com idades variando de 4 meses a 80 anos&#59; 53&#44;4&#37; das pacientes levaram entre dois e cinco anos para procurar atendimento m&#233;dico pela primeira vez&#46; Os diagn&#243;sticos mais frequentes foram l&#237;quen escleroso &#40;41&#44;9&#37;&#41;&#44; eczema irritativo da vulva &#40;14&#44;9&#37;&#41; e l&#237;quen simples cr&#244;nico &#40;10&#44;1&#37;&#41;&#46; Al&#233;m disso&#44; 83&#44;8&#37; relataram prurido anogenital&#44; 66&#44;2&#37; dor e 45&#44;9&#37; dispareunia&#46; O tratamento mais prescrito foi o corticoide t&#243;pico ultrapotente &#40;propionato de clobetasol&#59; 41&#44;2&#37;&#41;&#46; As pacientes com l&#237;quen escleroso eram significativamente mais velhas do que aquelas que apresentavam qualquer uma das outras doen&#231;as&#46; N&#227;o foram encontradas diferen&#231;as em rela&#231;&#227;o ao tempo de evolu&#231;&#227;o da doen&#231;a ou na apresenta&#231;&#227;o dos sintomas&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Limita&#231;&#245;es do estudo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospectivo&#46; As doen&#231;as da vulva com causa infecciosa geralmente s&#227;o tratadas na aten&#231;&#227;o prim&#225;ria e&#44; portanto&#44; n&#227;o foram inclu&#237;das&#46; Todas as pacientes foram recrutadas em um &#250;nico hospital privado&#44; o que limita as compara&#231;&#245;es com o sistema p&#250;blico de sa&#250;de&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">As doen&#231;as da vulva ocorrem com frequ&#234;ncia e est&#227;o associadas a alta morbidade&#46; &#201; fundamental promover o desenvolvimento de consultas espec&#237;ficas para essas pacientes nos hospitais&#46; Especialidades como dermatologia&#44; ginecologia&#44; urologia e fisioterapia devem fazer parte dessas unidades de atendimento&#46;</p></span>"
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                  \t\t\t\t">L&#237;quen plano&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">6 &#40;4&#44;1&#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">Vestibulod&#237;nia provocada secund&#225;ria&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">6 &#40;4&#44;1&#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">Candid&#237;ase vulvovaginal recorrente&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">4 &#40;2&#44;7&#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">Intertrigo por Candida&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">3 &#40;2&#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">Fissura vulvar&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">3 &#40;2&#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">Condilomas&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">3 &#40;2&#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">Melanose vulvar&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 &#40;1&#44;4&#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">Vulvod&#237;nia&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 &#40;1&#44;4&#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">Esp&#237;culas vestibulares&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 &#40;1&#44;4&#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">Doen&#231;a de Paget da vulva&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">1 &#40;0&#44;7&#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">Gl&#226;ndulas de Fordyce&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">1 &#40;0&#44;7&#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">Leucoplasia&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">1 &#40;0&#44;7&#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">Deisc&#234;ncia de episiotomia&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">1 &#40;0&#44;7&#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">S&#237;ndrome geniturin&#225;ria&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">1 &#40;0&#44;7&#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">Vulva normal&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">1 &#40;0&#44;7&#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">Sebocistomas&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">1 &#40;0&#44;7&#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">Fissura anal&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">1 &#40;0&#44;7&#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">Hiperestesia do clit&#243;ris&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">1 &#40;0&#44;7&#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">NIV comum&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">1 &#40;0&#44;7&#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">Esclerodermia&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">1 &#40;0&#44;7&#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">Herpes genital&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">1 &#40;0&#44;7&#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">TOTAL&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">148 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3688205.png"
              ]
            ]
            1 => 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">Diagn&#243;sticos secund&#225;rios&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">n &#40;&#37;&#41;&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">Nenhum&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">134 &#40;90&#44;5&#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">Candid&#237;ase secund&#225;ria&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 &#40;1&#44;4&#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">Intertrigo por <span class="elsevierStyleItalic">Candida</span>&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 &#40;1&#44;4&#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">Condilomas&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">1 &#40;0&#44;7&#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">Eczema irritativo&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">1 &#40;0&#44;7&#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">Eczema perianal&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">1 &#40;0&#44;7&#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">Fissura vulvar&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">1 &#40;0&#44;7&#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">L&#237;quen escleroso&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">1 &#40;0&#44;7&#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">L&#237;quen plano&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">1 &#40;0&#44;7&#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">Molusco&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"><span class="elsevierStyleHsp" style=""></span>Prurido&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">55 &#40;88&#44;7&#41;&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">69 &#40;80&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dor&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">60 &#40;69&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">13 &#40;15&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;14&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dispareunia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Microbiologia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bi&#243;psia de pele&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Corticosteroide t&#243;pico ultrapotente&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inibidores t&#243;picos da calcineurina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fisioterapia do assoalho p&#233;lvico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antibi&#243;ticos orais e&#47;ou t&#243;picos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cirurgia&nbsp;\t\t\t\t\t\t\n
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Artigo original
Dermatoses vulvares: estudo transversal de cinco anos. Experiência em unidade especializada em doenças da vulva
Fernando García‐Soutoa, Ana Isabel Lorente‐Lavirgena, Francisco Manuel Ildefonso Mendonçaa,
Corresponding author
franciscomendonsa@gmail.com

Autor para correspondência.
