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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Actinic keratosis &#40;AK&#41; is the fourth most commonly diagnosed dermatosis in Brazilian dermatology consultations and the most frequent diagnosis in patients over 65 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The risk of malignancy of a single AK is low&#59; however&#44; multiple AKs in the same patient multiply the individual risk&#44; which&#44; added to the impossibility of determining which lesion will become malignant&#44; makes the treatment and clinical follow-up of all AKs essential&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The presence of more than one AK in the same area clinically characterizes active skin field cancerization &#40;SFC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Recently&#44; SFC stabilization strategies have been studied&#44; aiming at preventing the incidence of skin tumors&#44; their recurrence&#44; or the evolution of existing lesions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">5-Fluorouracil &#40;5FU&#41; is a topical chemotherapeutic agent with excellent response&#44; reducing AK counts up to 80&#37;&#44; and stabilizing SFC&#46; However&#44; side effects caused by its daily use can lead to poor adherence and a poor outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Despite the description of several therapeutic regimens&#44; its intermittent use for SFC stabilization has not been adequately tested&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nicotinamide is a B-complex vitamin that works on DNA repair&#44; reducing the effects of skin immunosuppression caused by ultraviolet radiation &#40;UVR&#41;&#44; modulating the production of inflammatory cytokines&#44; and restoring cell energy levels after exposure to UVR&#46; Moreover&#44; oral nicotinamide seems to have a photoprotective effect in humans&#44; reducing AK count and the incidence of skin neoplasms in high-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">An open&#44; randomized&#44; comparative&#44; factorial&#44; self-controlled&#44; double-blind &#40;for nicotinamide&#41; clinical trial was carried out&#44; in which 36 patients whose forearms had three to ten AKs each&#44; were randomized into two groups&#46; One group received 500&#160;mg of oral nicotinamide every 12&#160;hours for 120 days and the other group received a placebo at the same dose&#46; Their forearms were subsequently randomized to receive topical 5FU in the evening&#44; three times a week&#44; or sunscreen with a sun protection factor &#40;SPF&#41; of 30 three times a day&#46; The patients were clinically evaluated for AK counts in a standardized area of &#8203;&#8203;the forearms&#44; and the forearm photoaging scale &#40;FPS&#41;&#44; which assesses the forearms regarding photoaging aspects&#44; such as wrinkles&#44; melanoses&#44; visible purpura&#44; elastosis&#44; and stellar scars&#44; associated with the presence of AKs&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Additionally&#44; patients were submitted to a biopsy in the central region of the forearm&#44; in the skin without clinically evident AKs&#44; to evaluate epithelial dysplasia based on KIN &#40;Keratinocyte Intraepithelial Neoplasia&#41; and immunohistochemical analysis of p53 and Ki67 markers&#44; at enrollment and after 120 days&#46; The primary outcome was complete clearance of AK and the secondary ones were partial clearance &#40;&#62; 50&#37;&#41; and reduced FPS&#44; KIN and p53&#44; and Ki67 expression&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The analysis unit of this study was each forearm&#46; The results were analyzed by intention to treat&#44; and dropouts were imputed using the mixed model&#46; Variables were compared according to time and the groups using a &#40;multilevel&#41; linear mixed-effects model with a robust covariance matrix&#46; The post-hoc analysis was performed using Sidak&#8217;s sequential procedure&#46; Statistical significance was set at p&#160;&#60;&#160;0&#46;05&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients&#8217; demographic data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Of the 36 analyzed patients&#44; three were dropouts&#58; one due to death &#40;unrelated to the study interventions&#41;&#44; one due to improvement in the lesions&#44; and one due to an adverse effect of the 5FU&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the main clinical and histopathological results of the study&#46; Improvement in AK count and photoaging scale were greater with 5FU when compared to sunscreen use&#44; with no difference between groups in terms of total AK clearance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Although nicotinamide did not provide additional clinical improvement compared to the use of 5FU or sunscreen&#44; there was a significant reduction in Ki67 expression in the nicotinamide group compared to the other groups&#46; There was no difference between nicotinamide and 5FU use in reducing p53 expression or improving the KIN score&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the reported adverse events&#46; Only one participant had severe erythema secondary to 5FU&#44; with consequent treatment discontinuation&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Previous studies with topical use of 5FU showed a greater reduction in AK count in the groups that used daily regimens&#44; albeit with greater skin irritation and adverse effects when compared to intermittent use&#46; By the way&#44; 5FU was the only treatment for SFC that showed a reduction in the incidence of malignancies&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Intermittent&#44; twice-daily&#44; weekly use led to a 66&#37; reduction in AK count after 12 weeks&#44; showing that it can improve adherence and tolerability&#44; promoting fewer local adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There were predictable and controllable adverse events in the 5FU group of mild or moderate intensity&#44; which did not cause treatment discontinuation&#46; Only one patient developed a generalized rash after local 5FU use&#44; leading to treatment discontinuation and highlighting the significant individual variability regarding the susceptibility to 5FU&#44; of which toxicity has been reported in cases of dihydropyrimidine dehydrogenase deficiency or with low levels of thymidylate synthase&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Previous studies using oral nicotinamide have shown reduction in AK count in high-risk patients&#46; In this study&#44; neither clinical improvement when compared to placebo nor an additive effect to the use of 5FU was identified&#46; It is worth noting&#44; however&#44; that the use of nicotinamide in the present study lasted for 120 days&#44; whereas in the largest previous study the drug was used&#44; on average&#44; for approximately 12 months&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; despite the difference in treatment time and the larger number of participants &#40;n&#160;&#61;&#160;386&#41;&#44; the reduction in AK count was only 13&#37; after 12 months of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Phototype variability&#44; a diet poor in vitamin B3&#44; lower hepatic metabolism rate&#44; and younger age may be associated with different clinical