array:24 [
  "pii" => "S2666275221002800"
  "issn" => "26662752"
  "doi" => "10.1016/j.abdp.2021.08.001"
  "estado" => "S300"
  "fechaPublicacion" => "2022-01-01"
  "aid" => "485"
  "copyright" => "Sociedade Brasileira de Dermatologia"
  "copyrightAnyo" => "2021"
  "documento" => "article"
  "crossmark" => 1
  "licencia" => "http://creativecommons.org/licenses/by/4.0/"
  "subdocumento" => "rev"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "en" => array:19 [
      "pii" => "S0365059621002774"
      "issn" => "03650596"
      "doi" => "10.1016/j.abd.2021.08.002"
      "estado" => "S300"
      "fechaPublicacion" => "2022-01-01"
      "aid" => "485"
      "copyright" => "Sociedade Brasileira de Dermatologia"
      "documento" => "article"
      "crossmark" => 1
      "licencia" => "http://creativecommons.org/licenses/by/4.0/"
      "subdocumento" => "rev"
      "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">Review</span>"
        "titulo" => "Skin manifestations associated with COVID-19"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => "en"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "75"
            "paginaFinal" => "88"
          ]
        ]
        "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" => 976
                "Ancho" => 2090
                "Tamanyo" => 120941
              ]
            ]
            "detalles" => array:1 [
              0 => array:3 [
                "identificador" => "at0015"
                "detalle" => "Figure "
                "rol" => "short"
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Livedo racemosa&#44; purpura and necrosis of the extremities in a patient with COVID-19&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Camila Arai Seque, Milvia Maria Sim&#245;es e Silva Enokihara, Adriana Maria Porro, Jane Tomimori"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "Camila Arai"
                "apellidos" => "Seque"
              ]
              1 => array:2 [
                "nombre" => "Milvia Maria Sim&#245;es e Silva"
                "apellidos" => "Enokihara"
              ]
              2 => array:2 [
                "nombre" => "Adriana Maria"
                "apellidos" => "Porro"
              ]
              3 => array:2 [
                "nombre" => "Jane"
                "apellidos" => "Tomimori"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "pt" => array:9 [
          "pii" => "S2666275221002800"
          "doi" => "10.1016/j.abdp.2021.08.001"
          "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/S2666275221002800?idApp=UINPBA00008Z"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059621002774?idApp=UINPBA00008Z"
      "url" => "/03650596/0000009700000001/v1_202201230559/S0365059621002774/v1_202201230559/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2666275221002666"
    "issn" => "26662752"
    "doi" => "10.1016/j.abdp.2021.11.010"
    "estado" => "S300"
    "fechaPublicacion" => "2022-01-01"
    "aid" => "469"
    "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
    ]
    "pt" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Dermatologia Tropical&#47;Infectoparasit&#225;ria</span>"
      "titulo" => "Caso exuberante de leishmaniose cut&#226;nea verrucosa"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => "pt"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "89"
          "paginaFinal" => "92"
        ]
      ]
      "contieneResumen" => array:1 [
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0020"
          "etiqueta" => "Figura 4"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr4.jpeg"
              "Alto" => 685
              "Ancho" => 750
              "Tamanyo" => 61558
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Resposta satisfat&#243;ria imediatamente ap&#243;s o tratamento com milfetosina&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Jana Regis Novaes, Luise Ribeiro Daltro, Thiago Amparo Ferreira, Paulo Roberto Lima Machado"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Jana Regis"
              "apellidos" => "Novaes"
            ]
            1 => array:2 [
              "nombre" => "Luise Ribeiro"
              "apellidos" => "Daltro"
            ]
            2 => array:2 [
              "nombre" => "Thiago Amparo"
              "apellidos" => "Ferreira"
            ]
            3 => array:2 [
              "nombre" => "Paulo Roberto Lima"
              "apellidos" => "Machado"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S0365059621002609"
        "doi" => "10.1016/j.abd.2020.11.011"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059621002609?idApp=UINPBA00008Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275221002666?idApp=UINPBA00008Z"
    "url" => "/26662752/0000009700000001/v1_202202030913/S2666275221002666/v1_202202030913/pt/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2666275221002770"
    "issn" => "26662752"
    "doi" => "10.1016/j.abdp.2021.11.020"
    "estado" => "S300"
    "fechaPublicacion" => "2022-01-01"
    "aid" => "483"
    "copyright" => "Sociedade Brasileira de Dermatologia"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by/4.0/"
    "subdocumento" => "rev"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "pt" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Revis&#227;o</span>"
      "titulo" => "Psor&#237;ase pustulosa generalizada &#40;von Zumbusch&#41;"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => "pt"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "63"
          "paginaFinal" => "74"
        ]
      ]
      "contieneResumen" => array:1 [
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0025"
          "etiqueta" => "Figura 5"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr5.jpeg"
              "Alto" => 665
              "Ancho" => 905
              "Tamanyo" => 119501
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Quadro eruptivo de psor&#237;ase pustulosa generalizada&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ricardo Romiti, Andr&#233; Lu&#237;s da Silva Hirayama, Marcelo Arnone, Renata Ferreira Magalh&#227;es"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Ricardo"
              "apellidos" => "Romiti"
            ]
            1 => array:2 [
              "nombre" => "Andr&#233; Lu&#237;s da Silva"
              "apellidos" => "Hirayama"
            ]
            2 => array:2 [
              "nombre" => "Marcelo"
              "apellidos" => "Arnone"
            ]
            3 => array:2 [
              "nombre" => "Renata Ferreira"
              "apellidos" => "Magalh&#227;es"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S0365059621002750"
        "doi" => "10.1016/j.abd.2021.05.011"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059621002750?idApp=UINPBA00008Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275221002770?idApp=UINPBA00008Z"
    "url" => "/26662752/0000009700000001/v1_202202030913/S2666275221002770/v1_202202030913/pt/main.assets"
  ]
  "pt" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Revis&#227;o</span>"
    "titulo" => "Manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "75"
        "paginaFinal" => "88"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Camila Arai Seque, Milvia Maria Sim&#245;es e Silva Enokihara, Adriana Maria Porro, Jane Tomimori"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "Camila Arai"
            "apellidos" => "Seque"
            "email" => array:1 [
              0 => "camilaseque@yahoo.com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "Milvia Maria Sim&#245;es e Silva"
            "apellidos" => "Enokihara"
          ]
          2 => array:2 [
            "nombre" => "Adriana Maria"
            "apellidos" => "Porro"
          ]
          3 => array:2 [
            "nombre" => "Jane"
            "apellidos" => "Tomimori"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Departamento de Dermatologia&#44; Universidade Federal de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#44; Brasil"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Autor para correspond&#234;ncia&#46;"
          ]
        ]
      ]
    ]
    "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" => 700
            "Ancho" => 1250
            "Tamanyo" => 67904
