What is your diagnosis?
Case for diagnosis. A pruritic eruption of keratotic papules over the face and neck
Maria Relvas
, Joana Calvão, Inês Coutinho, José Carlos Cardoso
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Department of Dermatology, Coimbra University Hospital Center, Coimbra, Portugal
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Erupção pruriginosa de pápulas ceratósicas na face e região cervical" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "100" "paginaFinal" => "102" ] ] "contieneResumen" => array:1 [ "pt" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 436 "Ancho" => 1750 "Tamanyo" => 115183 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Exame histológico. (A), Lesão crateriforme bem demarcada, preenchida por tampão de ceratina predominantemente ortoceratótico, com algumas áreas de paraceratose (Hematoxilina & eosina, 40×). (B), Epitélio circunjacente mostrando acantose irregular de pequeno grau e células com citoplasma em vidro fosco abundante, apresentando atipia e pleomorfismo mínimos na camada basal (Hematoxilina & eosina, 200×). 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Verrucous plaque on the pubic region" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "103" "paginaFinal" => "105" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 222291 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Detail of lobular proliferation with multivacuolated cells in the center and smaller, non vacuolated cells at the periphery (Hematoxylin & eosin, ×200).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diego Henrique Morais Silva, Anna Karoline Gouveia de Oliveira, Neusa Yuriko Sakai Valente, Thais do Amaral Carneiro Cunha" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Diego Henrique Morais" "apellidos" => "Silva" ] 1 => array:2 [ "nombre" => "Anna Karoline" "apellidos" => "Gouveia de Oliveira" ] 2 => array:2 [ "nombre" => "Neusa Yuriko Sakai" "apellidos" => "Valente" ] 3 => array:2 [ "nombre" => "Thais" "apellidos" => "do Amaral Carneiro Cunha" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S266627522030360X" "doi" => "10.1016/j.abdp.2020.07.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S266627522030360X?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620303081?idApp=UINPBA00008Z" "url" => "/03650596/0000009600000001/v3_202102051036/S0365059620303081/v3_202102051036/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S036505962030310X" "issn" => "03650596" "doi" => "10.1016/j.abd.2020.03.022" "estado" => "S300" "fechaPublicacion" => "2021-01-01" "aid" => "296" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">What is your diagnosis?</span>" "titulo" => "Case for diagnosis. Erythematous and infiltrated plaques in the infrahyoid region" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "97" "paginaFinal" => "99" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 676 "Ancho" => 900 "Tamanyo" => 130520 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presence of several acid-fast bacilli in the dermis (Wade, ×100).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Natália Tenório Cavalcante Bezerra, Antonio Pedro Mendes Schettini, André Luiz Leturiondo, Liana Hortencia Miranda Tubilla Mathias" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Natália Tenório Cavalcante" "apellidos" => "Bezerra" ] 1 => array:2 [ "nombre" => "Antonio Pedro Mendes" "apellidos" => "Schettini" ] 2 => array:2 [ "nombre" => "André Luiz" "apellidos" => "Leturiondo" ] 3 => array:2 [ "nombre" => "Liana Hortencia Miranda Tubilla" "apellidos" => "Mathias" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220303623" "doi" => "10.1016/j.abdp.2020.03.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220303623?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S036505962030310X?idApp=UINPBA00008Z" "url" => "/03650596/0000009600000001/v3_202102051036/S036505962030310X/v3_202102051036/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">What is your diagnosis?</span>" "titulo" => "Case for diagnosis. A pruritic eruption of keratotic papules over the face and neck" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "100" "paginaFinal" => "102" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Maria Relvas, Joana Calvão, Inês Coutinho, José Carlos Cardoso" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Maria" "apellidos" => "Relvas" "email" => array:1 [ 0 => "mariavrelvas@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Joana" "apellidos" => "Calvão" ] 2 => array:2 [ "nombre" => "Inês" "apellidos" => "Coutinho" ] 3 => array:2 [ "nombre" => "José Carlos" "apellidos" => "Cardoso" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Coimbra University Hospital Center, Coimbra, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 805 "Ancho" => 1750 "Tamanyo" => 223547 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple skin-colored to erythematous to brownish, 1 − 2 mm papules, with a slightly keratotic center, sometimes coalescing into verrucous plaques; koebnerization is also present.