responses to oral nicotinamide&#46; The studied topography &#40;e&#46;g&#46;&#44; face&#44; upper limbs or scalp&#41; and different degrees of AK may also justify the variability in the response to SFC treatments&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There was a change in Ki67 expression with both treatments&#44; with a significant difference in the nicotinamide group&#46; Thus&#44; although there is no additional clinical response of nicotinamide to the treatments implemented in this study&#44; there is evidence of a reduction in cellular proliferation&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Longer nicotinamide regimens might lead to more robust clinical outcomes&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The present study has some limitations&#58; it is monocentric&#44; with limited follow-up and includes elderly participants from a public institution&#44; which minimizes the generalization of the results&#46; Moreover&#44; a topical 5FU dose that is different from the usual one was used&#44; which may also make it difficult to compare the results with other previous studies&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; the efficacy of the treatment of SFC with topical 5FU&#44; using an intermittent regimen for 120 days was evidenced&#46; The present study results should stimulate clinical trials with topical 5FU using an intermittent regimen to explore its role in SFC stabilization&#44; reducing the incidence of AKs and skin neoplasms&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Eliane Roio Ferreira&#58; Design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; drafting and editing of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Anna Carolina Miola&#58; Collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; drafting and editing of the manuscript&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Thania Rios Rossi Lima&#58; Collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Juliano Vilaverde Schmitt&#58; Design and planning of the study&#59; critical review of the literature&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Luciana Patricia Fernandes Abbade&#58; Design and planning of the study&#59; critical review of the literature&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">H&#233;lio Amante Miot&#58; Design and planning of the study&#59; effective participation in research orientation&#59; statistical analysis&#59; critical review of the literature&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">How to cite this article&#58; Ferreira ER&#44; Miola AC&#44; Lima TRR&#44; Schmitt JV&#44; Abbade LPF&#44; Miot HA&#46; Efficacy of intermittent topical 5-fluorouracil 5&#37; and oral nicotinamide in the skin field cancerization&#58; a randomized clinical trial&#46; An Bras Dermatol&#46; 2021&#59;96&#58;784&#8211;7&#46;</p>"
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                  <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-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Values&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 colgroup " colspan="2" align="left" valign="\n
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                  \t\t\t\t">Age &#40;years&#41;&#44; mean &#40;SD&#41;</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">71&#46;6 &#40;8&#46;6&#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 rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&#44; n &#40;&#37;&#41;</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">Male&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">14 &#40;39&#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">Female&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;61&#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 rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fitzpatrick phototype&#44; n &#40;&#37;&#41;</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">I&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;36&#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">II&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">21 &#40;58&#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">III&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;6&#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 colgroup " colspan="2" align="left" valign="\n
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                  \t\t\t\t">34 &#40;94&#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 colgroup " colspan="2" align="left" valign="\n
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                  \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;5&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  <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
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Placebo</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \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">5FU &#40;n&#160;&#61;&#160;18&#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">FPS &#40;n&#160;&#61;&#160;18&#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="elsevierStyleBold">T0</span>&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">&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">&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">&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">&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
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                  \t\t\t\t">FPS&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">99 &#40;90&#8211;104&#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">100 &#40;86&#8211;103&#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">99 &#40;81&#8211;99&#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">97 &#40;81&#8211;103&#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
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                  \t\t\t\t"><span class="elsevierStyleBold">AK count</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&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">7 &#40;5&#8211;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">7 &#40;5&#8211;9&#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">6&#46;5 &#40;5&#8211;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
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                  \t\t\t\t">5 &#40;5&#8211;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
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                  \t\t\t\t"><span class="elsevierStyleBold">p53</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&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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                    0 => array:2 [
                      "titulo" => "Actinic keratoses&#58; review of clinical&#44; dermoscopic and therapeutic aspects"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;P&#46;H&#46; Reinehr"
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                      "doi" => "10.1016/j.abd.2019.10.004"
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Research Letter
Efficacy of intermittent topical 5-fluorouracil 5% and oral nicotinamide in the skin field cancerization: a randomized clinical trial
Eliane Roio Ferreira, Anna Carolina Miola
Autor para correspondência
anna.c.miola@unesp.br

Corresponding author.