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Les&#245;es vesico&#8208;bolhosas em paciente com COVID&#8208;19&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">No in&#237;cio da pandemia de COVID&#8208;19&#44; a dermatologia j&#225; parecia ter um papel importante dentre as manifesta&#231;&#245;es cl&#237;nicas dessa nova doen&#231;a&#46; Desde mar&#231;o de 2020&#44; mais de 1&#46;500 artigos correlacionando &#8220;dermatologia&#8221; e &#8220;COVID&#8208;19&#8221; foram publicados&#46; Nunca uma quantidade t&#227;o grande de informa&#231;&#245;es foi gerada em t&#227;o pouco tempo na comunidade cient&#237;fica&#44; inclusive dermatol&#243;gica&#46; Embora os primeiros relatos sejam escassos&#44; possivelmente em raz&#227;o da incapacidade de se realizarem exame dermatol&#243;gico completo&#44; registro fotogr&#225;fico&#44; an&#225;lise histopatol&#243;gica e&#47;ou imuno&#8208;histoqu&#237;mica e tamb&#233;m pela baixa presen&#231;a do especialista na assist&#234;ncia direta a esses pacientes&#44; pesquisas subsequentes trouxeram importantes contribui&#231;&#245;es sobre o envolvimento cut&#226;neo na COVID&#8208;19&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">1</span></a> Neste documento s&#227;o revisadas as principais publica&#231;&#245;es at&#233; o momento &#40;30&#47;04&#47;21&#41; sobre diferentes aspectos das manifesta&#231;&#245;es dermatol&#243;gicas da COVID&#8208;19&#44; segundo as metodologias adotadas nessas pesquisas&#46; Utilizamos como base de dados o Pubmed&#44; segundo as seguintes palavras chaves&#58; COVID&#8208;19&#44; SARS&#8208;CoV&#8208;2&#44; &#8220;<span class="elsevierStyleItalic">dermatology</span>&#8221;&#44; &#8220;<span class="elsevierStyleItalic">skin</span>&#8221;<span class="elsevierStyleItalic">&#46;</span> As informa&#231;&#245;es iniciais est&#227;o reunidas na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Frequ&#234;ncia das manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19</span><p id="par0010" class="elsevierStylePara elsevierViewall">Embora o primeiro relato de um quadro dermatol&#243;gico possivelmente associado a COVID&#8208;19 na literatura tenha sido publicado em 22&#47;03&#47;2020 por Joob e Wiwanitkit<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">2</span></a> no Journal of the American Academy of Dermatology &#40;JAAD&#41;&#44; j&#225; no final de 2019 Guan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">3</span></a> fizeram a primeira cita&#231;&#227;o sobre a frequ&#234;ncia de manifesta&#231;&#245;es cut&#226;neas&#46; Dentre os 1&#46;099 pacientes com infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 descritos&#44; 0&#44;2&#37; apresentaram <span class="elsevierStyleItalic">rash&#46;</span></p><p id="par0015" class="elsevierStylePara elsevierViewall">O primeiro artigo com foco principal na frequ&#234;ncia das manifesta&#231;&#245;es cut&#226;neas&#44; publicado por Recalcati<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">4</span></a> em 26&#47;03&#47;20&#44; relatou que entre 88 casos avaliados por dermatologistas&#44; 20&#44;4&#37; apresentaram les&#245;es de pele&#46; Desde ent&#227;o&#44; a estimativa de tal frequ&#234;ncia tem sido amplamente vari&#225;vel&#44; em diferentes pa&#237;ses&#44; com dados obtidos por diferentes metodologias&#46; Matar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">5</span></a> na Fran&#231;a&#44; Reknimitr et al&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">6</span></a> na Tail&#226;ndia e Solak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">7</span></a> na Turquia mostraram frequ&#234;ncias de 1&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>756&#41;&#44; 15&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>183&#41; e 18&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>382&#41;&#44; respectivamente&#44; por meio da coleta a dist&#226;ncia em entrevista telef&#244;nica ap&#243;s avalia&#231;&#227;o realizada pelo pr&#243;prio paciente &#40;autoexame&#41;&#46; Frequ&#234;ncias mais baixas foram registradas por Gaspari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">8</span></a> na It&#225;lia &#40;1&#44;4&#37;&#41;&#44; Tammaro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">9</span></a> tamb&#233;m na It&#225;lia &#40;1&#44;5&#37; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>130&#41; e Tamai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">10</span></a> no Jap&#227;o &#40;4&#44;3&#37; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>69&#41; em avalia&#231;&#227;o presencial dos pacientes realizada por dermatologista &#8211; fator fundamental para maior sensibilidade na detec&#231;&#227;o de les&#245;es de pele e acur&#225;cia em atribu&#237;&#8208;las &#224; COVID&#8208;19&#46; Pela metodologia mais adequada&#44; acredita&#8208;se que a real frequ&#234;ncia esteja pr&#243;xima &#224;s relatadas por esses &#250;ltimos estudos&#46; As principais cr&#237;ticas aos trabalhos iniciais s&#227;o a avalia&#231;&#227;o a dist&#226;ncia&#44; avalia&#231;&#227;o pelo pr&#243;prio paciente ou por profissionais de sa&#250;de n&#227;o dermatologistas&#44; inclus&#227;o de casos suspeitos de COVID&#8208;19 &#40;n&#227;o confirmados&#41; e a n&#227;o exclus&#227;o de afec&#231;&#245;es cut&#226;neas comuns&#44; como outras infec&#231;&#245;es virais e rea&#231;&#245;es adversas a medicamentos&#46; O significado biol&#243;gico real de tais manifesta&#231;&#245;es ainda parece incerto&#46; Mais dados sobre frequ&#234;ncia ser&#227;o citados adiante&#44; nos t&#243;picos &#8220;Estudos prospectivos&#8221; e &#8220;Revis&#245;es sistem&#225;ticas&#8221; e resumidos na <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Curiosamente&#44; um estudo espanhol mostrou que a frequ&#234;ncia de manifesta&#231;&#245;es dermatol&#243;gicas foi ainda menor na segunda onda da epidemia naquele pa&#237;s&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">11</span></a> Poss&#237;veis explica&#231;&#245;es s&#227;o&#58; melhor conhecimento sobre a doen&#231;a propiciou tratamento precoce e com medica&#231;&#245;es mais assertivas&#44; o que reduziu a propor&#231;&#227;o de casos graves e rea&#231;&#245;es adversas a medicamentos &#40;um dos principais diagn&#243;sticos diferenciais&#41;&#59; maior aplica&#231;&#227;o de medidas preventivas e testes diagn&#243;sticos para exclus&#227;o de outras infec&#231;&#245;es virais&#59; novas muta&#231;&#245;es com maior diversidade de virul&#234;ncia e antigenicidade&#46; Al&#233;m disso&#44; a aparente baixa frequ&#234;ncia de les&#245;es dermatol&#243;gicas em compara&#231;&#227;o &#224;s manifesta&#231;&#245;es cl&#237;nicas &#8220;cl&#225;ssicas&#8221; podem ser explicadas pela menor express&#227;o de receptores virais na pele em rela&#231;&#227;o a outros &#243;rg&#227;os&#8208;alvo e pela presen&#231;a de proteases de membrana com a&#231;&#227;o protetora &#224; pele&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Por fim&#44; um recente estudo austr&#237;aco com metodologia caso&#8208;controle n&#227;o mostrou signific&#226;ncia estat&#237;stica entre a presen&#231;a de les&#245;es de pele no grupo dos pacientes com COVID&#8208;19 confirmados &#40;casos&#41; e no grupo n&#227;o COVID &#40;controles&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">13</span></a> Sugere&#8208;se que as les&#245;es de pele s&#227;o menos espec&#237;ficas do que outros sinais cl&#237;nicos&#44; n&#227;o s&#227;o boas pistas diagn&#243;sticas&#44; devem ser avaliadas com crit&#233;rio e ser atribu&#237;das &#224; COVID&#8208;19 apenas depois de exclu&#237;dos outros diagn&#243;sticos diferenciais&#44; como rea&#231;&#245;es adversas a medicamentos e outras infec&#231;&#245;es virais&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Fisiopatologia</span><p id="par0030" class="elsevierStylePara elsevierViewall">Os mecanismos pelos quais o SARS&#8208;CoV&#8208;2 causa doen&#231;a nos diversos &#243;rg&#227;os&#44; incluindo a pele&#44; s&#227;o bastante complexos e n&#227;o totalmente elucidados&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">O risco de um &#243;rg&#227;o desenvolver infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 &#233; determinado pela presen&#231;a dos receptores funcionais virais da enzima conversora de angiotensina&#8208;2 &#40;ACE2&#41; e transmembrana <span class="elsevierStyleItalic">protease serine</span> 2 &#40;TMPRSS2&#41; expressos nas c&#233;lulas locais&#46; A ACE2 &#233; encontrada principalmente em c&#233;lulas epiteliais alveolares&#44; o que explica a alta vulnerabilidade dos pulm&#245;es &#224; COVID&#8208;19&#46; Alguns estudos mostraram que a ACE2 &#233; detect&#225;vel na camada basal da epiderme&#44; bem como nos fol&#237;culos capilares&#46; No entanto&#44; a presen&#231;a de SARS&#8208;CoV&#8208;2 em amostras de pele foi relacionada com a express&#227;o da ACE2 nas c&#233;lulas endoteliais de capilares cut&#226;neos&#44; n&#227;o em queratin&#243;citos e melan&#243;citos&#44;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">14</span></a> o que faz com que o v&#237;rus n&#227;o consiga penetrar e infectar direta e primariamente a pele&#46; O acometimento cut&#226;neo &#233; indireto&#44; ou seja&#44; ocorre por infec&#231;&#227;o das c&#233;lulas endoteliais dos vasos d&#233;rmicos&#46; A presen&#231;a do SARS&#8208;CoV&#8208;2 nas les&#245;es de pele j&#225; foi confirmada por t&#233;cnica de rea&#231;&#227;o em cadeia da polimerase &#40;PCR&#41; em tecido com baixa replica&#231;&#227;o&#44; mesmo em paciente com PCR no <span class="elsevierStyleItalic">swab</span> nasal e sorologias negativas&#44; mostrando que a pele pode ser um &#243;rg&#227;o infectado&#44; eventualmente at&#233; diagn&#243;stico&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">15</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A primeira e maior evid&#234;ncia sobre a fisiopatologia das les&#245;es cut&#226;neas na COVID&#8208;19 foi publicada por Magro et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">16</span></a> ainda no in&#237;cio da pandemia &#40;15&#47;04&#47;20&#41;&#46; Por meio de t&#233;cnicas de histopatologia e imuno&#8208;histoqu&#237;mica de componentes do complemento e da prote&#237;na <span class="elsevierStyleItalic">spike viral</span>&#44; o trabalho de Magro mostra que o processo fisiopatol&#243;gico respons&#225;vel pelo acometimento pulmonar pode