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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">To date&#44; several cases of multiple lentigines in resolved psoriasis lesions have been reported&#46; Herein&#44; we describe a rare case of psoriasis that resolved leaving multiple small lentiginous patches in the lesions after successful treatment with a Tumor Necrosis Factor &#40;TNF&#41; inhibitor&#46; Moreover&#44; a recurrence of psoriasis was observed in the pigmentary patches&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 55-year-old male was diagnosed with psoriasis vulgaris 6 years previously and had been treated with topical corticosteroid ointment&#46; Joint pain appeared on the bilateral fingers&#44; wrists&#44; and ankles 3 years previously&#44; and he received systemic therapy with adalimumab &#40;subcutaneous injection of 80&#8239;mg&#44; and 40&#8239;mg thereafter every other week&#41;&#46; Both cutaneous and joint manifestations responded well to adalimumab&#46; Psoriasis Activity and Severity Index &#40;PASI&#41; score was reduced from 6&#46;0 to 0 &#40;PASI clear&#41;&#44; and also&#44; he was relieved from joint pain&#46; After the complete disappearance of psoriasis&#44; pigmentation emerged&#46; However&#44; during maintenance therapy with adalimumab&#44; cutaneous psoriasis relapsed 7 months later&#44; but without recurrence of joint pain&#46; Physical examination showed multiple brownish plaques on the lower extremities&#46; A few psoriatic plaques were observed in some&#44; but not all&#44; of the resolved lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#8210;C&#41;&#46; In one of the lesions&#44; psoriatic lesions appeared within the pigmented macule and spread beyond the pigmented macule &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">There are several cases of psoriatic plaques that were treated with biologics such as TNF inhibitors&#44; Interleukin-17 &#40;IL-17&#41; inhibitors&#44; IL-12&#47;23 inhibitors&#44; T-cell inhibitors&#44; and phosphodiesterase 4 inhibitors&#44; and left lentiginous lesions in the resolved area&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Previous studies have shown that inflammatory cytokines such as TNF-&#945; and IL-17 can inhibit melanocyte growth&#44; downregulate pigmentation-related gene expression&#44; and render tyrosinase activity&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore&#44; inhibitors of those cytokines may cause hyperpigmentation in susceptible individuals&#8217; skin type and genetic predisposition&#46; It is known that psoriasis arises in the resolved areas&#44; which is considered to be an isomorphic response of K&#246;bner&#46; In the present case&#44; scaly erythematous lesions recurred on some of the pre-existing lesions&#46; The recurred psoriasis plaques did not perfectly but mostly correspond to the pre-existing areas&#46; In another lesion&#44; psoriasis initially recurred in the resolved areas and extended beyond the pigmentary macule&#46; Previous studies showed that epidermal CD8&#43; T-cells increased in the K&#246;bner-positive psoriasis skin&#44; and CD8<span class="elsevierStyleSup">&#43;</span> tissue Resident Memory T-cells &#40;T<span class="elsevierStyleInf">RM</span>&#41; enriched in the resolved lesion preferentially produced IL-17 and IL-22 upon restimulation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; triggering factors that stimulate T-cell activation are currently unknown&#46; One possible cause may be the decrease in the efficacy of TNF inhibitors on cutaneous psoriasis&#46; Unfortunately&#44; we could not compare the frequency of epidermal T<span class="elsevierStyleInf">RM</span> on the non-lesional skin&#44; improved skin with pigmentation&#44; recurred psoriasis lesion in the resolved area&#44; and recurred psoriasis lesion in the previously non-lesional area&#44; because the patient refused biopsy&#46; Further studies are necessary to elucidate the mechanism of lentiginous pigmentation after the improvement of psoriasis and the role of T<span class="elsevierStyleInf">RM</span> in such conditions&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0020" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author&#39; contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto&#58; Study conception and planning&#59; data collection&#44; analysis and interpretation&#59; management of studied cases&#59; preparation and writing 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="par0030" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Clinical
Recurrence of psoriasis on the resolution sites left with lentiginous pigmented patches after TNF inhibitor therapy
Toshiyuki Yamamoto
Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; A number of small brownish lentiginous patches appeared after improvement of psoriasis&#46; &#40;B&#41; Psoriatic plaques were observed within part of the pigmentary macule&#46; &#40;C&#41; Psoriasis occurred within the pigmentary macule and spread beyond the pigmentary macule</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">To date&#44; several cases of multiple lentigines in resolved psoriasis lesions have been reported&#46; Herein&#44; we describe a rare case of psoriasis that resolved leaving multiple small lentiginous patches in the lesions after successful treatment with a Tumor Necrosis Factor &#40;TNF&#41; inhibitor&#46; Moreover&#44; a recurrence of psoriasis was observed in the pigmentary patches&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 55-year-old male was diagnosed with psoriasis vulgaris 6 years previously and had been treated with topical corticosteroid ointment&#46; Joint pain appeared on the bilateral fingers&#44; wrists&#44; and ankles 3 years previously&#44; and he received systemic therapy with adalimumab &#40;subcutaneous injection of 80&#8239;mg&#44; and 40&#8239;mg thereafter every other week&#41;&#46; Both cutaneous and joint manifestations responded well to adalimumab&#46; Psoriasis Activity and Severity Index &#40;PASI&#41; score was reduced from 6&#46;0 to 0 &#40;PASI clear&#41;&#44; and also&#44; he was relieved from joint pain&#46; After the complete disappearance of psoriasis&#44; pigmentation emerged&#46; However&#44; during maintenance therapy with adalimumab&#44; cutaneous psoriasis relapsed 7 months later&#44; but without recurrence of joint pain&#46; Physical examination showed multiple brownish plaques on the lower extremities&#46; A few psoriatic plaques were observed in some&#44; but not all&#44; of the resolved lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#8210;C&#41;&#46; In one of the lesions&#44; psoriatic lesions appeared within the pigmented macule and spread beyond the pigmented macule &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">There are several cases of psoriatic plaques that were treated with biologics such as TNF inhibitors&#44; Interleukin-17 &#40;IL-17&#41; inhibitors&#44; IL-12&#47;23 inhibitors&#44; T-cell inhibitors&#44; and phosphodiesterase 4 inhibitors&#44; and left lentiginous lesions in the resolved area&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Previous studies have shown that inflammatory cytokines such as TNF-&#945; and IL-17 can inhibit melanocyte growth&#44; downregulate pigmentation-related gene expression&#44; and render tyrosinase activity&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore&#44; inhibitors of those cytokines may cause hyperpigmentation in susceptible individuals&#8217; skin type and genetic predisposition&#46; It is known that psoriasis arises in the resolved areas&#44; which is considered to be an isomorphic response of K&#246;bner&#46; In the present case&#44; scaly erythematous lesions recurred on some of the pre-existing lesions&#46; The recurred psoriasis plaques did not perfectly but mostly correspond to the pre-existing areas&#46; In another lesion&#44; psoriasis initially recurred in the resolved areas and extended beyond the pigmentary macule&#46; Previous studies showed that epidermal CD8&#43; T-cells increased in the K&#246;bner-positive psoriasis skin&#44; and CD8<span class="elsevierStyleSup">&#43;</span> tissue Resident Memory T-cells &#40;T<span class="elsevierStyleInf">RM</span>&#41; enriched in the resolved lesion preferentially produced IL-17 and IL-22 upon restimulation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; triggering factors that stimulate T-cell activation are currently unknown&#46; One possible cause may be the decrease in the efficacy of TNF inhibitors on cutaneous psoriasis&#46; Unfortunately&#44; we could not compare the frequency of epidermal T<span class="elsevierStyleInf">RM</span> on the non-lesional skin&#44; improved skin with pigmentation&#44; recurred psoriasis lesion in the resolved area&#44; and recurred psoriasis lesion in the previously non-lesional area&#44; because the patient refused biopsy&#46; Further studies are necessary to elucidate the mechanism of lentiginous pigmentation after the improvement of psoriasis and the role of T<span class="elsevierStyleInf">RM</span> in such conditions&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0020" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author&#39; contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto&#58; Study conception and planning&#59; data collection&#44; analysis and interpretation&#59; management of studied cases&#59; preparation and writing 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="par0030" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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