, Manuel García‐de‐Lomasb, Mariana Viktoria Hoffner‐Zuchellia, Desiree Rodriguez‐Ojedaa, Elena Pozoc, José Bernabéu‐Wittela
a Departamento de Dermatologia, Hospital Viamed Santa Angela de la Cruz, Sevilha, Espanha
b Departamento de Ginecologia e Obstetrícia, Hospital Viamed Santa Angela de la Cruz, Sevilha, Espanha
c Fisinergia Fisioterapia Pélvico‐Perineal, Sevilha, Espanha
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pois pacientes com sintomas vulvares comumente levam muito tempo para consultar um m&#233;dico&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Embora em geral os ginecologistas sejam os primeiros especialistas a atender pacientes com sintomas vulvovaginais&#44; eles geralmente recebem pouco treinamento no manejo de doen&#231;as dermatol&#243;gicas da vulva&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Os dermatologistas s&#227;o especialistas na avalia&#231;&#227;o e tratamento da pele e das membranas mucosas&#44; incluindo a regi&#227;o genital&#46; No entanto&#44; a vulva &#233; uma &#225;rea muitas vezes negligenciada pelos dermatologistas&#46; Os motivos mais comuns para isso incluem falta de treinamento&#44; desconforto durante a entrevista cl&#237;nica e falta de conhecimento dos exames complementares comumente utilizados em doen&#231;as vulvares&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Em pesquisa realizada nos Estados Unidos da Am&#233;rica do Norte que objetivou avaliar compet&#234;ncias no manejo de doen&#231;as da vulva entre estudantes de medicina e residentes de dermatologia e ginecologia&#44; apenas 19&#37; dos estudantes avaliados relataram ter recebido treinamento espec&#237;fico durante a resid&#234;ncia&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Embora tenha havido interesse crescente entre os dermatologistas no estudo da vulva nos &#250;ltimos anos<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> &#8211; particularmente entre os dermatologistas do Reino Unido&#44; um dos principais pa&#237;ses a desenvolver unidades espec&#237;ficas dedicadas ao tratamento de doen&#231;as da vulva &#8211;&#44; h&#225; atualmente poucos estudos cient&#237;ficos sobre o assunto&#46; Assim&#44; o objetivo deste estudo &#233; descrever a experi&#234;ncia dos autores como dermatologistas no manejo de consultas de dermatoses da vulva&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Materiais e m&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Estudo observacional retrospectivo foi realizado durante um per&#237;odo de cinco anos no hospital Viamed Santa Angela de la Cruz&#44; em Sevilha&#44; sul da Espanha&#46; Entre maio de 2015 e maio de 2020&#59; todas as pacientes que visitaram a unidade vulvar foram inclu&#237;das no estudo&#46; A coleta de dados foi realizada por especialista em dermatologia&#46; Os dados foram obtidos da hist&#243;ria cl&#237;nica de cada paciente&#46; As seguintes vari&#225;veis foram coletadas para an&#225;lise&#58; idade das pacientes&#44; sintomas&#44; tempo de evolu&#231;&#227;o&#44; diagn&#243;sticos principais e secund&#225;rios&#44; exames complementares e tratamentos utilizados&#46; O estudo foi aprovado pelo comit&#234; de &#233;tica do hospital&#44; e um documento de informa&#231;&#245;es sobre o estudo foi fornecido &#224;s pacientes interessadas em participar do mesmo&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Foi realizada an&#225;lise descritiva utilizando medidas de tend&#234;ncia central e dispers&#227;o para vari&#225;veis quantitativas e distribui&#231;&#227;o de frequ&#234;ncia para vari&#225;veis qualitativas&#46; 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13&#44;5&#37;&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">O diagn&#243;stico prim&#225;rio mais frequente foi l&#237;quen escleroso &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>62&#59; 41&#44;9&#37;&#41;&#44; seguido de eczema irritativo da vulva &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#59; 14&#44;9&#37;&#41; e l&#237;quen simples cr&#244;nico &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#59; 10&#44;1&#37;&#41;&#46; Quatorze &#40;9&#44;5&#37;&#41; pacientes tamb&#233;m apresentavam outra dermatose concomitante no momento da consulta&#46; A evolu&#231;&#227;o das diferentes doen&#231;as prim&#225;rias foi a seguinte&#58; menos de um ano &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41&#59; 27&#44;7&#37;&#41;&#44; entre dois e cinco anos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>79&#59; 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28&#44;4&#37;&#41;&#46; Em 34 &#40;23&#37;&#41; mulheres foi indicada fisioterapia do assoalho p&#233;lvico para desconforto vulvar&#59; em 23&#44; &#40;15&#44;5&#37;&#41; anti&#8208;histam&#237;nicos&#59; e em 15&#44; &#40;10&#44;1&#37;&#41; f&#243;rmula com 0&#44;5&#37; de triancinolona&#46; Em oito casos &#40;5&#44;4&#37;&#41; foram prescritos inibidores de calcineurina&#46; Outros tratamentos prescritos foram crioterapia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#59; 2&#44;7&#37;&#41;&#44; antif&#250;ngicos t&#243;picos &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#59; 10&#44;1&#37;&#41;&#44; antibi&#243;ticos t&#243;picos e&#47;ou orais &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#59; 4&#44;7&#37;&#41;&#44; dilatadores vaginais &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#59; 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As diferentes caracter&#237;sticas das doen&#231;as mais relevantes identificadas durante este estudo s&#227;o mostradas nas <a class="elsevierStyleCrossRefs" href="#tbl0010">tabelas 2 e 3</a>&#46; A <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> mostra a propor&#231;&#227;o de dor&#44; prurido e dispareunia que representam as principais doen&#231;as identificadas neste trabalho&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas das pacientes s&#227;o descritas com base nos diagn&#243;sticos mais relevantes&#46; Foi realizada uma an&#225;lise comparativa entre as pacientes que apresentavam l&#237;quen escleroso <span class="elsevierStyleItalic">versus</span> as que apresentavam outras dermatoses da vulva&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">L&#237;quen escleroso</span><p id="par0055" class="elsevierStylePara elsevierViewall">Ao todo&#44; 62 pacientes com l&#237;quen escleroso foram estudadas&#59; as pacientes tinham m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177; DP de idade de 46&#44;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;35 anos &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46; A evolu&#231;&#227;o foi menos de um ano em 13 &#40;21&#37;&#41; pacientes&#44; entre dois e cinco anos em 34 &#40;54&#44;8&#37;&#41; e mais de cinco anos em 15 &#40;24&#44;2&#37;&#41;&#46; Uma segunda dermatose concomitante foi registrada em sete pacientes&#59; o vitiligo foi a mais frequente &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#59; 3&#44;2&#37;&#41;&#46; Em geral&#44; 55 &#40;88&#44;7&#37;&#41; pacientes apresentavam prurido&#44; 38 &#40;61&#44;3&#37;&#41; dor e 27 &#40;43&#44;5&#37;&#41; dispareunia&#46; A bi&#243;psia de pele foi realizada em nove &#40;14&#44;5&#37;&#41; casos&#44; e amostras microbiol&#243;gicas foram obtidas em quatro &#40;6&#44;5&#37;&#41;&#46; Bi&#243;psias de pele foram realizadas para confirmar o diagn&#243;stico de l&#237;quen escleroso em casos clinicamente duvidosos&#44; em casos resistentes a esteroides &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41; e em les&#245;es ulceradas ou hipercerat&#243;ticas para descartar neoplasia maligna &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">figs&#46; 5 e 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">O tratamento mais frequente foi corticoide t&#243;pico ultrapotente &#40;propionato de clobetasol&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#59; 