ocorrer tamb&#233;m na pele&#44; tanto s&#227; como lesada&#44; al&#233;m de comprovar a presen&#231;a viral nesses &#243;rg&#227;os&#46; Da mesma maneira&#44; Colmenero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">17</span></a> tamb&#233;m identificaram part&#237;culas virais no endot&#233;lio de les&#245;es do tipo eritema p&#233;rnio em crian&#231;as&#44; o que sustenta a rela&#231;&#227;o causal entre o acometimento cut&#226;neo e a presen&#231;a viral&#46; O dano endotelial induzido pelo SARS&#8208;CoV&#8208;2 na pele pode ser um dos mecanismos&#8208;chave na patog&#234;nese&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Sabe&#8208;se que a fisiopatologia da COVID&#8208;19 &#233; multifatorial e envolve resposta imune inata&#44; humoral&#44; hipercoagulabilidade&#44; ativa&#231;&#227;o monoc&#237;tica&#47;macrof&#225;gica&#44; aumento expressivo de citocinas &#40;&#8220;tempestade de citocinas&#8221;&#41;&#44; entre outros&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">18</span></a> De maneira bastante simplificada&#44; as manifesta&#231;&#245;es cut&#226;neas t&#234;m sido divididas em duas formas quanto &#224; fisiopatologia&#58; &#40;1&#41; inflamat&#243;ria&#44; como resposta imune aos nucleot&#237;dios virais&#44; e &#40;2&#41; vascular&#44; secund&#225;ria aos fen&#244;menos de vasculite&#44; vasculopatia e trombose&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">19</span></a> Sobre a resposta inflamat&#243;ria&#44; as infec&#231;&#245;es virais est&#227;o relacionadas com o desencadear de respostas imunes inatas e adaptativas&#46; O sistema monoc&#237;tico&#8208;macr&#243;fago produz uma resposta imune exacerbada&#44; gerando processo inflamat&#243;rio sist&#234;mico intenso&#46; A ativa&#231;&#227;o viral de mast&#243;citos e bas&#243;filos poderia justificar les&#245;es como urtic&#225;ria e exantemas&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">20</span></a> Com rela&#231;&#227;o aos mecanismos vasculares&#44; as les&#245;es mais estudadas s&#227;o do tipo eritema p&#233;rnio&#44; em analogia &#224; fisiopatologia de doen&#231;as j&#225; conhecidas&#44; como eritema p&#233;rnio &#8220;cl&#225;ssico&#8221; &#40;desencadeado pelo frio&#41;&#44; &#8220;l&#250;pico&#8221; e outras entidades vasculares&#44; como a vasculopatia livedoide&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">21</span></a> Acredita&#8208;se que o eritema p&#233;rnio associado &#224; COVID&#8208;19 decorra tamb&#233;m de uma rea&#231;&#227;o imune exagerada com sinaliza&#231;&#227;o via interferon tipo I&#44; importante para a erradica&#231;&#227;o viral&#44; por&#233;m com resposta generalizada altamente inflamat&#243;ria&#46; J&#225; nos quadros de p&#250;rpura retiforme dos pacientes graves&#44; a trombose vascular na pele e em outros &#243;rg&#227;os estaria associada a uma resposta m&#237;nima de interferon&#44; possibilitando a replica&#231;&#227;o viral excessiva com libera&#231;&#227;o de prote&#237;nas virais que se localizam no endot&#233;lio extrapulmonar e desencadeiam extensa ativa&#231;&#227;o do complemento&#46;<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Controv&#233;rsias quanto &#224; fisiopatologia e &#224; presen&#231;a de part&#237;culas virais desencadeando les&#245;es cut&#226;neas baseiam&#8208;se em estudos que constatam a aus&#234;ncia dessas part&#237;culas em pesquisa&#44; por t&#233;cnica de PCR nos fragmentos obtidos por bi&#243;psia de les&#245;es de pele&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">24</span></a> Al&#233;m disso&#44; recentemente&#44; sugere&#8208;se que o SARS&#8208;CoV&#8208;2 poderia causar a reativa&#231;&#227;o de outros v&#237;rus latentes&#44; como o HHV&#8208;6&#44; e que este seria o real respons&#225;vel por algumas manifesta&#231;&#245;es cut&#226;neas inicialmente atribu&#237;das &#224; COVID&#8208;19&#44;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">25</span></a> como os exantemas e quadros pitir&#237;ase r&#243;sea s&#237;mile&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Grandes s&#233;ries nacionais e internacionais</span><p id="par0055" class="elsevierStylePara elsevierViewall">Logo ap&#243;s os primeiros relatos de casos isolados de manifesta&#231;&#245;es cut&#226;neas em pacientes com COVID&#8208;19&#44; principalmente com a chegada da pandemia na Europa&#44; alguns pa&#237;ses realizaram estudos com colabora&#231;&#227;o nacional e internacional sob lideran&#231;a de suas respectivas sociedades acad&#234;micas&#46; Surgem&#44; ent&#227;o&#44; os primeiros estudos com grandes s&#233;ries de casos sobre as manifesta&#231;&#245;es cut&#226;neas mais prevalentes&#44; incluindo sugest&#245;es de classifica&#231;&#245;es em grupos&#44; conforme o padr&#227;o cl&#237;nico e mecanismos fisiopatol&#243;gicos&#46; Tais estudos foram fundamentais na compreens&#227;o inicial da rela&#231;&#227;o entre dermatologia e COVID&#8208;19&#44; e s&#227;o refer&#234;ncias importantes at&#233; o presente momento&#46; Os principais dados desses estudos est&#227;o reunidos na <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Espanha</span><p id="par0060" class="elsevierStylePara elsevierViewall">A primeira grande s&#233;rie retrospectiva foi publicada em 29&#47;04&#47;20 por Galv&#225;n&#8208;Casas et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">26</span></a> amplamente divulgada&#44; contendo um atlas dermatol&#243;gico&#46; Com o apoio da Academia Espa&#241;ola de Dermatolog&#237;a y Venereolog&#237;a&#44; dermatologistas de toda a Espanha inclu&#237;ram imagens de les&#245;es de pele de 375 pacientes com COVID&#8208;19 &#40;suspeitos ou confirmados&#41;&#44; agrupados em cinco padr&#245;es principais&#58; erup&#231;&#245;es maculopapulares &#40;47&#37;&#41;&#44; urticariformes &#40;19&#37;&#41;&#44; EP&#8208;s&#237;mile &#40;19&#37;&#41;&#44; vesico&#8208;bolhosas &#40;9&#37;&#41;&#44; e livedo&#47;necrose &#40;6&#37;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">O padr&#227;o mais encontrado foi de erup&#231;&#245;es maculopapulares&#44; com in&#237;cio concomitante aos sintomas gerais e dura&#231;&#227;o m&#233;dia de 8&#44;6 dias&#44; em semelhan&#231;a aos quadros urticariformes&#46; Ambos n&#227;o foram considerados &#250;teis para o diagn&#243;stico da COVID&#8208;19 por serem manifesta&#231;&#245;es inespec&#237;ficas&#44; comuns a outras afec&#231;&#245;es frequentes&#44; como rea&#231;&#245;es adversas a medicamentos e outras infec&#231;&#245;es virais&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">As les&#245;es EP&#8208;s&#237;mile ocorreram em pacientes mais jovens com quadros sist&#234;micos leves&#44; de surgimento tardio &#40;m&#233;dia 12&#44;7 dias do in&#237;cio dos sintomas gerais&#41; e dura&#231;&#227;o prolongada&#46; Apenas 1 dos 71 casos relatava EP pr&#233;vio&#46; Teriam valor como marcador epidemiol&#243;gico e n&#227;o diagn&#243;stico&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As les&#245;es vesiculares surgiram antes dos sintomas gerais em 15&#37; dos casos dessa s&#233;rie&#44; com dura&#231;&#227;o m&#233;dia de 10&#44;4 dias e relativa especificidade diagn&#243;stica&#44; j&#225; que s&#227;o manifesta&#231;&#245;es cut&#226;neas n&#227;o relatadas nos exantemas virais&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Livedo&#47;necrose incluem uma gama vari&#225;vel de apresenta&#231;&#245;es relacionadas com a COVID&#8208;19 ou &#224;s suas complica&#231;&#245;es&#44; como estado de hipercoagulabilidade e dano vascular&#46; Est&#227;o associadas com faixa et&#225;ria elevada e maior mortalidade&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Embora haja grande m&#233;rito pelo pioneirismo e expressivo n&#250;mero de casos&#44; a inclus&#227;o de pacientes n&#227;o confirmados para COVID&#8208;19 &#40;suspeitos&#41;&#44; em sua maioria ambulatoriais&#44; avaliados por registro fotogr&#225;fico&#44; sem an&#225;lise histol&#243;gica ou exclus&#227;o dos principais diagn&#243;sticos diferenciais &#233; uma limita&#231;&#227;o do estudo&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fran&#231;a</span><p id="par0090" class="elsevierStylePara elsevierViewall">Em 04&#47;05&#47;20&#44; de Masson et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">27</span></a> com apoio da Soci&#233;t&#233; Fran&#231;aise de Dermatologie&#44; publicaram um estudo retrospectivo observacional em forma de carta que incluiu imagens de manifesta&#231;&#245;es cut&#226;neas de 277 pacientes com COVID&#8208;19 &#40;252 suspeitos e 25 confirmados&#41; de cl&#237;nicas privadas de toda a Fran&#231;a&#46; Surpreendentemente&#44; as les&#245;es EP&#8208;s&#237;mile corresponderam &#224; grande maioria dos casos &#40;75&#37;&#41;&#44; relatadas inclusive como manifesta&#231;&#227;o &#250;nica da doen&#231;a&#46; Estudo histol&#243;gico realizado em tr&#234;s casos mostrou dermatite de interface liquenoide com a presen&#231;a de microtrombos&#46; Outros padr&#245;es cut&#226;neos encontrados foram&#58; vesicular &#40;15&#37;&#41;&#44; urticariforme &#40;9&#37;&#41;&#44; morbiliforme &#40;9&#37;&#41;&#44; petequial &#40;3&#37;&#41;&#44; livedo reticular &#40;1&#37;&#41;&#44; outros &#40;15&#37;&#41;&#46; Alguns pacientes foram contabilizados em mais de uma categoria&#46; Vale lembrar que os franceses foram os primeiros a descrever