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">An 83-year-old female presented with a three-month history of extremely pruritic, multiple, skin-coloured to erythematous to brownish, millimetric papules, with a keratotic center, sometimes coalescing into verrucous plaques (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesions were distributed bilaterally over the face and neck, without mucosal involvement. There was no deterioration of her general condition. She had no relevant personal or family medical history. Laboratory findings included a complete blood count and renal and liver function tests, which were all normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Incisional cutaneous biopsy revealed a well-demarcated, crateriform lesion, whose center was filled with a predominantly orthokeratotic keratin plug, with some areas of parakeratosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The surrounding epithelium showed mild irregular acanthosis containing abundant ground-glass cytoplasm cells, displaying minimal atypia and pleomorphism at the basal layer (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Intratumoral neutrophilic microabscesses were observed, alongside with lymphocytic infiltrate in the underlying dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). These findings were consistent with the diagnosis of keratoacanthoma.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is your diagnosis?</span><p id="par0015" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Muir-Torre syndrome</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Follicular lichen planus</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pityriasis rubra pilaris</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0035" class="elsevierStylePara elsevierViewall">Generalized eruptive keratoacanthomas of Grzybowski</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Correlating the clinical and histological findings, the diagnosis of generalized eruptive keratoacanthomas of Grzybowski (GEKA) was established.</p><p id="par0045" class="elsevierStylePara elsevierViewall">GEKA is a rare variant of multiple keratoacanthomas, with only around 40 cases reported.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Its onset most commonly occurs between the fifth and seventh decades, without sex predilection.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Unlike other types of multiple keratoacanthomas, such as Ferguson-Smith or Witten and Zak, all cases are sporadic.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is characterized by a relatively sudden onset of hundreds to thousands of small (1−3 millimeters), skin-colored to erythematous papules with a tendency to coalesce. Some show a central umbilication containing a horny keratotic plug.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> They predominate on sun-exposed areas, namely the face and neck, leading to masked facies and ectropion. Furthermore, sun-protected sites, including mucous membranes, the trunk and intertriginous areas are commonly affected.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The lesions tend to be severely pruritic and koebnerization is frequently reported.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The histopathological findings are similar to those observed in solitary keratoacanthomas. These comprise an exo-endophytic, well-demarcated lesion, with an invaginating keratin filled-crater, surrounded by glassy eosinophilic keratinocytes. Unlike squamous cell carcinoma, cytologic atypia is usually minimal.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Sometimes the lesions may show features of proliferative or regressive stages of keratoacanthomas, so that histological diagnosis can easily be missed.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The exact etiology of GEKA is still unknown. Nonetheless, several factors have been proposed to play a role in its pathogenesis, including trauma, immunological abnormalities, ultraviolet radiation, chemical carcinogens, and viruses, particularly human papillomavirus.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">GEKA is a chronic and progressive disease for which none of the described therapeutic options has been entirely satisfactory. Surgical excision, cryotherapy, laser ablation, and radiotherapy are restricted to bigger lesions, being impractical for the remaining.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Topical agents, such as 5-fluorouracil, corticosteroids, imiquimod, and tretinoin, also demonstrated little benefit.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Systemic therapies, especially oral retinoids, are the preferred approach. Other reported options include methotrexate, cyclophosphamide, corticosteroids, and erlotinib, with variable results.