72&#44;6&#37;&#41;&#44; com gel t&#243;pico de cetoconazol a 2&#37; servindo como terapia adjuvante em 25 &#40;40&#44;3&#37;&#41; casos&#46; Em oito &#40;12&#44;95&#37;&#41; pacientes foi utilizada f&#243;rmula com 0&#44;5&#37; de triancinolona gel&#46; Em nove &#40;14&#44;5&#37;&#41; mulheres&#44; os anti&#8208;histam&#237;nicos tamb&#233;m foram indicados para o prurido&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Foi realizada uma an&#225;lise comparativa entre as pacientes com l&#237;quen escleroso e o restante das pacientes inclu&#237;das no estudo&#46; Foram encontradas diferen&#231;as estatisticamente significativas em rela&#231;&#227;o a idade e alguns dos tratamentos prescritos &#40;corticosteroides t&#243;picos ultrapotentes&#44; inibidores de calcineurina&#44; fisioterapia do assoalho p&#233;lvico e gel t&#243;pico de cetoconazol&#41;&#46; N&#227;o foram encontradas diferen&#231;as no tempo de evolu&#231;&#227;o da doen&#231;a ou nos sintomas&#46; A <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a> mostra as caracter&#237;sticas das pacientes com l&#237;quen escleroso e apresenta uma an&#225;lise comparativa com os demais casos&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Eczema irritativo da vulva</span><p id="par0070" class="elsevierStylePara elsevierViewall">Vinte e duas pacientes com eczema irritativo da vulva foram avaliadas &#40;<a class="elsevierStyleCrossRef" href="#fig0035">fig&#46; 7</a>&#41;&#59; tinham m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 38&#44;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;41 anos &#8211; a mais nova era uma crian&#231;a de 4 meses&#46; A evolu&#231;&#227;o era menos de um ano em cinco &#40;22&#44;7&#37;&#41; pacientes&#44; de dois a cinco anos em 15 &#40;68&#44;2&#37;&#41; e mais de cinco anos em duas pacientes &#40;9&#44;1&#37;&#41;&#46; Em uma &#250;nica paciente &#40;a referida paciente de 4 meses de idade&#41; foi registrada uma dermatose concomitante&#58; intertrigo por c&#226;ndida&#46; Ao todo&#44; 19 &#40;86&#44;4&#37;&#41; pacientes apresentavam prurido&#44; 19 &#40;86&#44;4&#37;&#41; dor e 12 &#40;54&#44;5&#37;&#41; dispareunia&#46; Bi&#243;psia de pele foi realizada em apenas dois &#40;9&#44;1&#37;&#41; casos&#44; e amostras microbiol&#243;gicas foram coletadas em tr&#234;s &#40;13&#44;6&#37;&#41;&#59; corticoide t&#243;pico ultrapotente foi indicado para quatro &#40;18&#44;2&#41; pacientes&#44; fisioterapia do assoalho p&#233;lvico para cinco &#40;22&#44;7&#37;&#41; e formula&#231;&#227;o com triancinolona 0&#44;5&#37; para uma paciente &#40;4&#44;5&#37;&#41;&#59; como terapia adjuvante&#44; anti&#8208;histam&#237;nicos foram indicados em cinco &#40;22&#44;7&#37;&#41; casos&#44; e gel t&#243;pico de cetoconazol a 2&#37; em cinco &#40;22&#44;7&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Entre os produtos para uso nas dermatoses&#44; foi observada grande variedade de cremes para uso &#237;ntimo e geral&#59; os mais frequentes foram blastoestimulina e uso de len&#231;os &#237;ntimos para higiene&#46; Em um caso&#44; a dermatose foi relacionada ao uso de tintura de cabelo em paciente com diagn&#243;stico pr&#233;vio de alergia &#224; p&#8208;fenilenodiamina&#59; esse representa o &#250;nico caso de dermatite al&#233;rgica de contato em toda a presente s&#233;rie&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">L&#237;quen simples cr&#244;nico</span><p id="par0080" class="elsevierStylePara elsevierViewall">Quinze pacientes com l&#237;quen simples cr&#244;nico foram estudadas&#59; tinham m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 41&#44;51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;00 anos&#46; A evolu&#231;&#227;o mais frequente foi menos de um ano em sete &#40;46&#44;7&#37;&#41; pacientes&#46; Dermatose concomitante&#44; intertrigo por c&#226;ndida&#44; foi registrada em uma &#250;nica paciente&#46; Todas as pacientes apresentavam prurido &#40;100&#44;0&#37;&#41;&#44; bem como dor &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#59; 66&#44;7&#37;&#41; e dispareunia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#59; 46&#44;7&#37;&#41;&#46; Em nenhum caso foi realizada bi&#243;psia de pele&#44; e amostras microbiol&#243;gicas foram obtidas em um &#250;nico caso&#46; O uso de corticoide t&#243;pico ultrapotente foi indicado em sete &#40;46&#44;7&#37;&#41; pacientes&#44; fisioterapia do assoalho p&#233;lvico em duas &#40;13&#44;3&#37;&#41; e f&#243;rmula contendo 0&#44;5&#37; de triancinolona em dois casos &#40;13&#44;3&#37;&#41;&#46; Como terapia adjuvante&#44; anti&#8208;histam&#237;nicos foram indicados em seis &#40;40&#37;&#41; casos e gel t&#243;pico de cetoconazol em seis &#40;40&#37;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Hidradenite supurativa</span><p id="par0085" class="elsevierStylePara elsevierViewall">Foram observadas seis mulheres com hidradenite supurativa&#44; com m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 45&#44;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;69 anos &#40;<a class="elsevierStyleCrossRef" href="#fig0040">fig&#46; 8</a>&#41;&#46; A evolu&#231;&#227;o foi menos de um ano em uma &#40;16&#44;7&#37;&#41; paciente&#44; entre dois e cinco anos em tr&#234;s &#40;50&#37;&#41; e mais de cinco anos em duas pacientes &#40;33&#44;3&#37;&#41;&#46; Quatro &#40;66&#44;7&#37;&#41; pacientes apresentavam prurido&#44; cinco &#40;83&#44;3&#37;&#41; apresentavam dor e sete dispareunia &#40;50&#37;&#41;&#46; Em nenhum caso foram realizadas bi&#243;psias de pele ou coletadas amostras microbiol&#243;gicas&#46; Antibi&#243;ticos t&#243;picos e&#47;ou orais foram prescritos para tr&#234;s pacientes&#46; A fisioterapia do assoalho p&#233;lvico foi indicada para uma paciente&#46; Como terapia adjuvante&#44; gel t&#243;pico de cetoconazol a 2&#37; foi indicado em um caso&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">L&#237;quen plano</span><p id="par0090" class="elsevierStylePara elsevierViewall">Foram avaliadas seis pacientes com l&#237;quen plano vulvar&#44; com m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 56&#44;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;22 anos&#46; O tempo de evolu&#231;&#227;o mais frequente foi de dois a cinco anos em cinco &#40;83&#44;3&#37;&#41; pacientes&#46; Cinco &#40;83&#44;3&#37;&#41; pacientes apresentavam prurido&#44; cinco &#40;83&#44;3&#37;&#41; dor e quatro &#40;66&#44;7&#37;&#41; dispareunia&#46; A bi&#243;psia de pele foi realizada em cinco &#40;83&#44;3&#37;&#41; casos&#44; e amostras microbiol&#243;gicas foram obtidas de uma &#250;nica paciente&#46; Corticoide t&#243;pico ultrapotente foi indicado em quatro &#40;66&#44;7&#37;&#41; pacientes&#59; triancinolona 0&#44;5&#37; foi prescrita para quatro &#40;66&#44;7&#37;&#41; pacientes&#44; e fisioterapia do assoalho p&#233;lvico foi indicada em tr&#234;s pacientes &#40;50&#37;&#41;&#46; Como terapia adjuvante&#44; gel t&#243;pico de cetoconazol a 2&#37; foi indicado para uma &#250;nica paciente&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">S&#237;ndromes de dor vulvar</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Vestibulodinia provocada secund&#225;ria</span><p id="par0095" class="elsevierStylePara elsevierViewall">Oito pacientes compareceram &#224;s consultas por dor vulvar inespec&#237;fica&#44; seis das quais foram diagnosticadas com vestibulodinia provocada secund&#225;ria&#44; com m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 44&#44;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;48 anos&#46; A evolu&#231;&#227;o era de menos de um ano em uma &#40;16&#44;7&#37;&#41; paciente&#44; entre dois e cinco anos em tr&#234;s &#40;50&#37;&#41; e mais de cinco anos em duas pacientes &#40;33&#44;3&#37;&#41;&#46; A candid&#237;ase vulvovaginal&#44; como concomitante&#44; foi