as les&#245;es EP&#8208;s&#237;mile relacionadas com a COVID&#8208;19&#44; o que poderia ser um vi&#233;s para a alta frequ&#234;ncia apresentada nesse estudo&#44; n&#227;o reprodut&#237;vel nos demais trabalhos semelhantes&#46; Al&#233;m disso&#44; a elevada preval&#234;ncia das les&#245;es EP&#8208;s&#237;mile provavelmente reflete&#8208;se na grande porcentagem de casos n&#227;o confirmados inclu&#237;dos na an&#225;lise&#44; uma vez que tais les&#245;es predominam em quadros oligo ou assintom&#225;ticos da COVID&#8208;19&#44; que habitualmente s&#227;o pouco testados quanto &#224; confirma&#231;&#227;o laboratorial da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">EUA&#47;internacional &#40;31 pa&#237;ses&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Em colabora&#231;&#227;o com a American Academy of Dermatology e com a International League of Dermatological Societies&#44; Freeman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">28</span></a> coletaram dados de 716 casos de 31 pa&#237;ses por meio de registro eletr&#244;nico&#44; resultados publicados em 02&#47;07&#47;20&#46; Dermatologistas forneceram dados de 54&#37; dos casos &#40;89&#37; de todos os registros eram provenientes dos EUA&#41;&#46; Apenas 34 pacientes hisp&#226;nicos&#47;latinos e 13 afro&#8208;americanos foram inclu&#237;dos&#44; comprometendo a diversidade racial necess&#225;ria para a compreens&#227;o das manifesta&#231;&#245;es cut&#226;neas&#46; Apenas 171 pacientes eram COVID&#8208;19 confirmados&#44; com as seguintes manifesta&#231;&#245;es e suas frequ&#234;ncias&#58; morbiliforme &#40;22&#37;&#41;&#44; EP&#8208;s&#237;mile &#40;18&#37;&#41;&#44; urticariforme &#40;16&#37;&#41;&#44; eritema macular &#40;13&#37;&#41;&#44; vesicular &#40;11&#37;&#41;&#44; papuloescamoso &#40;9&#44;9&#37;&#41; e p&#250;rpura retiforme &#40;6&#44;4&#37;&#41;&#46; A maioria das manifesta&#231;&#245;es cut&#226;neas teve in&#237;cio concomitante aos sintomas gerais&#46; No entanto&#44; em 12&#37; as les&#245;es de pele foram os primeiros sintomas da doen&#231;a&#44; mostrando a poss&#237;vel import&#226;ncia das les&#245;es cut&#226;neas como marcador para o diagn&#243;stico precoce da COVID&#8208;19&#46; Com rela&#231;&#227;o &#224; gravidade&#44; as les&#245;es EP&#8208;s&#237;mile associaram&#8208;se a quadros sist&#234;micos mais leves e os casos com p&#250;rpura retiforme estavam 100&#37; hospitalizados&#46; Estudo histopatol&#243;gico foi realizado em 14 casos confirmados&#46; As limita&#231;&#245;es apresentadas pelo pr&#243;prio estudo foram&#58; vi&#233;s do avaliador&#44; impossibilidade de estimar frequ&#234;ncia&#47;preval&#234;ncia das manifesta&#231;&#245;es cut&#226;neas&#44; baixa taxa de casos COVID&#8208;19 confirmados &#40;25&#37;&#41; e pouca diversidade &#233;tnica&#44; apesar da aparente alta representatividade por 31 pa&#237;ses&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">It&#225;lia</span><p id="par0100" class="elsevierStylePara elsevierViewall">Em semelhan&#231;a &#224; Espanha e Fran&#231;a&#44; em 18&#47;01&#47;21 a Societ&#224; Italiana di Dermatologia medica&#44; chirurgica&#44; estetica e delle Malattie Sessualmente Trasmesse tamb&#233;m coordenou um estudo nacional que reuniu dados de 200 pacientes com manifesta&#231;&#245;es cut&#226;neas&#46; Um dos crit&#233;rios de inclus&#227;o para Marzano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">29</span></a> foi a presen&#231;a de les&#245;es de pele relacionada com a COVID&#8208;19&#44; confirmada por um dermatologista experiente&#59; 62&#37; apresentavam diagn&#243;stico confirmado de COVID&#8208;19&#46; Os principais padr&#245;es identificados foram&#58; erup&#231;&#227;o maculopapular&#47;exantema morbiliforme &#40;25&#44;7&#37;&#41;&#44; EP&#8208;s&#237;mile &#40;24&#44;6&#37;&#41;&#44; erup&#231;&#227;o papulovesicular &#40;15&#44;5&#37;&#41;&#44; urticariforme &#40;10&#44;2&#37;&#41;&#44; p&#250;rpura&#47;vasculite &#40;6&#44;9&#37;&#41;&#44; livedo reticular&#47;racemoso &#40;2&#44;1&#37;&#41; e outros &#40;15&#37;&#41;&#44; que inclu&#237;ram pitir&#237;ase r&#243;sea s&#237;mile&#44; eritema multiforme s&#237;mile&#44; eritema nodoso s&#237;mile&#44; paniculite e angioedema&#46; N&#227;o foram identificadas les&#245;es mucosas&#46; O quadro cut&#226;neo surgiu&#44; em m&#233;dia&#44; 14 dias ap&#243;s o in&#237;cio dos sintomas sist&#234;micos e durou&#44; em m&#233;dia&#44; 12 dias&#46; As les&#245;es EP&#8208;s&#237;mile apresentaram dura&#231;&#227;o maior em rela&#231;&#227;o aos demais padr&#245;es&#44; ocorreram em faixa et&#225;ria mais jovem e representaram menor risco de desenvolver doen&#231;a sist&#234;mica grave &#8211; todos fatores com signific&#226;ncia estat&#237;stica&#46; A idade m&#233;dia dos grupos livedo reticular&#47;racemoso e erup&#231;&#227;o maculopapular&#47;exantema morbiliforme tamb&#233;m foi maior &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; Uma limita&#231;&#227;o do estudo &#233; a aus&#234;ncia de confirma&#231;&#227;o diagn&#243;stica da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 em 36&#44;5&#37; da amostra&#44; por fatores econ&#244;micos que limitaram a ampla testagem diagn&#243;stica na It&#225;lia e em diversos outros pa&#237;ses&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Reino Unido</span><p id="par0105" class="elsevierStylePara elsevierViewall">Por fim&#44; o estudo populacional mais recente&#44; com n&#250;meros bastante expressivos&#44; cujos resultados geraram muita repercuss&#227;o&#44; foi publicado em 14&#47;01&#47;21 por Visconti et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">30</span></a> com dados de todo o Reino Unido e desenho distinto das publica&#231;&#245;es citadas anteriormente&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">O primeiro bra&#231;o do estudo coletou dados de 336&#46;847 usu&#225;rios do aplicativo &#8220;COVID <span class="elsevierStyleItalic">Symptom Study</span>&#8221;&#44; em que indiv&#237;duos forneceram informa&#231;&#245;es epidemiol&#243;gicas&#44; laboratoriais e cl&#237;nicas&#44; dentre elas acerca da presen&#231;a ou n&#227;o de les&#245;es de pele identificadas pelo pr&#243;prio usu&#225;rio&#46; Apenas 2&#46;021 &#40;7&#44;4&#37;&#41; usu&#225;rios apresentavam confirma&#231;&#227;o laboratorial de COVID&#8208;19&#59; desses&#44; 178 &#40;8&#44;8&#37;&#41; relataram les&#245;es cut&#226;neas&#46; A preval&#234;ncia foi ligeiramente maior entre as mulheres&#46; Al&#233;m disso&#44; a preval&#234;ncia de les&#245;es na pele foi significativamente maior entre os que testaram positivo para SARS&#8208;CoV&#8208;2 em compara&#231;&#227;o aos que testaram negativo&#44; o que justificaria a inclus&#227;o do acometimento cut&#226;neo na lista dos sintomas de suspei&#231;&#227;o da COVID&#8208;19&#44; por seu fator preditivo diagn&#243;stico&#44; independentemente da frequ&#234;ncia com que ocorra&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">O segundo bra&#231;o do estudo procurou investigar com detalhes as manifesta&#231;&#245;es cut&#226;neas por meio de question&#225;rio dirigido aos usu&#225;rios que as relataram e o compartilhamento de fotos&#46; Dentre os 11&#46;544 question&#225;rios respondidos&#44; apenas 694 &#40;6&#37;&#41; apresentavam diagn&#243;stico confirmado de COVID&#8208;19&#46; Nesse grupo&#44; embora a maioria tenha referido in&#237;cio das les&#245;es cut&#226;neas juntamente ou logo ap&#243;s os sintomas gerais&#44; 17&#37; relataram que as les&#245;es de pele surgiram antes dos sintomas sist&#234;micos&#44; e em 21&#37; o quadro cut&#226;neo foi o &#250;nico sintoma&#46; No entanto&#44; o estudo n&#227;o trouxe informa&#231;&#245;es adicionais detalhadas sobre tais constata&#231;&#245;es&#46; N&#227;o houve descri&#231;&#227;o sobre quais foram as manifesta&#231;&#245;es cut&#226;neas ocorridas previamente aos sintomas gerais e quanto tempo antes elas surgiram&#46; Tampouco especificou quais foram as les&#245;es de pele consideradas pelo pr&#243;prio indiv&#237;duo como manifesta&#231;&#227;o &#250;nica da COVID&#8208;19 ou esclareceu o motivo pelo qual foi realizada a confirma&#231;&#227;o laboratorial da doen&#231;a na aus&#234;ncia de qualquer sintoma suspeito&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nesse mesmo bra&#231;o do estudo&#44; 2&#46;328 usu&#225;rios compartilharam fotos das les&#245;es cut&#226;neas&#44; 260 imagens foram selecionadas de modo randomizado para an&#225;lise por dermatologistas e&#44; dessas&#44; 30 foram descartadas por n&#227;o serem atribu&#237;veis &#224; infec&#231;&#227;o pelo SARS&#8208;CoV&#8208;2 &#8211; p&#46; ex&#46;&#44; acne&#44; molusco contagioso&#44; herpes&#8208;z&#243;ster&#44; eczema&#44; dermatite perioral&#44; impetigo&#44; dermatofitose &#8211;&#44; o que mostra a limita&#231;&#227;o do pr&#243;prio usu&#225;rio como avaliador das les&#245;es de pele&#46; As imagens finais foram avaliadas por quatro dermatologistas experientes&#46; A apresenta&#231;&#227;o dermatol&#243;gica mais frequente foi erup&#231;&#245;es papulosas &#40;41&#44;2&#37; incluindo eritemato&#8208;papulosas e eritemato&#8208;vesiculosas&#41;&#44; urticariformes &#40;30&#37;&#41; e acrais &#40;23&#44;1&#37;&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">At&#233; o momento&#44; essa &#233; a primeira e &#250;nica