, Thania Rios Rossi Lima, Juliano Vilaverde Schmitt, Luciana Patricia Fernandes Abbade, Hélio Amante Miot
Department of Dermatology, Faculty of Medicine, Universidade Estadual Paulista, São Paulo, SP, Brazil
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    "titulo" => "Efficacy of intermittent topical 5-fluorouracil 5&#37; and oral nicotinamide in the skin field cancerization&#58; a randomized clinical trial"
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        "autoresLista" => "Eliane Roio Ferreira, Anna Carolina Miola, Thania Rios Rossi Lima, Juliano Vilaverde Schmitt, Luciana Patricia Fernandes Abbade, H&#233;lio Amante Miot"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Actinic keratoses count at T0 and T120 for the oral nicotinamide&#44; placebo&#44; 5FU&#44; and topical sunscreen groups&#58; improvement in all groups with time&#44; mainly in the group using topical 5FU&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Actinic keratosis &#40;AK&#41; is the fourth most commonly diagnosed dermatosis in Brazilian dermatology consultations and the most frequent diagnosis in patients over 65 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The risk of malignancy of a single AK is low&#59; however&#44; multiple AKs in the same patient multiply the individual risk&#44; which&#44; added to the impossibility of determining which lesion will become malignant&#44; makes the treatment and clinical follow-up of all AKs essential&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The presence of more than one AK in the same area clinically characterizes active skin field cancerization &#40;SFC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Recently&#44; SFC stabilization strategies have been studied&#44; aiming at preventing the incidence of skin tumors&#44; their recurrence&#44; or the evolution of existing lesions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">5-Fluorouracil &#40;5FU&#41; is a topical chemotherapeutic agent with excellent response&#44; reducing AK counts up to 80&#37;&#44; and stabilizing SFC&#46; However&#44; side effects caused by its daily use can lead to poor adherence and a poor outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Despite the description of several therapeutic regimens&#44; its intermittent use for SFC stabilization has not been adequately tested&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nicotinamide is a B-complex vitamin that works on DNA repair&#44; reducing the effects of skin immunosuppression caused by ultraviolet radiation &#40;UVR&#41;&#44; modulating the production of inflammatory cytokines&#44; and restoring cell energy levels after exposure to UVR&#46; Moreover&#44; oral nicotinamide seems to have a photoprotective effect in humans&#44; reducing AK count and the incidence of skin neoplasms in high-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">An open&#44; randomized&#44; comparative&#44; factorial&#44; self-controlled&#44; double-blind &#40;for nicotinamide&#41; clinical trial was carried out&#44; in which 36 patients whose forearms had three to ten AKs each&#44; were randomized into two groups&#46; One group received 500&#160;mg of oral nicotinamide every 12&#160;hours for 120 days and the other group received a placebo at the same dose&#46; Their forearms were subsequently randomized to receive topical 5FU in the evening&#44; three times a week&#44; or sunscreen with a sun protection factor &#40;SPF&#41; of 30 three times a day&#46; The patients were clinically evaluated for AK counts in a standardized area of &#8203;&#8203;the forearms&#44; and the forearm photoaging scale &#40;FPS&#41;&#44; which assesses the forearms regarding photoaging aspects&#44; such as wrinkles&#44; melanoses&#44; visible purpura&#44; elastosis&#44; and stellar scars&#44; associated with the presence of AKs&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Additionally&#44; patients were submitted to a biopsy in the central region of the forearm&#44; in the skin without clinically evident AKs&#44; to evaluate epithelial dysplasia based on KIN &#40;Keratinocyte Intraepithelial Neoplasia&#41; and immunohistochemical analysis of p53 and Ki67 markers&#44; at enrollment and after 120 days&#46; The primary outcome was complete clearance of AK and the secondary ones were partial clearance &#40;&#62; 50&#37;&#41; and reduced FPS&#44; KIN and p53&#44; and Ki67 expression&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The analysis unit of this study was each forearm&#46; The results were analyzed by intention to treat&#44; and dropouts were imputed using the mixed model&#46; Variables were compared according to time and the groups using a &#40;multilevel&#41; linear mixed-effects model with a robust covariance matrix&#46; The post-hoc analysis was performed using Sidak&#8217;s sequential procedure&#46; Statistical significance was set at p&#160;&#60;&#160;0&#46;05&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients&#8217; demographic data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Of the 36 analyzed patients&#44; three were dropouts&#58; one due to death &#40;unrelated to the study interventions&#41;&#44; one due to improvement in the lesions&#44; and one due to an adverse effect of the 5FU&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the main clinical and histopathological results of the study&#46; Improvement in AK count and photoaging scale were greater with 5FU when compared to sunscreen use&#44; with no difference between groups in terms of total AK