registrada em uma &#250;nica paciente&#46; Cinco &#40;83&#44;3&#37;&#41; pacientes apresentavam prurido&#44; cinco &#40;83&#44;3&#37;&#41; dor e quatro dispareunia &#40;66&#44;7&#37;&#41;&#59; as outras duas pacientes n&#227;o tinham rela&#231;&#245;es sexuais&#44; de modo que n&#227;o foi poss&#237;vel avaliar a presen&#231;a ou aus&#234;ncia de dispareunia&#46; Em nenhum caso foi realizada bi&#243;psia de pele&#44; e amostras microbiol&#243;gicas foram obtidas em apenas um caso&#46; Dentre os tratamentos&#44; a fisioterapia do assoalho p&#233;lvico foi indicada em cinco casos&#44; gabapentina t&#243;pica em um caso e cirurgia em um caso&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Vulvod&#237;nia</span><p id="par0105" class="elsevierStylePara elsevierViewall">Duas pacientes foram &#224; consulta por vulvod&#237;nia com m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP de idade de 30&#44;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;5 anos&#46; Ambas as pacientes apresentavam tempo de evolu&#231;&#227;o da doen&#231;a maior que cinco anos&#46; Em nenhum caso foram realizadas bi&#243;psias de pele ou coletadas amostras microbiol&#243;gicas&#46; Quanto ao tratamento&#44; foi indicada fisioterapia do assoalho p&#233;lvico em uma paciente e psicoterapia em outra&#46;</p></span></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discuss&#227;o</span><p id="par0110" class="elsevierStylePara elsevierViewall">O presente estudo mostra a experi&#234;ncia de cinco anos dos autores como dermatologistas no manejo de consultas espec&#237;ficas relacionadas a doen&#231;as da vulva&#46; Em todos os momentos&#44; essas consultas foram organizadas em estreita colabora&#231;&#227;o e com constante comunica&#231;&#227;o entre os v&#225;rios membros da equipe do servi&#231;o de ginecologia do hospital&#46; Ao todo&#44; 148 mulheres foram avaliadas&#59; as que compareceram &#224; consulta tinham maior probabilidade de ter entre 40 e 60 anos&#44; e o diagn&#243;stico mais frequente foi o de l&#237;quen escleroso&#46; Esse diagn&#243;stico foi seguido por eczema irritativo e l&#237;quen simples cr&#244;nico&#44; como em outras s&#233;ries&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8&#8211;10</span></a> A pr&#225;tica cl&#237;nica dos autores tem verificado aumento no n&#250;mero de pacientes atendidas a cada ano&#44; especialmente nos &#250;ltimos dois anos&#46; De fato&#44; no per&#237;odo de 2018 a 2020&#44; 89&#44;2&#37; das mulheres desta s&#233;rie compareceram &#224; consulta pela primeira vez&#46; Por um lado&#44; esses dados refletem o aumento do conhecimento e das preocupa&#231;&#245;es das pacientes em rela&#231;&#227;o &#224; vulva e suas diferentes altera&#231;&#245;es&#59; por outro lado&#44; os dados tamb&#233;m representam um aumento na procura por um especialista em dermatologia que possa atuar como m&#233;dico de refer&#234;ncia no diagn&#243;stico e tratamento de doen&#231;as da vulva&#46; Essa necessidade provavelmente surgiu tamb&#233;m pelo contato direto e pr&#243;ximo com outros especialistas como ginecologistas&#44; urologistas e m&#233;dicos generalistas no hospital&#44; o que &#233; alcan&#231;ado por meio de reuni&#245;es e sess&#245;es cl&#237;nicas bimestrais&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Pacientes com doen&#231;as da vulva costumam demorar muito para procurar atendimento m&#233;dico&#44; principalmente por causa da ansiedade e do constrangimento&#46; Al&#233;m disso&#44; essa demora em ir ao m&#233;dico faz com que muitas pacientes utilizem rem&#233;dios caseiros como tratamento&#44; o que est&#225; frequentemente associado ao agravamento dos sintomas&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Mais da metade das pacientes no presente estudo &#40;54&#44;8&#37;&#41; levaram entre dois e cinco anos para buscar consulta m&#233;dica&#46; Considerando que muitas das doen&#231;as t&#234;m impacto muito negativo na qualidade de vida das pacientes&#44; e que algumas dessas doen&#231;as s&#227;o pr&#233;&#8208;neopl&#225;sicas&#44; &#233; essencial evitar esse atraso no diagn&#243;stico&#44; promovendo o atendimento m&#233;dico precoce &#224;s pacientes com sintomas na regi&#227;o da vulva&#44; facilitando assim o diagn&#243;stico precoce&#46; Estima&#8208;se que aproximadamente uma em cada seis mulheres experimentar&#225; desconforto vulvovaginal n&#227;o diagnosticado ou n&#227;o tratado durante a vida&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">A doen&#231;a mais frequentemente identificada em nossa s&#233;rie foi o l&#237;quen escleroso&#44; doen&#231;a inflamat&#243;ria cr&#244;nica que acomete principalmente a regi&#227;o anogenital&#46; Ela afeta mais frequentemente as mulheres na pr&#233;&#8208;puberdade e na p&#243;s&#8208;menopausa&#44; e sua etiologia &#233; influenciada por fatores gen&#233;ticos e autoimunes&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Sua verdadeira preval&#234;ncia &#233; desconhecida e varia dependendo se a mesma &#233; avaliada por especialistas em ginecologia ou dermatologia&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> Entretanto&#44; sua incid&#234;ncia parece estar aumentando&#44; e &#233; um dos diagn&#243;sticos mais frequentes nas consultas relacionadas a doen&#231;as vulvares&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> embora isso tamb&#233;m possa ser resultado do aumento das consultas e do n&#250;mero de diagn&#243;sticos&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">No presente estudo&#44; o l&#237;quen escleroso representou 41&#44;9&#37; do total de doen&#231;as identificadas&#44; tornando&#8208;se a doen&#231;a mais frequentemente identificada&#44; similar ao relatado em outros estudos&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8&#8211;10</span></a> Eczema irritativo e l&#237;quen simples cr&#244;nico s&#227;o dermatoses comuns que frequentemente afetam a vulva na popula&#231;&#227;o geral&#46; Entre as causas de ambas as dermatoses&#44; &#233; importante investigar todos os produtos que foram aplicados topicamente na vulva&#59; os m&#233;dicos tamb&#233;m devem perguntar sobre h&#225;bitos de higiene &#237;ntima e perguntar se a paciente est&#225; apresentando algum tipo de incontin&#234;ncia&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Nos casos em que n&#227;o houver melhora&#44; seria conveniente realizar testes epicut&#226;neos para descartar etiologia al&#233;rgica&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Assim como o l&#237;quen escleroso&#44; essas dermatoses representam importante causa de consulta&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Foi detectado um &#250;nico caso de dermatite al&#233;rgica de contato em paciente j&#225; diagnosticada com alergia de contato a p&#8208;fenilenodiamina&#46; A demora no diagn&#243;stico dessa paciente foi de quase seis meses&#44; pois ela n&#227;o associou o uso de tintura nos pelos da regi&#227;o genital com o desconforto que apresentava e n&#227;o comentou sobre isso durante a consulta&#46; Com esse caso espec&#237;fico&#44; os autores querem destacar a import&#226;ncia de obter hist&#243;rico m&#233;dico exaustivo&#44; essencial para o diagn&#243;stico de doen&#231;as cut&#226;neas da vulva&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Em conjunto&#44; as doen&#231;as inflamat&#243;rias&#44; incluindo l&#237;quen escleroso&#44; eczema vulvar&#44; l&#237;quen simples cr&#244;nico e l&#237;quen plano&#44; representaram 71&#37; do total da s&#233;rie&#46; Por outro lado&#44; oito pacientes da s&#233;rie &#40;5&#44;4&#37;&#41; procuraram a consulta por s&#237;ndromes de dor vulvar&#44; incluindo vulvod&#237;nia e vestibulod&#237;nia&#46; Atualmente&#44; a preval&#234;ncia dessa condi&#231;&#227;o &#233; desconhecida na Espanha&#44; tanto pela falta de consultas espec&#237;ficas