publica&#231;&#227;o de impacto que afirma a frequ&#234;ncia e a relev&#226;ncia das les&#245;es cut&#226;neas como &#250;nica manifesta&#231;&#227;o da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2&#46; Portanto&#44; s&#227;o necess&#225;rios cautela e estudos mais aprofundados sobre o tema para compreendermos sua real import&#226;ncia e impacto no diagn&#243;stico da COVID&#8208;19&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">A natureza do estudo apresenta quatro principais limita&#231;&#245;es&#58; dados baseados na autoavalia&#231;&#227;o&#44; n&#227;o representativos da popula&#231;&#227;o geral&#44; desconsiderou manifesta&#231;&#245;es dermatol&#243;gicas raras e a impossibilidade de excluir diagn&#243;stico diferenciais importantes&#44; como rea&#231;&#227;o adversa a medicamentos&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Estudos prospectivos</span><p id="par0135" class="elsevierStylePara elsevierViewall">S&#227;o poucos estudos prospectivos sobre manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19 publicados at&#233; o momento&#46; Tal metodologia ofereceria informa&#231;&#245;es mais fidedignas sobre a real preval&#234;ncia das les&#245;es cut&#226;neas e os padr&#245;es identificados&#44; especialmente por meio da busca ativa de les&#245;es cut&#226;neas pelo especialista&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Ainda assim&#44; diferentes preval&#234;ncias&#44; propor&#231;&#245;es e classifica&#231;&#245;es de manifesta&#231;&#245;es cut&#226;neas diagnosticadas por dermatologistas em pacientes com infec&#231;&#227;o confirmada por SARS&#8208;CoV&#8208;2 de maneira prospectiva foram relatadas&#46; De Giorgi et at&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">31</span></a> avaliaram 678 pacientes em hospitais na It&#225;lia e na China com frequ&#234;ncia de 7&#44;8&#37; de presen&#231;a de les&#245;es cut&#226;neas &#8211; 44&#37; identificadas ao diagn&#243;stico de COVID&#8208;19 e 56&#37; nos dias subsequentes&#44; em m&#233;dia ap&#243;s 11&#44;7 dias&#46; O achado mais frequente foi o exantema &#40;70&#37;&#41;&#44; seguido de les&#245;es urticariformes &#40;26&#37;&#41; e vesiculares &#40;4&#37;&#41;&#46; Todos os casos de exantema melhoraram espontaneamente em dois a cinco dias&#46; Rehktman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">32</span></a> avaliaram 296 pacientes em dois hospitais em Nova York&#44; com frequ&#234;ncia de 11&#44;8&#37; de les&#245;es cut&#226;neas nas seguintes propor&#231;&#245;es&#58; &#250;lceras &#40;37&#44;1&#37;&#41;&#44; p&#250;rpura &#40;25&#44;7&#37;&#41;&#44; necrose &#40;14&#44;3&#37;&#41;&#44; eritema inespec&#237;fico &#40;11&#44;4&#37;&#41;&#44; erup&#231;&#227;o morbiliforme &#40;11&#44;4&#37;&#41;&#44; EP&#8208;s&#237;mile &#40;11&#44;4&#37;&#41; e ves&#237;culas &#40;2&#44;9&#37;&#41;&#46; J&#225; M&#233;ndez&#8208;Maestro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">33</span></a> avaliaram 75 pacientes em hospital espanhol&#44; dos quais 14 &#40;18&#44;7&#37;&#41; apresentavam les&#245;es de pele possivelmente associada &#224; COVID&#8208;19&#58; EP&#8208;s&#237;mile &#40;42&#44;8&#37;&#41;&#44; erup&#231;&#227;o maculopapular &#40;28&#44;6&#37;&#41;&#44; urticariforme &#40;14&#44;3&#37;&#41;&#44; livedo reticular s&#237;mile &#40;7&#44;15&#37;&#41; e vesicular &#40;7&#44;15&#37;&#41;&#46; Por fim&#44; Nuno&#8208;Gonzales et al&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">34</span></a> avaliaram 666 pacientes&#44; tamb&#233;m em ambiente hospitalar na Espanha&#44; e relataram a alt&#237;ssima frequ&#234;ncia de 45&#44;65&#37; de les&#245;es mucocut&#226;neas&#46; No entanto&#44; o estudo incluiu altera&#231;&#245;es bastante inespec&#237;ficas tanto mucosas &#40;p&#46; ex&#46;&#44; papilite&#44; glossite&#44; estomatite&#44; despapila&#231;&#227;o&#44; mucosite&#41; como cut&#226;neas &#40;p&#46; ex&#46;&#44; descama&#231;&#227;o e m&#225;culas eritemato&#8208;acastanhada palmoplantares&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">No Brasil&#44; at&#233; o momento n&#227;o h&#225; dados sobre a preval&#234;ncia de les&#245;es cut&#226;neas&#46; Avancini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">35</span></a> relataram que dentre os 86 pacientes internados em um centro de refer&#234;ncia com infec&#231;&#227;o confirmada por SARS&#8208;CoV&#8208;2 para os quais foi solicitada avalia&#231;&#227;o da equipe de dermatologia&#44; em nenhum foi poss&#237;vel atribuir correla&#231;&#227;o direta entre as les&#245;es de pele e a COVID&#8208;19&#44; uma vez que o perfil de dermatoses encontrado se assemelhou ao per&#237;odo pr&#233;&#8208;pandemia&#46; Cinco pacientes apresentaram exantema indistingu&#237;vel de rea&#231;&#227;o medicamentosa e um apresentou les&#245;es EP&#8208;s&#237;mile&#44; por&#233;m com antecedente pessoal de l&#250;pus eritematoso sist&#234;mico&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Revis&#245;es sistem&#225;ticas</span><p id="par0150" class="elsevierStylePara elsevierViewall">A grande quantidade de publica&#231;&#245;es em um curto per&#237;odo de tempo tornou poss&#237;vel que j&#225; no final de 2020 surgissem os primeiros estudos de revis&#245;es sistem&#225;ticas sobre as manifesta&#231;&#245;es cut&#226;neas da COVID&#8208;19&#44; com o intuito de reunir e compilar os resultados at&#233; ent&#227;o&#44; produzindo dados com maior evid&#234;ncia cientifica&#46; Ainda assim&#44; as conclus&#245;es s&#227;o divergentes&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Em dois artigos de revis&#227;o sistem&#225;tica&#44; a preval&#234;ncia de les&#245;es de pele em pacientes com COVID&#8208;19 foi bastante semelhante&#58; 5&#44;69 e 5&#44;95&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">36</span></a> No entanto&#44; mesmo os estudos de metan&#225;lise ainda diferem sobre quais seriam as manifesta&#231;&#245;es cut&#226;neas mais frequentes&#46; A maioria das revis&#245;es sistem&#225;ticas encontrou maior frequ&#234;ncia das erup&#231;&#245;es maculopapulares&#58; 37&#44;1&#37;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">36</span></a> e 48&#37;&#44; seguida das les&#245;es vasculares &#40;incluindo EP&#8208;s&#237;mile&#41;&#58; 23&#37; e 33&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">37</span></a> No entanto&#44; outros afirmam que o padr&#227;o mais comum seria o de les&#245;es EP&#8208;s&#237;mile &#40;51&#44;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">38</span></a> Os quadros urticariformes&#44; vesiculares e livedo&#47;necrose s&#227;o tidos como mais raros&#46;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">36&#8211;38</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Em sua revis&#227;o sistem&#225;tica&#44; Jamshidi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">36</span></a> concentraram&#8208;se nos fatores progn&#243;sticos associados aos diferentes padr&#245;es de manifesta&#231;&#245;es cut&#226;neas&#46; As erup&#231;&#245;es maculopapulares associam&#8208;se a quadros leves de COVID&#8208;19 em 48&#37; dos casos&#44; assim como os padr&#245;es urticariforme e EP&#8208;s&#237;mile&#46; Pacientes com les&#245;es vasculares do espectro livedo&#44; p&#250;rpura e necrose apresentaram a maior mortalidade &#40;18&#44;2&#37;&#41; e aqueles com les&#245;es urticariformes&#44; a menor &#40;2&#44;2&#37;&#41;&#46; Sobre o tempo de surgimento das manifesta&#231;&#245;es cut&#226;neas&#44; em sua grande maioria &#40;92&#37;&#41; ocorrem em at&#233; quatro semanas do in&#237;cio dos sintomas gerais da COVID&#8208;19&#44; especialmente nos primeiros dias e at&#233; duas semanas nos casos dos exantemas e urtic&#225;rias&#46; J&#225; as les&#245;es EP&#8208;s&#237;mile s&#227;o mais tardias e surgem entre a segunda e quarta semanas&#44; assim como as p&#250;rpuras e a necrose&#46; Em 8 a 10&#37;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">37</span></a> dos casos as manifesta&#231;&#245;es cut&#226;neas podem preceder&#44; em m&#233;dia&#44; por tr&#234;s dias os sintomas cl&#237;nicos &#8211; s&#227;o&#44; portanto&#44; possivelmente &#250;teis como indicadores para o diagn&#243;stico precoce da COVID&#8208;19&#46; &#201; importante ressaltar que quase a totalidade dos estudos inclu&#237;dos nas revis&#245;es sistem&#225;ticas &#233; origin&#225;ria da Europa e dos EUA&#44; com raros relatos da &#193;sia e Am&#233;rica Latina &#40;pela escassez de dados publicados&#41;&#44; o que poderia gerar um vi&#233;s&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Principais manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Erup&#231;&#227;o maculopapular</span><p id="par0165" class="elsevierStylePara elsevierViewall">Na maioria dos estudos &#233; considerada a manifesta&#231;&#227;o cut&#226;nea mais frequente na COVID&#8208;19&#46; Engloba quadros de exantema &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#44; <span class="elsevierStyleItalic">rash&#44;</span> p&#225;pulas difusas&#44; pitir&#237;ase r&#243;sea s&#237;mile&#44; eritema multiforme s&#237;mile&#44; entre outros&#46; Habitualmente&#44; surge nos primeiros dias de sintomas gerais da infec&#231;&#227;o viral ou em at&#233; duas semanas&#44; embora haja relatos espor&#225;dicos de surgimento tardio &#40;ap&#243;s um m&#234;s&#41;&#46; Correlaciona&#8208;se