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The present patient started acitretin 25 mg daily, with a complete resolution of pruritus and regression of numerous lesions (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The dosage was then decreased over the next five months. She is currently on 10 mg three times per week and, so far, no new lesions have emerged.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors' contributions</span><p id="par0080" class="elsevierStylePara elsevierViewall">Maria Relvas: Drafting and editing of the manuscript; collection, analysis, and interpretation of data; participation in the design of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Joana Calvão: Collection, analysis, and interpretation of data; participation in the design of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Inês Coutinho: Collection, analysis, and interpretation of data; participation in the design of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.</p><p id="par0095" class="elsevierStylePara elsevierViewall">José Carlos Cardoso: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1461404" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1331588" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "What is your diagnosis?" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors' contributions" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-23" "fechaAceptado" => "2020-06-02" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1331588" "palabras" => array:3 [ 0 => "Acitretin" 1 => "Grzybowski" 2 => "Keratoacanthoma" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Generalized eruptive keratoacanthoma of Grzybowski is a rare variant of multiple keratoacanthomas counting with about 40 cases reported. It is a chronic and progressive disease for which none of the described therapeutic options has been entirely satisfactory. We report a case of an 83-year-old female who presented with a 3-month history of extremely pruritic, multiple, skin-coloured to erythematous to brownish, millimetric papules, with a keratotic centre. Histological examination of an incisional biopsy was consistent with the diagnosis of keratoacanthoma. The patient started acitretin 25 milligrams daily with a complete resolution of pruritus and regression of numerous lesions.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Relvas M, Calvão J, Coutinho I, Cardoso JC. Case for diagnosis A pruritic eruption of keratotic papules over the face and neck. An Bras Dermatol. 2021;96:100–2.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology, Coimbra University Hospital Center, Coimbra, Portugal.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 805 "Ancho" => 1750 "Tamanyo" => 223547 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple skin-colored to erythematous to brownish, 1 − 2 mm papules, with a slightly keratotic center, sometimes coalescing into verrucous plaques; koebnerization is also present.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 436 "Ancho" => 1750 "Tamanyo" => 114972 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histological examination. A, Well-demarcated, crateriform lesion filled with a predominantly orthokeratotic keratin plug, with some areas of parakeratosis. B, Surrounding epithelium showing mild irregular acanthosis and cells with abundant ground-glass cytoplasm, displaying minimal atypia and pleomorphism at the basal layer. C, Intratumoral neutrophilic microabscesses and lymphocytic inflammatory infiltrate in the underlying dermis. (Hematoxylin & eosin, A × 40; B × 200; C × 100).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 889 "Ancho" => 1500 "Tamanyo" => 149192 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Regression of numerous lesions after 7 weeks of therapy with acitretin.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful treatment of generalized eruptive keratoacanthoma of Grzybowski with acitretin" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
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| 2024 Fevereiro | 74 | 70 | 144 |
| 2024 Janeiro | 75 | 57 | 132 |
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| 2023 Novembro | 63 | 70 | 133 |
| 2023 Outubro | 72 | 67 | 139 |
| 2023 Setembro | 62 | 71 | 133 |
| 2023 Agosto | 47 | 41 | 88 |
| 2023 Julho | 52 | 47 | 99 |
| 2023 Junho | 55 | 42 | 97 |
| 2023 Maio | 48 | 22 | 70 |
| 2023 Abril | 32 | 26 | 58 |
| 2023 Março | 45 | 40 | 85 |
| 2023 Fevereiro | 38 | 38 | 76 |
| 2023 Janeiro | 38 | 31 | 69 |
| 2022 Dezembro | 55 | 39 | 94 |
| 2022 Novembro | 74 | 64 | 138 |
| 2022 Outubro | 74 | 59 | 133 |
| 2022 Setembro | 47 | 64 | 111 |
| 2022 Agosto | 38 | 50 | 88 |
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| 2022 Junho | 47 | 57 | 104 |
| 2022 Maio | 39 | 45 | 84 |
| 2022 Abril | 45 | 59 | 104 |
| 2022 Março | 49 | 71 | 120 |
| 2022 Fevereiro | 30 | 44 | 74 |
| 2022 Janeiro | 61 | 94 | 155 |
| 2021 Dezembro | 43 | 54 | 97 |
| 2021 Novembro | 60 | 66 | 126 |
| 2021 Outubro | 62 | 81 | 143 |
| 2021 Setembro | 55 | 59 | 114 |
| 2021 Agosto | 65 | 76 | 141 |
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