das pacientes quanto pela falta de treinamento dos especialistas que as atendem&#46; Vulvod&#237;nia &#233; um dist&#250;rbio de dor vulvar que ocorre frequentemente&#44; mas raramente &#233; reconhecido e &#233; definido como dor espont&#226;nea ou provocada na &#225;rea vulvar com dura&#231;&#227;o maior que tr&#234;s meses de evolu&#231;&#227;o&#44; sem causa estabelecida&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#44;13</span></a> Embora sua etiologia seja multifatorial&#44; parece que a disfun&#231;&#227;o muscular do assoalho p&#233;lvico &#233; fator chave&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> Quando a dor vulvar &#233; limitada ao vest&#237;bulo e geralmente &#233; desencadeada por fric&#231;&#227;o&#44; ela &#233; chamada de vestibulodinia provocada secund&#225;ria&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> Na presente s&#233;rie&#44; seis das oito pacientes com dor vulvar foram diagnosticadas com vestibulod&#237;nia&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Onze pacientes &#40;7&#44;4&#37;&#41; buscaram consulta por causa infecciosa&#46; Ao contr&#225;rio do presente estudo&#44; outros autores afirmaram que as doen&#231;as da vulva mais frequentes em consultas m&#233;dicas s&#227;o infec&#231;&#245;es f&#250;ngicas e bacterianas&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> Embora seja poss&#237;vel que as causas mais frequentes de doen&#231;as da vulva sejam infec&#231;&#245;es&#44; a maioria &#233; tratada por m&#233;dicos da aten&#231;&#227;o prim&#225;ria ou encaminhadas a ginecologistas&#44; e esses geralmente n&#227;o realizam consultas espec&#237;ficas da vulva&#46; De fato&#44; outros estudos semelhantes ao presente trabalho&#44; realizados por dermatologistas&#44; relataram percentual semelhante de infec&#231;&#245;es&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8&#44;9</span></a> Da mesma maneira&#44; as v&#225;rias doen&#231;as inflamat&#243;rias que afetam a vulva &#8211; e que foram t&#227;o prevalentes nas consultas &#8211; inclu&#237;ram dermatite at&#243;pica&#44; psor&#237;ase ou hidradenite supurativa &#40;<a class="elsevierStyleCrossRef" href="#fig0040">fig&#46; 8</a>&#41;&#46; Essas doen&#231;as geralmente n&#227;o s&#227;o observadas durante as consultas&#44; pois os dermatologistas ou outros especialistas est&#227;o familiarizados com seu tratamento e geralmente n&#227;o encaminham as pacientes para outros especialistas&#46; Isso explicaria por que o l&#237;quen escleroso&#44; doen&#231;a espec&#237;fica da vulva&#44; &#233; a mais frequentemente diagnosticada&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Em decorr&#234;ncia de caracter&#237;sticas anat&#244;micas particulares da vulva&#44; as doen&#231;as dessa regi&#227;o s&#227;o tratadas de modo diferente de outras &#225;reas da pele&#46; Em doen&#231;as inflamat&#243;rias&#44; o uso de corticosteroides t&#243;picos ultrapotentes &#233; essencial&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Esses agentes s&#227;o conhecidos por melhorar muito os sintomas e&#44; al&#233;m disso&#44; em algumas doen&#231;as&#44; como o l&#237;quen escleroso&#44; parecem reduzir o risco de progress&#227;o para carcinoma de c&#233;lulas escamosas da vulva&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#44;17</span></a> De fato&#44; foi o tratamento mais frequentemente prescrito na presente s&#233;rie&#46; Uma segunda op&#231;&#227;o comum para tratar doen&#231;as inflamat&#243;rias da vulva&#44; e tamb&#233;m de acordo com as diretrizes atuais&#44; inclui os inibidores de calcineurina&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18&#44;19</span></a> &#201; de opini&#227;o dos autores que sua efic&#225;cia &#233; um pouco limitada por seus efeitos colaterais frequentes de dor e ard&#234;ncia ap&#243;s a aplica&#231;&#227;o&#46; Por essa raz&#227;o&#44; no presente estudo&#44; esses agentes foram prescritos apenas para 5&#44;4&#37; das pacientes&#46; Em muitas ocasi&#245;es&#44; as pacientes n&#227;o toleravam os cremes ou prepara&#231;&#245;es comerciais que s&#227;o distribu&#237;dos na farm&#225;cia em raz&#227;o de sua intoler&#226;ncia &#224; f&#243;rmula ou a seus excipientes&#46; Portanto&#44; a formula&#231;&#227;o de corticosteroides ultrapotentes e potentes&#44; como a triancinolona&#44; &#233; essencial em fun&#231;&#227;o de sua toler&#226;ncia para aplica&#231;&#227;o na &#225;rea genital&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Deve&#8208;se destacar o trabalho multidisciplinar na presente pr&#225;tica&#44; pois os autores n&#227;o trabalharam apenas com a ginecologia&#44; mas integraram uma unidade espec&#237;fica do assoalho p&#233;lvico&#44; contaram com a colabora&#231;&#227;o de especialistas em psicolog&#237;a e sexologia&#46; Quase 100&#37; das pacientes atendidas relataram dor vulvar relacionada aos surtos de sua doen&#231;a espec&#237;fica&#44; ou mesmo nos per&#237;odos entre surtos&#44; representando parte das s&#237;ndromes de dor vulvar secund&#225;ria&#46; Em geral&#44; a dor vulvar pode afetar at&#233; 20&#37; das mulheres em algum momento de suas vidas&#44; e sabe&#8208;se que a maioria dos casos est&#225; associada a dist&#250;rbios do assoalho p&#233;lvico&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">A fisioterapia do assoalho p&#233;lvico &#233; uma disciplina relativamente nova que vem ganhando relev&#226;ncia na &#250;ltima d&#233;cada&#44; n&#227;o apenas por sua efic&#225;cia como tratamento para mulheres com dor vulvar prim&#225;ria ou secund&#225;ria&#44; mas tamb&#233;m por auxiliar na preven&#231;&#227;o e manuten&#231;&#227;o da sa&#250;de do assoalho p&#233;lvico durante a gravidez&#44; p&#243;s&#8208;parto e climat&#233;rio&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14&#44;20</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">A grande maioria das pacientes atendidas no servi&#231;o dos autores relatou dor ou desconforto vulvar&#46; A fisioterapia do assoalho p&#233;lvico possibilita a avalia&#231;&#227;o desses processos e o diagn&#243;stico precoce e tratamento de poss&#237;veis vulvod&#237;nias secund&#225;rias e disfun&#231;&#245;es musculares p&#233;lvicas&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Infelizmente&#44; na Espanha&#44; nem o sistema p&#250;blico de sa&#250;de nem as seguradoras de sa&#250;de normalmente cobrem esse tipo de assist&#234;ncia&#46; Assim&#44; embora seja recomendado que uma grande porcentagem de pacientes compare&#231;a para avalia&#231;&#227;o&#44; as limita&#231;&#245;es econ&#244;micas e a falta de informa&#231;&#227;o sobre essa especialidade fazem com que apenas uma pequena porcentagem compare&#231;a &#40;23&#37; do total&#41;&#44; com melhoras evidentes em todos elas&#46; Algo semelhante ocorreu com a psicoterapia e a sexologia&#46; Uma grande porcentagem de mulheres &#40;45&#44;9&#37;&#41; relatou dor ou desconforto na rela&#231;&#227;o sexual&#44; mas apenas duas pacientes foram &#224;s consultas com especialistas em psicologia e sexologia&#46; Motivos financeiros&#44; vergonha e o fato de que a consulta com psic&#243;logo&#47;sex&#243;logo &#233; considerada tabu social foram os principais motivos citados para que as pacientes se abstivessem da consulta&#46; Os autores consideram que a partir de estudos de base como esse&#44; estudos futuros possam avaliar como a fisioterapia e a psicoterapia do assoalho p&#233;lvico influenciam a qualidade de vida de pacientes com doen&#231;as da vulva&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">O presente estudo tem algumas limita&#231;&#245;es&#46; Por um lado&#44; apresentou as v&#225;rias limita&#231;&#245;es associadas aos estudos retrospectivos&#46; Por outro lado&#44; o n&#250;mero limitado de pacientes&#44; bem como o fato de que determinadas doen&#231;as como as de causa