com quadros sist&#234;micos leves e tem melhora espont&#226;nea em sete a dez dias&#44;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">26</span></a> sem necessidade de tratamento espec&#237;fico&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Embora sejam manifesta&#231;&#245;es frequentes&#44; s&#227;o altamente inespec&#237;ficas uma vez que outras infec&#231;&#245;es virais s&#227;o causas comuns de exantemas&#44; bem como as rea&#231;&#245;es adversas a medicamentos&#46; Discute&#8208;se na literatura a necessidade de excluir tais diagn&#243;sticos diferenciais antes de atribuirmos o quadro cut&#226;neo unicamente &#224; COVID&#8208;19&#44; mesmo em casos confirmados da doen&#231;a&#46; Outro fator de confus&#227;o &#233; a reativa&#231;&#227;o viral que ocorre nos casos de farmacodermia&#44; como a ativa&#231;&#227;o de HHV&#8208;6 nos quadros <span class="elsevierStyleItalic">drug reaction with eosinofilia and systemic symptoms</span> &#40;DRESS&#41;<span class="elsevierStyleItalic">&#46;</span> Uma hip&#243;tese seria que a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 levaria a uma reativa&#231;&#227;o de v&#237;rus latentes&#44; como o HHV&#8208;6&#44; e assim predisporia a um quadro de rea&#231;&#227;o adversa a medicamentos&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">25&#44;39</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Eritema p&#233;rnio &#40;EP&#41; s&#237;mile</span><p id="par0175" class="elsevierStylePara elsevierViewall">Sem d&#250;vida&#44; s&#227;o as manifesta&#231;&#245;es mais relatadas em grandes s&#233;ries de casos na literatura&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">40&#44;41</span></a> Com a chegada da pandemia de COVID&#8208;19 na Europa&#44; observou&#8208;se uma explos&#227;o de casos semelhantes ao eritema p&#233;rnio &#8220;cl&#225;ssico&#8221;&#44; por&#233;m com caracter&#237;sticas peculiares&#44; distintas da forma cl&#225;ssica&#58; predom&#237;nio em crian&#231;as e jovens&#44; em &#233;poca de temperaturas amenas &#40;primavera&#41;&#44; sem antecedente pessoal de eritema p&#233;rnio&#44; colagenoses ou outras condi&#231;&#245;es predisponentes&#46; Foi descrito&#44; ent&#227;o&#44; o EP&#8208;s&#237;mile associado &#224; COVID&#8208;19&#46; Desde ent&#227;o&#44; h&#225; in&#250;meras publica&#231;&#245;es sobre o tema&#44; inclusive mostrando a presen&#231;a do <span class="elsevierStyleItalic">spike viral</span> nas les&#245;es cut&#226;neas&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">17</span></a> mesmo em pacientes com PCR negativo &#40;<span class="elsevierStyleItalic">swab</span>&#41;&#46; O EP&#8208;s&#237;mile &#233; mais frequente em crian&#231;as e adultos jovens&#44; saud&#225;veis&#44; oligo ou assintom&#225;ticos para COVID&#8208;19&#44; e pode ser a &#250;nica manifesta&#231;&#227;o da doen&#231;a&#46; Portanto&#44; na presen&#231;a dessas les&#245;es&#44; sugere&#8208;se que a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 seja investigada&#46; Surge em m&#233;dia ap&#243;s 10 a 14 dias dos sintomas gerais&#44; duram em m&#233;dia 14 dias&#44; com melhora espont&#226;nea&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">41</span></a> A maioria dos pacientes &#40;em algumas s&#233;ries&#44; at&#233; a totalidade&#41; apresentam pesquisa viral por PCR &#40;<span class="elsevierStyleItalic">swab</span>&#41; negativa&#46; Tal fato poderia ser explicado pela baixa carga viral encontrada habitualmente nos quadros oligo ou assintom&#225;ticos de COVID&#8208;19 nas crian&#231;as e nos est&#225;gios mais tardios da doen&#231;a &#40;ap&#243;s 10 a 14 dias do in&#237;cio dos sintomas&#41;&#46; Por outro lado&#44; a aus&#234;ncia de positividade de PCR&#44; portanto&#44; da confirma&#231;&#227;o laboratorial da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2&#44; levanta a d&#250;vida se esses pacientes realmente foram infectados&#46; Estudos de imuno&#8208;histoqu&#237;mica e imunofluoresc&#234;ncia podem contribuir para elucidar a rela&#231;&#227;o entre o EP&#8208;s&#237;mile e a COVID&#8208;19&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">42</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Recentemente&#44; a rela&#231;&#227;o entre o EP&#8208;s&#237;mile e a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 tem sido bastante questionada na literatura&#46; Uma das principais controv&#233;rsias &#233; justamente a aus&#234;ncia de comprova&#231;&#227;o de infec&#231;&#227;o pelo SARS&#8208;CoV&#8208;2 nesses pacientes&#46; Foram publicadas s&#233;ries de casos de EP&#8208;s&#237;mile em que n&#227;o havia nenhuma evid&#234;ncia epidemiol&#243;gica&#44; cl&#237;nica ou laboratorial que corroborasse para o diagn&#243;stico de COVID&#8208;19&#44;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">43</span></a> ou mesmo sorol&#243;gica&#44; que poderia contribuir para a fisiopatologia do EP&#8208;s&#237;mile&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">44</span></a> Embora a presen&#231;a do <span class="elsevierStyleItalic">spike viral</span> nas les&#245;es de EP&#8208;s&#237;mile j&#225; tenha sido mostrada por t&#233;cnicas de imuno&#8208;histoqu&#237;mica&#44; e inclusive a estrutura viral completa identificada por microscopia eletr&#244;nica&#44; esses foram relatos pontuais na literatura &#8211; a grande maioria das publica&#231;&#245;es sobre EP&#8208;s&#237;mile n&#227;o conta com essa evid&#234;ncia&#46; Sobre a fisiopatologia&#44; no in&#237;cio da pandemia as les&#245;es EP&#8208;s&#237;mile&#44; livedo&#44; p&#250;rpura e necrose foram interpretadas como fases de um mesmo espectro de acometimento cut&#226;neo&#46; Atualmente&#44; acredita&#8208;se que elas tenham mecanismos fisiopatol&#243;gicos distintos&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Les&#245;es urticariformes</span><p id="par0185" class="elsevierStylePara elsevierViewall">As infec&#231;&#245;es&#44; inclusive virais&#44; s&#227;o fatores desencadeantes j&#225; conhecidos de les&#245;es urticariformes&#46; Nesse sentido&#44; a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 poderia ser um novo fator desencadeante&#46; S&#227;o relatados quadros de urtic&#225;ria associados &#224; COVID&#8208;19 em pacientes sem relatos pr&#233;vios da doen&#231;a&#46; Um estudo em uma cl&#237;nica privada relatou aumento da incid&#234;ncia dos casos de urtic&#225;ria diagnosticados durante a pandemia&#44; por&#233;m n&#227;o foi realizada investiga&#231;&#227;o quanto &#224; presen&#231;a de COVID&#8208;19 nesses pacientes&#46; Clinicamente&#44; as les&#245;es s&#227;o disseminadas&#44; indistintas das demais causas&#44; e o angioedema &#233; raro&#46; Estima&#8208;se que em 10&#37; dos pacientes o quadro cut&#226;neo possa preceder em alguns dias os sintomas gerais de COVID&#8208;19 e que&#44; portanto&#44; a detec&#231;&#227;o das les&#245;es de pele poderia favorecer o diagn&#243;stico precoce da infec&#231;&#227;o&#46; Por&#233;m&#44; em sua grande maioria&#44; as les&#245;es urticariformes surgem concomitantemente aos demais sintomas&#46; N&#227;o h&#225; predile&#231;&#227;o por faixa et&#225;ria e associa&#8208;se a quadros sist&#234;micos leves&#44; com baixa mortalidade&#46; &#201; relatada melhora espont&#226;nea em sete dias&#44; ou com uso de anti&#8208;histam&#237;nicos e&#47;ou corticoide sist&#234;mico em baixa dose&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Erup&#231;&#245;es v&#233;sico&#8208;bolhosas</span><p id="par0190" class="elsevierStylePara elsevierViewall">Embora raras&#44; as erup&#231;&#245;es vesico&#8208;bolhosas s&#227;o consideradas padr&#227;o espec&#237;fico de les&#227;o cut&#226;nea associada &#224; COVID&#8208;19&#44; uma vez que n&#227;o s&#227;o comumente observadas nos exantemas virais e por farmacodemia &#40;principais diagn&#243;sticos diferenciais&#41;&#46; S&#227;o quadros de ves&#237;culas ou bolhas localizadas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41; ou disseminadas&#44; que podem acometer regi&#227;o palmoplantar&#44; poupando mucosas&#46; T&#234;m in&#237;cio cerca de tr&#234;s dias ap&#243;s os sintomas gerais e perduram por 7 a 14 dias&#44; com melhora espont&#226;nea&#46; Associam&#8208;se a quadro sist&#234;mico leve a moderado&#46; Em uma s&#233;rie de casos&#44; tentou&#8208;se isolar o agente viral por t&#233;cnica de PCR do conte&#250;do da bolha&#44; sem sucesso&#46; &#201; fundamental excluir outras infec&#231;&#245;es virais&#44; especialmente a herp&#233;tica&#44; uma vez que j&#225; foi relatado um caso de herpes disseminado com pneumonia em paciente com COVID&#8208;19&#44; mostrando a import&#226;ncia do diagn&#243;stico diferencial&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">47</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Livedo&#44; p&#250;rpura&#44; necrose</span><p id="par0195" class="elsevierStylePara elsevierViewall">As manifesta&#231;&#245;es cut&#226;neas vasculares associadas &#224; COVID&#8208;19 compreendem um amplo espectro&#44; que varia desde livedo reticular transit&#243;rio a fixo&#44; livedo racemoso&#44; p&#250;rpuras e necrose de extremidades &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46; S&#227;o manifesta&#231;&#245;es raras associadas a quadros sist&#234;micos graves&#44; que ocorrem de maneira tardia em pacientes idosos&#44; internados