clearance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Although nicotinamide did not provide additional clinical improvement compared to the use of 5FU or sunscreen&#44; there was a significant reduction in Ki67 expression in the nicotinamide group compared to the other groups&#46; There was no difference between nicotinamide and 5FU use in reducing p53 expression or improving the KIN score&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the reported adverse events&#46; Only one participant had severe erythema secondary to 5FU&#44; with consequent treatment discontinuation&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Previous studies with topical use of 5FU showed a greater reduction in AK count in the groups that used daily regimens&#44; albeit with greater skin irritation and adverse effects when compared to intermittent use&#46; By the way&#44; 5FU was the only treatment for SFC that showed a reduction in the incidence of malignancies&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Intermittent&#44; twice-daily&#44; weekly use led to a 66&#37; reduction in AK count after 12 weeks&#44; showing that it can improve adherence and tolerability&#44; promoting fewer local adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There were predictable and controllable adverse events in the 5FU group of mild or moderate intensity&#44; which did not cause treatment discontinuation&#46; Only one patient developed a generalized rash after local 5FU use&#44; leading to treatment discontinuation and highlighting the significant individual variability regarding the susceptibility to 5FU&#44; of which toxicity has been reported in cases of dihydropyrimidine dehydrogenase deficiency or with low levels of thymidylate synthase&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Previous studies using oral nicotinamide have shown reduction in AK count in high-risk patients&#46; In this study&#44; neither clinical improvement when compared to placebo nor an additive effect to the use of 5FU was identified&#46; It is worth noting&#44; however&#44; that the use of nicotinamide in the present study lasted for 120 days&#44; whereas in the largest previous study the drug was used&#44; on average&#44; for approximately 12 months&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; despite the difference in treatment time and the larger number of participants &#40;n&#160;&#61;&#160;386&#41;&#44; the reduction in AK count was only 13&#37; after 12 months of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Phototype variability&#44; a diet poor in vitamin B3&#44; lower hepatic metabolism rate&#44; and younger age may be associated with different clinical responses to oral nicotinamide&#46; The studied topography &#40;e&#46;g&#46;&#44; face&#44; upper limbs or scalp&#41; and different degrees of AK may also justify the variability in the response to SFC treatments&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There was a change in Ki67 expression with both treatments&#44; with a significant difference in the nicotinamide group&#46; Thus&#44; although there is no additional clinical response of nicotinamide to the treatments implemented in this study&#44; there is evidence of a reduction in cellular proliferation&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Longer nicotinamide regimens might lead to more robust clinical outcomes&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The present study has some limitations&#58; it is monocentric&#44; with limited follow-up and includes elderly participants from a public institution&#44; which minimizes the generalization of the results&#46; Moreover&#44; a topical 5FU dose that is different from the usual one was used&#44; which may also make it difficult to compare the results with other previous studies&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; the efficacy of the treatment of SFC with topical 5FU&#44; using an intermittent regimen for 120 days was evidenced&#46; The present study results should stimulate clinical trials with topical 5FU using an intermittent regimen to explore its role in SFC stabilization&#44; reducing the incidence of AKs and skin neoplasms&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Eliane Roio Ferreira&#58; Design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; drafting and editing of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Anna Carolina Miola&#58; Collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; drafting and editing of the manuscript&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Thania Rios Rossi Lima&#58; Collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Juliano Vilaverde Schmitt&#58; Design and planning of the study&#59; critical review of the literature&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Luciana Patricia Fernandes Abbade&#58; Design and planning of the study&#59; critical review of the literature&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">H&#233;lio Amante Miot&#58; Design and planning of the study&#59; effective participation in research orientation&#59; statistical analysis&#59; critical review of the literature&#59; critical review of the manuscript&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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    "fechaRecibido" => "2020-06-16"
    "fechaAceptado" => "2020-09-14"
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                  \t\t\t\t">14 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
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