infecciosa&#44; costumam ser atendidas na aten&#231;&#227;o prim&#225;ria&#59; portanto&#44; esses casos n&#227;o foram inclu&#237;dos no presente estudo&#46; Al&#233;m disso&#44; n&#227;o foram coletados dados sobre a resposta e&#47;ou satisfa&#231;&#227;o das pacientes aos diferentes tratamentos&#46; Por fim&#44; o fato de todas as pacientes serem oriundas de um &#250;nico hospital privado limitou a possibilidade de obter&#8208;se conclus&#245;es relevantes&#44; pois&#44; quando comparado ao sistema p&#250;blico de sa&#250;de&#44; &#233; acentuadamente mais f&#225;cil consultar um dermatologista e outras especialidades m&#233;dicas e servi&#231;os de sa&#250;de relacionados&#46; Por outro lado&#44; h&#225; diferentes limita&#231;&#245;es socioecon&#244;micas associadas ao acesso &#224; sa&#250;de privada e &#224;s diferentes coberturas de seguros de sa&#250;de&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclus&#227;o</span><p id="par0170" class="elsevierStylePara elsevierViewall">Apresentamos a experi&#234;ncia dos autores ap&#243;s cinco anos de realiza&#231;&#227;o de consultas espec&#237;ficas de vulva&#46; As doen&#231;as da vulva s&#227;o frequentes e comumente associadas a alta morbidade&#46; Assim&#44; &#233; fundamental que essas pacientes sejam avaliadas em unidades espec&#237;ficas que garantam assist&#234;ncia integral&#46; Tamb&#233;m &#233; necess&#225;rio que essas unidades incluam outros especialistas com experi&#234;ncia na &#225;rea&#44; como ginecologistas&#44; urologistas&#44; fisioterapeutas e psic&#243;logos&#44; que possam garantir abordagem multidisciplinar no atendimento &#224;s pacientes com sintomas vulvovaginais&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Suporte financeiro</span><p id="par0175" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Contribui&#231;&#227;o dos autores</span><p id="par0180" class="elsevierStylePara elsevierViewall">Fernando Garc&#237;a&#8208;Souto&#58; Elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; an&#225;lise estat&#237;stica&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Ana Isabel Lorente&#8208;Lavirgen&#58; Concep&#231;&#227;o e planeamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Francisco Manuel Ildefonso Mendon&#231;a&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Manuel Garc&#237;a&#8208;de&#8208;Lomas&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Mariana Viktoria Hoffner&#8208;Zuchelli&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Desiree Rodriguez&#8208;Ojeda&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Elena Pozo&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Jos&#233; Bernab&#233;u&#8208;Wittel&#58; Participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflito de interesses</span><p id="par0220" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">As doen&#231;as da vulva s&#227;o comuns na popula&#231;&#227;o em geral e t&#234;m impacto negativo na qualidade de vida&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descrever a experi&#234;ncia dos autores como dermatologistas na conduta de consultas de dermatose da vulva&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Foi realizado um estudo observacional retrospectivo com pacientes que compareceram a consultas para les&#245;es na vulva durante um per&#237;odo de cinco anos&#46; As informa&#231;&#245;es cl&#237;nicas foram obtidas dos prontu&#225;rios dos pacientes&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Foram estudadas 148 mulheres&#46; A m&#233;dia de idade foi de 43&#44;24 anos &#40;desvio padr&#227;o&#58; 15&#44;15 anos&#41;&#44; com idades variando de 4 meses a 80 anos&#59; 53&#44;4&#37; das pacientes levaram entre dois e cinco anos para procurar atendimento m&#233;dico pela primeira vez&#46; Os diagn&#243;sticos mais frequentes foram l&#237;quen escleroso &#40;41&#44;9&#37;&#41;&#44; eczema irritativo da vulva &#40;14&#44;9&#37;&#41; e l&#237;quen simples cr&#244;nico &#40;10&#44;1&#37;&#41;&#46; Al&#233;m disso&#44; 83&#44;8&#37; relataram prurido anogenital&#44; 66&#44;2&#37; dor e 45&#44;9&#37; dispareunia&#46; O tratamento mais prescrito foi o corticoide t&#243;pico ultrapotente &#40;propionato de clobetasol&#59; 41&#44;2&#37;&#41;&#46; As pacientes com l&#237;quen escleroso eram significativamente mais velhas do que aquelas que apresentavam qualquer uma das outras doen&#231;as&#46; N&#227;o foram encontradas diferen&#231;as em rela&#231;&#227;o ao tempo de evolu&#231;&#227;o da doen&#231;a ou na apresenta&#231;&#227;o dos sintomas&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Limita&#231;&#245;es do estudo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospectivo&#46; As doen&#231;as da vulva com causa infecciosa geralmente s&#227;o tratadas na aten&#231;&#227;o prim&#225;ria e&#44; portanto&#44; n&#227;o foram inclu&#237;das&#46; Todas as pacientes foram recrutadas em um &#250;nico hospital privado&#44; o que limita as compara&#231;&#245;es com o sistema p&#250;blico de sa&#250;de&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">As doen&#231;as da vulva ocorrem com frequ&#234;ncia e est&#227;o associadas a alta morbidade&#46; &#201; fundamental promover o desenvolvimento de consultas espec&#237;ficas para essas pacientes nos hospitais&#46; Especialidades como dermatologia&#44; ginecologia&#44; urologia e fisioterapia devem fazer parte dessas unidades de atendimento&#46;</p></span>"
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Porcentagem dos diferentes diagn&#243;sticos identificados durante o estudo&#46;</p>"
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      ]
      1 => array:7 [
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        "etiqueta" => "Figura 2"
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          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1303
            "Ancho" => 2508
            "Tamanyo" => 160908
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Porcentagens de prurido&#44; dor e dispareunia para cada um dos diagn&#243;sticos mais relevantes identificados durante o estudo&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
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        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2215
            "Ancho" => 1675
            "Tamanyo" => 307137
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">L&#237;quen escleroso&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figura 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 2500
            "Ancho" => 1675
            "Tamanyo" => 301244
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">L&#237;quen escleroso avan&#231;ado&#46; Fus&#227;o completa dos grandes l&#225;bios&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figura 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1332
            "Ancho" => 1675
            "Tamanyo" => 228744
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        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Doen&#231;a de Paget da vulva&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figura 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 1669
            "Ancho" => 1675
            "Tamanyo" => 299686
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        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Neoplasia intraepitelial vulvar comum&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figura 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1890
            "Ancho" => 1675
            "Tamanyo" => 254075
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        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Eczema irritativo da vulva&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Figura 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 1890
            "Ancho" => 1675
            "Tamanyo" => 287448
