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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41;&#44; The patient with severe AD&#44; alopecia areata and molluscum contagiosum infection before treatment with dupilumab&#46; Excoriation&#44; eczematous lesions&#44; and dome-shaped papules with central umbilication widespread all over the body but especially on her face and scalp&#46; &#40;B&#41;&#44; Two months after starting treatment with dupilumab&#46; Clinical remission of atopic dermatitis and resolution of molluscum contagiosum infection&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atopic dermatitis &#40;AD&#41; predisposes to skin infections such as <span class="elsevierStyleItalic">Staphylococcus aureu</span>s&#44; herpes simplex virus&#44; and molluscum contagiosum &#40;MC&#41; infection&#46; MC is often a self-limited viral infection with pathogenesis poorly understood&#46; It is known that some therapies used for AD worsen MC infection that may present with lesions that are diffuse&#44; resistant to treatment&#44; and persistent over time&#46; Here&#44; the authors describe an AD patient with widespread MC lesions who experienced clearance of the infection shortly after treatment of AD with dupilumab&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 47-year-old woman came to the present study&#8217;s clinic with severe AD since childhood and a 16-year history of alopecia areata to start treatment with dupilumab &#40;a monoclonal antibody that inhibits both interleukin-4 and interleukin-13&#41;&#46; She had been treated several years ago with topical and systemic corticosteroids&#44; phototherapy&#44; and cyclosporine with no improvement&#46; During her physical examination&#44; she had severe AD with Eczema Area and Severity Index &#40;EASI&#41; 24&#46;7&#44; Scoring Atopic Dermatitis &#40;SCORAD&#41; 60&#46;26&#44; and Body Surface Area &#40;BSA&#41; 30&#46; Unexpectedly&#44; she also had dome-shaped papules with central umbilication consistent with MC widespread all over the body but especially on her face and scalp&#44; which had appeared 2-months previously &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#41;&#46; Laboratory studies did not reveal any abnormalities except high levels of IgE&#46; HIV infection and hyper IgE syndrome were ruled out&#46; Topical treatment with 10&#37; potassium hydroxide solution and 5&#37; imiquimod cream was initiated&#44; worsening both the AD &#40;EASI 38&#46;5&#44; SCORAD 76&#46;82&#44; BSA 70&#41; and the MC&#46; Therefore&#44; the authors started treatment for AD with dupilumab and continued with topical treatment for MC associating curettage in the areas with more lesions&#46; After two months&#44; AD went into clinical remission &#40;EASI 1&#44; BSA 1&#41; with a resolution of MC as well &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1</a>&#8210;<a class="elsevierStyleCrossRef" href="#fig0015">3</a>&#41;&#44; including the lesions that did not receive any topical treatment or curettage&#46; Alopecia areata did not improve during the treatment&#46; The patient continued with dupilumab treatment with no recurrence after a 12-months follow-up&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">AD patients are at an increased risk of disseminated MC&#44; probably because of locally impaired cell-mediated immunity due to a dominant T helper 2 &#40;Th2&#41;-mediated immune response in the skin&#44; impaired epidermal barrier function&#44; alterations in the skin microbiome&#44; autoinoculation associated with scratching and the use of immunosuppressive therapies&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">To our knowledge&#44; only four reports of disseminated MC during dupilumab therapy have been reported with contrasting effects&#46; Three of them <a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> describe a total of six patients with AD and concomitant MC infection&#44; which started treatment with dupilumab&#46; In all of them&#44; complete resolution of MC was achieved during treatment with dupilumab&#44; although some cases experienced an initial inflammation or even dissemination of the MC&#46; However&#44; Sevray et al&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> reported a case of a 47-year-old patient with AD and alopecia areata&#44; which both improved after eight weeks of treatment with dupilumab&#44; but worsened his previous MC infection&#46; Then dupilumab was stopped&#44; and MC regressed partially after six months&#46; Regarding this case&#44; Di Lernia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> propose that dupilumab withdrawal may have prevented the observation of subsequent clearance of MC&#46; They also consider that partial regression of MC six months after stopping dupilumab&#44; cannot be regarded as proof of drug causality&#44; as suggested by the authors&#44; due to the nature of the infection itself&#44; with spontaneous resolution within months&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Dupilumab inhibits IL-4 and IL-13&#44; thus inhibiting the Th2 immune response that plays a key role in atopic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It may affect host responses to helminth infections&#44; but additional infections have not been identified&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> On the other hand&#44; Th2 cytokines are able to inhibit anti-infective immunity&#44; and their enhanced expression may be a selective advantage for the virus&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Therefore&#44; the selective inhibition of the Th2 pathway induces a Th1&#47;Th2 balance&#44; a &#39;normalization&#39; of the skin barrier&#44; and permits effective innate and cell-mediated mechanisms to clear the MC&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In the studied patient&#44; there was already initial dissemination of MC with no response to topical treatment&#46; Due to the worsening of AD&#44; the authors started treatment with dupilumab&#44; obtaining a prompt remission of both AD and the infection without any acute inflammation of MC lesions&#46; In summary&#44; according to the literature and our experience&#44; treatment with dupilumab appears to be a safe alternative in AD with extensive MC infection&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#39; contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Marta Elosua-Gonz&#225;lez&#58; Had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis&#59; drafting and editing of the manuscript&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">&#193;ngel Rosell-D&#237;az&#58; Collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; design and planning of the study&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Fernando Alfageme-Rold&#225;n&#58; Collection&#44; analysis&#44; and interpretation of data&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Mercedes Sig&#252;enza-Sanz&#58; 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="par0060" class="elsevierStylePara elsevierViewall">Gaston Roustan-Gull&#243;n&#58; Collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Atopic dermatitis predisposes to skin infections&#44; and on the other hand&#44; some therapies used for atopic dermatitis may worsen viral infections whose lesions may be more diffuse and resistant to treatment&#46; The authors present a patient with severe atopic dermatitis and disseminated molluscum contagiosum infection&#46; The molluscum contagiosum did not clear with topical treatment&#44; and it worsened her atopic dermatitis even more&#44; so the authors started treatment with dupilumab&#46; After two months&#44; the patient&#39;s dermatitis went into clinical remission and there was resolution of the infection with no recurrence at the 12-month follow-up&#46; Dupilumab is nowadays a promising treatment for severe atopic dermatitis&#46; To our knowledge&#44; only four reports of molluscum contagiosum during dupilumab therapy have been reported in the literature&#44; with contrasting effects&#46; According to the authors&#8217; experience&#44; treatment with dupilumab appears to be a safe alternative for patients with severe atopic dermatitis who are also infected with molluscum contagiosum&#44; as opposed to other treatments such as systemic corticosteroids or cyclosporine&#46;</p></span>"
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