em ambiente de terapia intensiva&#44; com m&#250;ltiplas comorbidades e altera&#231;&#245;es laboratoriais &#40;exemplo&#58; coagulopatias&#44; eleva&#231;&#227;o de D&#8208;d&#237;mero&#41;&#46; Frequentemente&#44; associam&#8208;se a outros eventos tromb&#243;ticos como trombose venosa profunda&#44; acidente vascular encef&#225;lico &#40;AVE&#41; isqu&#234;mico e coagula&#231;&#227;o intravascular disseminada&#44; que s&#227;o respons&#225;veis pela elevada mortalidade nesae grupo&#46; Assim&#44; os achados cut&#226;neos em pacientes com doen&#231;a potencialmente fatal s&#227;o bastante espec&#237;ficos e distintos do perfil ambulatorial&#46; Isso acontece pois provavelmente os mesmos mecanismos microangiop&#225;ticos e tromb&#243;ticos ocorrem simultaneamente nos principais &#243;rg&#227;os&#8208;alvo&#44; como pulm&#227;o e rim e na pele&#46; Desse modo&#44; o tratamento das les&#245;es cut&#226;neas consiste no tratamento da pr&#243;pria doen&#231;a de base&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">16&#44;22&#44;26</span></a> Um resumo das principais caracter&#237;sticas das manifesta&#231;&#245;es dermatol&#243;gicas acima descritas encontra&#8208;se na <a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Outras manifesta&#231;&#245;es</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Acometimento de mucosas</span><p id="par0200" class="elsevierStylePara elsevierViewall">Les&#245;es orais durante o curso da COVID&#8208;19 tamb&#233;m foram descritas e reunidas em artigos de revis&#227;o&#46; Sabe&#8208;se que o SARS&#8208;CoV&#8208;2 pode ser detectado na saliva por t&#233;cnica de PCR &#8211; inclusive&#44; atualmente&#44; para fins diagn&#243;sticos&#46; Al&#233;m disso&#44; o ACE2 &#40;receptor funcional viral no organismo&#41; est&#225; presente na mucosa oral&#44; com maior densidade no dorso da l&#237;ngua e gl&#226;ndulas salivares menores&#44; o que justificaria a presen&#231;a de les&#245;es mucosas&#46; Disgeusia foi o primeiro sintoma oral reconhecido na COVID&#8208;19&#44; com frequ&#234;ncia amplamente vari&#225;vel de 5 a 88&#37;&#46; Posteriormente&#44; foram tamb&#233;m descritas in&#250;meras les&#245;es orais&#44; das quais as mais frequentes foram&#58; enantema&#44; pet&#233;quias&#44; les&#245;es aftoides ou &#250;lceras&#44; herpetiformes&#44; candid&#237;ase e les&#245;es orais associadas a doen&#231;a de Kawasaki&#46; Geralmente s&#227;o sintom&#225;ticas &#40;dor&#44; queima&#231;&#227;o ou prurido&#41; e surgem quatro dias antes ou at&#233; 12 semanas ap&#243;s os sintomas gerais&#46; O tratamento depende do padr&#227;o de les&#227;o encontrado&#46; Higiene oral inadequada&#44; imunossupress&#227;o&#44; reativa&#231;&#227;o de v&#237;rus latentes &#40;p&#46; ex&#46;&#44; herpes&#8208;v&#237;rus&#41;&#44; infec&#231;&#245;es oportunistas&#44; estresse&#44; trauma secund&#225;rio a intuba&#231;&#227;o&#44; resposta hiperinflamat&#243;ria da COVID&#8208;19 s&#227;o fatores predisponentes&#46; S&#227;o necess&#225;rios mais estudos para definir quais manifesta&#231;&#245;es orais est&#227;o diretamente ligadas &#224; infec&#231;&#227;o pelo SARS&#8208;CoV&#8208;2 e quais s&#227;o indiretas&#44; devido &#224; presen&#231;a de outras afec&#231;&#245;es mucosas que&#44; nestes casos&#44; ocorrem no contexto da COVID&#8208;19&#46; Nesse sentido&#44; &#233; fundamental a investiga&#231;&#227;o para excluir tais condi&#231;&#245;es&#46; Sugere&#8208;se que manifesta&#231;&#245;es induzidas pelas altera&#231;&#245;es vasculares e microtrombos&#44; como pet&#233;quias e &#250;lceras&#44; e o enantema &#40;em semelhan&#231;a ao exantema viral&#41; possam estar associadas diretamente &#224; fisiopatologia do SARS&#8208;CoV&#8208;2&#46;<a class="elsevierStyleCrossRefs" href="#bib0620"><span class="elsevierStyleSup">34&#8211;48</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Efl&#250;vio tel&#243;geno e COVID&#8208;19</span><p id="par0205" class="elsevierStylePara elsevierViewall">Amplamente e h&#225; muito tempo conhecido na Dermatologia&#44; o efl&#250;vio tel&#243;geno &#40;ET&#41; pode ser desencadeado por altera&#231;&#245;es metab&#243;licas&#44; nutricionais&#44; medicamentosas e in&#250;meras condi&#231;&#245;es sist&#234;micas&#44; entre elas as infec&#231;&#245;es&#46; Na COVID&#8208;19&#44; cogita&#8208;se que as citocinas inflamat&#243;rias liberadas e o uso de medica&#231;&#245;es&#44; como a heparina&#44; possam estar envolvidas no mecanismo do ET&#46; H&#225; relato de aumento da incid&#234;ncia do ET em quase tr&#234;s vezes durante a pandemia&#46; Estima&#8208;se que 10&#37; dos pacientes com COVID&#8208;19 evoluam com ET nas semanas e meses subsequentes &#224; infec&#231;&#227;o&#44; especialmente nos pacientes com comorbidades&#44; mas podem ocorrer inclusive nos quadros subcl&#237;nicos&#46; At&#233; o momento&#44; as informa&#231;&#245;es sobre o in&#237;cio&#44; evolu&#231;&#227;o e progn&#243;stico do ET associado a COVID&#8208;19 s&#227;o indistintas do ET por outras causas j&#225; conhecidas&#46; N&#227;o h&#225; nenhuma peculiaridade ou caracter&#237;stica espec&#237;fica no ET induzido pela infec&#231;&#227;o por SARS&#8208;CoV&#8208;2&#46; Portanto&#44; a abordagem&#44; o tratamento e o seguimento desses pacientes devem ser os mesmas adotados para o ET na pr&#225;tica dermatol&#243;gica&#46;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Relatos dos casos</span><p id="par0210" class="elsevierStylePara elsevierViewall">Al&#233;m das manifesta&#231;&#245;es mais descritas e agrupadas em &#8220;padr&#245;es&#8221; nas grandes s&#233;ries de casos&#44; estudos prospectivos e de revis&#227;o sistem&#225;tica&#44; existem in&#250;meros relatos de casos isolados na literatura sobre diversos quadros cut&#226;neos possivelmente associados &#224; COVID&#8208;19&#46; Em fun&#231;&#227;o da limita&#231;&#227;o metodol&#243;gica inerente &#224;s publica&#231;&#245;es do tipo relato de casos&#44; n&#227;o se pode afirmar o real papel da infec&#231;&#227;o pelo SARS&#8208;CoV&#8208;2 nessas entidades &#8211; ou seja&#44; se s&#227;o de fato atribu&#237;veis &#224; COVID&#8208;19 ou n&#227;o&#46; As condi&#231;&#245;es isoladamente associadas &#224; COVID&#8208;19 publicadas em relatos de casos encontram&#8208;se reunidas na <a class="elsevierStyleCrossRef" href="#tbl0025">tabela 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Os primeiros relatos foram de casos de urtic&#225;ria&#44; inclusive precedendo os sintomas cl&#237;nicos&#44;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">51</span></a> urtic&#225;ria vasculite<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">52</span></a> e angioedema&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">53</span></a> Casos de pitir&#237;ase r&#243;sea ou les&#245;es pitir&#237;ase r&#243;sea s&#237;mile<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">54</span></a>&#44; sendo que um relato mostrou a presen&#231;a do SARS&#8208;CoV&#8208;2 por t&#233;cnicas imuno&#8208;histoqu&#237;micas&#44;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">55</span></a> e outro apontou para o poss&#237;vel papel da reativa&#231;&#227;o do HHV&#8208;6 e outros v&#237;rus nesses quadros&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">56</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">H&#225; tamb&#233;m relatos de vasculites de pequenos vasos associadas &#224; COVID&#8208;19&#44;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">57</span></a> vasculite leucocitocl&#225;stica&#44;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">58</span></a> vasculite por IgA&#44;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">59</span></a> granulomatose com poliange&#237;te &#40;antes chamada de doen&#231;a de Wegener&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">60</span></a> granulomatose eosinof&#237;lica com poliange&#237;te &#40;antes chamada de s&#237;ndrome de Churg&#8208;Strauss&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">61</span></a> p&#250;rpura de Schamberg<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">62</span></a> e p&#250;rpura fulminans&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">63</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Sobre os quadros que se assemelham a farmacodermias&#44; foram descritos pacientes com COVID&#8208;19 e eritema multiforme&#44;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">64</span></a> s&#233;rie de casos de pustulose exantem&#225;tica generalizada aguda &#40;PEGA&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">65</span></a> relatos de necr&#243;lise epid&#233;rmica t&#243;xica &#40;NET&#41;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">66</span></a> e SDRIFE &#40;<span class="elsevierStyleItalic">symmetrical drug&#8208;related intertriginous and flexural exanthema</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">67</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">H&#225; tamb&#233;m relatos de caso em topografias espec&#237;ficas &#8211; acometimento ungueal&#44; com descri&#231;&#227;o do &#8220;<span class="elsevierStyleItalic">red half&#8208;moon sign</span>&#8221;&#59;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">68</span></a> acometimento palmoplantar com eritrodisestesia&#59;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">69</span></a> erup&#231;&#227;o