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Hidradenite supurativa&#46;</p>"
        ]
      ]
      8 => array:8 [
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        "etiqueta" => "Tabela 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">NIV&#44; neoplasia intraepitelial vulvar&#46;</p>"
          "tablatextoimagen" => array:2 [
            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">Diagn&#243;stico prim&#225;rio&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">n &#40;&#37;&#41;&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">L&#237;quen escleroso&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">62 &#40;41&#44;9&#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">Eczema irritativo&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 &#40;14&#44;9&#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">L&#237;quen simples cr&#244;nico&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">15 &#40;10&#44;1&#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">Hidradenite supurativa&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">6 &#40;4&#44;1&#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">L&#237;quen plano&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">6 &#40;4&#44;1&#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">Vestibulod&#237;nia provocada secund&#225;ria&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">6 &#40;4&#44;1&#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">Candid&#237;ase vulvovaginal recorrente&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">4 &#40;2&#44;7&#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">Intertrigo por Candida&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">3 &#40;2&#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">Fissura vulvar&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">3 &#40;2&#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">Condilomas&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">3 &#40;2&#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">Melanose vulvar&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 &#40;1&#44;4&#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">Vulvod&#237;nia&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 &#40;1&#44;4&#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">Esp&#237;culas vestibulares&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 &#40;1&#44;4&#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">Doen&#231;a de Paget da vulva&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">1 &#40;0&#44;7&#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">Gl&#226;ndulas de Fordyce&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">1 &#40;0&#44;7&#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">Leucoplasia&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">1 &#40;0&#44;7&#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">Deisc&#234;ncia de episiotomia&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">1 &#40;0&#44;7&#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">S&#237;ndrome geniturin&#225;ria&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">1 &#40;0&#44;7&#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">Vulva normal&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">1 &#40;0&#44;7&#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">Sebocistomas&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">1 &#40;0&#44;7&#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">Fissura anal&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">1 &#40;0&#44;7&#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">Hiperestesia do clit&#243;ris&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">1 &#40;0&#44;7&#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">NIV comum&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">1 &#40;0&#44;7&#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">Esclerodermia&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">1 &#40;0&#44;7&#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">Herpes genital&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">1 &#40;0&#44;7&#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">TOTAL&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">148 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3688205.png"
              ]
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            1 => 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">Diagn&#243;sticos secund&#225;rios&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">n &#40;&#37;&#41;&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">Nenhum&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">134 &#40;90&#44;5&#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">Candid&#237;ase secund&#225;ria&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 &#40;1&#44;4&#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">Intertrigo por <span class="elsevierStyleItalic">Candida</span>&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 &#40;1&#44;4&#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">Condilomas&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">1 &#40;0&#44;7&#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">Eczema irritativo&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">1 &#40;0&#44;7&#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">Eczema perianal&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">1 &#40;0&#44;7&#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">Fissura vulvar&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">1 &#40;0&#44;7&#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">L&#237;quen escleroso&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">1 &#40;0&#44;7&#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">L&#237;quen plano&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">1 &#40;0&#44;7&#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">Molusco&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">1 &#40;0&#44;7&#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">NIV diferenciado&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">1 &#40;0&#44;7&#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">Vitiligo&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">1 &#40;0&#44;7&#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">TOTAL&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">148 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3688204.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Lista de diagn&#243;sticos prim&#225;rios e secund&#225;rios observados durante o per&#237;odo do estudo</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabela 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">L&#237;quen escleroso &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>62&#41;&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">Outras dermatoses &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>86&#41;&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">p&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">Idade &#40;anos&#41;&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">46&#44;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;33&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">41&#44;01<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;29&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">0&#44;002&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">n &#40;&#37;&#41;&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">n &#40;&#37;&#41;&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Evolu&#231;&#227;o &#40;anos&#41;</span></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"><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>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">13 &#40;21&#41;&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">28 &#40;32&#44;6&#41;&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">0&#44;186&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"><span class="elsevierStyleHsp" style=""></span>2&#8211;5&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">34 &#40;54&#44;8&#41;&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">45 &#40;52&#44;3&#41;&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#62; 5&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">15 &#40;24&#44;2&#41;&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">13 &#40;15&#44;1&#41;&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sintomas</span></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"><span class="elsevierStyleHsp" style=""></span>Prurido&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">55 &#40;88&#44;7&#41;&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">0 &#40;0&#41;&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"><span class="elsevierStyleHsp" style=""></span>Corticosteroide t&#243;pico ultrapotente&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;66&#44;7&#41;&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">0 &#40;0&#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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inibidores t&#243;picos da calcineurina&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">0 &#40;0&#41;&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">0 &#40;0&#41;&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">0 &#40;0&#41;&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">0 &#40;0&#41;&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">0 &#40;0&#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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fisioterapia do assoalho p&#233;lvico&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">5 &#40;22&#44;7&#41;&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;13&#44;3&#41;&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">1 &#40;16&#44;7&#41;&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">3 &#40;50&#41;&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 &#40;75&#41;&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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Triancinolona 0&#44;5&#37; gel&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">1 &#40;4&#44;5&#41;&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">2 &#40;13&#44;3&#41;&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">0 &#40;0&#41;&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">4 &#40;66&#44;7&#41;&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">0 &#40;0&#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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antibi&#243;ticos orais e&#47;ou t&#243;picos&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">0 &#40;0&#41;&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">0 &#40;0&#41;&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;50&#41;&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">0 &#40;0&#41;&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">0 &#40;0&#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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cirurgia&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">0 &#40;0&#41;&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">0 &#40;0&#41;&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
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                  \t\t\t\t">0 &#40;0&#41;&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">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Psicoterapia&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">0 &#40;0&#41;&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">0 &#40;0&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamentos adjuvantes</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cetoconazol t&#243;pico&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">5 &#40;22&#44;7&#41;&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">6 &#40;40&#41;&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">1 &#40;16&#44;7&#41;&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">1 &#40;16&#44;7&#41;&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">0 &#40;0&#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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anti&#8208;histam&#237;nicos&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 &#40;40&#41;&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">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  """
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          "pt" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas demogr&#225;ficas&#44; evolu&#231;&#227;o&#44; sintomas&#44; testes complementares e tratamento de alguns dos diagn&#243;sticos mais frequentemente identificados no estudo</p>"
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            0 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalences of and risk factors for vulvar diseases in Nepal&#58; A hospital&#8208;based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Pathak"
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                      "doi" => "10.1111/j.1365-4632.2010.04631.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2011"
                        "volumen" => "50"
                        "paginaInicial" => "161"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21244379"
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                    0 => array:2 [
                      "titulo" => "Quality of life in the vulvar clinic&#58; A pilot study"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "S&#46; Hickey"
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                    0 => array:2 [
                      "doi" => "10.1097/LGT.0b013e3181dc1e45"
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                        "tituloSerie" => "J Low Genit Tract Dis"
                        "fecha" => "2010"
                        "volumen" => "14"
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                        "paginaFinal" => "229"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20592559"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vulval skin conditions&#58; Disease activity and quality of life"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "S&#46; Lawton"
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                    0 => array:2 [
                      "doi" => "10.1097/LGT.0b013e3182652450"
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                        "volumen" => "17"
                        "paginaInicial" => "117"
                        "paginaFinal" => "124"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23343705"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vulvar diseases&#58; Approach to the patient"
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                            0 => "M&#46;M&#46; Mauskar"
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                            2 => "A&#46; Venkatesan"
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                            4 => "L&#46; Edwards"
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                      "doi" => "10.1016/j.jaad.2019.07.115"
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                        "tituloSerie" => "J Am Acad Dermatol&#46;"
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                        "volumen" => "82"
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ISSN: 26662752
Original language: Portuguese
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