folicular&#44;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">70</span></a> exantema unilateral&#44;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">71</span></a> livedo reticular unilateral<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">72</span></a> e &#250;lceras de press&#227;o em localiza&#231;&#245;es n&#227;o usuais &#40;como esterno&#44; joelhos&#41; por prona&#231;&#227;o prolongada&#46;<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">73</span></a> Foram publicadas descri&#231;&#245;es dermatosc&#243;picas de erup&#231;&#227;o papular purp&#250;rica<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">74</span></a> e les&#245;es EP&#8208;s&#237;mile&#46;<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">75</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">H&#225; ainda relatos de herpes&#8208;z&#243;ster<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">76</span></a> e relatos isolados de quadros semelhantes a doen&#231;a de Grover&#44;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">77</span></a> s&#237;ndrome de Melkersson&#8208;Rosenthal&#44;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">78</span></a> eritema nodoso&#44;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">79</span></a> les&#227;o sarco&#237;dea&#44;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">80</span></a> s&#237;ndrome de Gianotti&#8208;Crosti&#44;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">81</span></a> dermatite seborreica&#44;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">82</span></a> l&#237;quen plano anular&#44;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">83</span></a> eritema anular centr&#237;fugo&#44;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">84</span></a> granuloma anular<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">85</span></a> e alopecia areata rapidamente progressiva&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">86</span></a></p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Histopatologia das manifesta&#231;&#245;es cut&#226;neas da COVID&#8208;19</span><p id="par0240" class="elsevierStylePara elsevierViewall">Alguns estudos trazem as primeiras descri&#231;&#245;es sobre as altera&#231;&#245;es histopatol&#243;gicas e imuno&#8208;histoqu&#237;micas das les&#245;es de pele associadas &#224; COVID&#8208;19&#44; com o intuito de colaborar para a compreens&#227;o dos mecanismos fisiopatol&#243;gicos das manifesta&#231;&#245;es&#46; A seguir&#44; ser&#227;o brevemente citadas as principais altera&#231;&#245;es histol&#243;gicas dos padr&#245;es cut&#226;neos mais descritos&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">87</span></a></p><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Erup&#231;&#245;es m&#225;culo&#8208;papulares</span><p id="par0245" class="elsevierStylePara elsevierViewall">Dermatite perivascular superficial com discreta linfocitose&#44; vasos trombosados com debris neutrof&#237;licos e eosinof&#237;licos&#59; dermatite de interface&#44; infiltrado linfoc&#237;tico perivascular superficial e profundo&#44; com ou sem vasculite &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Eritema p&#233;rnio &#40;EP&#41; s&#237;mile</span><p id="par0250" class="elsevierStylePara elsevierViewall">Na epiderme&#44; presen&#231;a de paraqueratose e hiperqueratose&#44; com queratin&#243;citos apopt&#243;ticos e&#44; eventualmente&#44; necrose epid&#233;rmica&#46; Infiltrado linfoc&#237;tico denso na derme superficial e profunda&#44; tamb&#233;m na hipoderme&#44; com padr&#227;o perivascular e sinais de ativa&#231;&#227;o endotelial&#46; Por vezes&#44; infiltrado linfoc&#237;tico &#233;crino semelhante ao observado na hidradenite &#233;crina linfoc&#237;tica&#46; Outros achados frequentes s&#227;o&#58; eritrodiapedese&#44; edema na derme papilar com forma&#231;&#227;o de bolha subepid&#233;rmica e aumento do dep&#243;sito de mucina intersticial&#46; Raramente h&#225; presen&#231;a de microtrombos vasculares nos capilares da derme superficial e v&#234;nulas d&#233;rmicas&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Erup&#231;&#245;es urticariformes</span><p id="par0255" class="elsevierStylePara elsevierViewall">Infiltrado linfoc&#237;tico perivascular com alguns eosin&#243;filos e edema na derme superficial&#44; eventualmente com dermatite de interface vacuolar e necrose de queratin&#243;citos&#44; com padr&#227;o semelhante ao do eritema multiforme&#46; Na urtic&#225;ria vasculite h&#225; extravasamento de hem&#225;cias com infiltrado neutrof&#237;lico perivascular&#44; macr&#243;fagos&#44; necrose e dep&#243;sito de fibrina&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Erup&#231;&#245;es vesiculares</span><p id="par0260" class="elsevierStylePara elsevierViewall">Acantose&#44; ves&#237;culas por degenera&#231;&#227;o vacuolar da camada basal com c&#233;lulas disquerat&#243;ticas&#44; multinucleadas &#40;sugestivas de inclus&#227;o viral&#41; sem infiltrado inflamat&#243;rio&#46; Nesses casos&#44; &#233; fundamental o diagn&#243;stico diferencial com as dermatoviroses herp&#233;ticas&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Livedo&#44; p&#250;rpura</span><p id="par0265" class="elsevierStylePara elsevierViewall">Vasculopatia tromb&#243;tica com extensa deposi&#231;&#227;o de C5b&#8208;9 e C4d &#40;t&#233;cnica imuno&#8208;histoqu&#237;mica&#41; na microvasculatura&#46;</p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Andr&#243;genos e COVID&#8208;19</span><p id="par0270" class="elsevierStylePara elsevierViewall">Durante toda a pandemia observou&#8208;se que a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 afetava mais homens do que mulheres&#46; Os homens t&#234;m duas vezes mais chance de serem admitidos em unidades de terapia intensiva &#40;UTI&#41;&#46; A associa&#231;&#227;o entre a via dos andr&#243;genos e a infectividade do SARS&#8208;CoV&#8208;2 j&#225; foi descrita&#46; Portanto&#44; tal predisposi&#231;&#227;o &#224; infec&#231;&#227;o mediada pelos andr&#243;genos poderia justificar as altas taxas de interna&#231;&#227;o e mortalidade concentradas nos homens&#46; Assim&#44; a express&#227;o androg&#234;nica em forma de alopecia &#40;alop&#233;cia androgen&#233;tica &#8211; AGA&#41; poderia&#44; por si s&#243;&#44; ser um fator de risco para a COVID&#8208;19&#44; e j&#225; foi relatada alta frequ&#234;ncia de AGA entre homens internados&#46; Al&#233;m disso&#44; o uso de anti&#8208;andr&#243;genos poderia ser um fator protetor e&#47;ou terap&#234;utico na evolu&#231;&#227;o desses pacientes&#46; Nesse sentido&#44; estudo publicado mostrou que homens com AGA ou hiperplasia prost&#225;tica benigna em uso sist&#234;mico de inibidor de 5&#8208;alfa&#8208;redutase que contra&#237;ram COVID&#8208;19 apresentaram redu&#231;&#227;o importante dos sintomas no contexto ambulatorial&#46; Em estudo caso&#8208;controle em ambiente hospitalar&#44; homens em uso de inibidor de 5&#8208;alfa&#8208;redutase tiveram menor chance de serem admitidos em UTI&#44; sugerindo tal efeito protetor&#46; No entanto&#44; ainda &#233; incerto se a introdu&#231;&#227;o de antiandr&#243;genos ap&#243;s a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 teria algum benef&#237;cio&#46; Aparentemente&#44; os dermatologistas deveriam encorajar seus pacientes com AGA a manterem o uso de antiandr&#243;genos durante a pandemia&#46; Esse &#233;&#44; sem d&#250;vida&#44; um campo de pesquisa bastante promissor&#46;<a class="elsevierStyleCrossRefs" href="#bib0890"><span class="elsevierStyleSup">88&#8211;90</span></a></p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Considera&#231;&#245;es finais</span><p id="par0275" class="elsevierStylePara elsevierViewall">Embora o n&#250;mero de publica&#231;&#245;es em um curto intervalo de tempo seja expressivo e crescente&#44; ainda h&#225; muitas perguntas desafiadoras sobre as manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19&#46; A verdadeira frequ&#234;ncia dos achados cut&#226;neos &#233; amplamente vari&#225;vel &#40;0&#44;2 a 45&#37;&#41; na literatura&#59; os estudos de revis&#227;o sistem&#225;tica apontam para frequ&#234;ncia pr&#243;xima a 6&#37;&#46; As manifesta&#231;&#245;es dermatol&#243;gicas mais encontradas foram as erup&#231;&#245;es maculopapulares&#44; seguidas das les&#245;es EP&#8208;s&#237;mile&#46; No entanto&#44; h&#225; publica&#231;&#245;es que trazem as les&#245;es EP&#8208;s&#237;mile como as manifesta&#231;&#245;es mais prevalentes&#46; Os quadros de erup&#231;&#245;es urticariforme&#44; vesicular e livedo&#44; al&#233;m de p&#250;rpura e necrose s&#227;o menos descritos&#46; Quanto ao tempo de surgimento&#44; as les&#245;es cut&#226;neas s&#227;o habitualmente concomitantes aos sintomas gerais e raramente podem preced&#234;&#8208;los&#44; como nos casos de urtic&#225;ria e les&#245;es vesiculares&#46; O EP&#8208;s&#237;mile pode surgir tardiamente ou&#44; inclusive&#44; ser a &#250;nica manifesta&#231;&#227;o cl&#237;nica de COVID&#8208;19&#46; Os quadros vasculares como livedo&#44; p&#250;rpura e necrose s&#227;o igualmente tardios&#44; por&#233;m associados a maior gravidade e pior progn&#243;stico&#46; Estudos histopatol&#243;gicos e de imuno&#8208;histoqu&#237;mica dos diferentes padr&#245;es de les&#245;es cut&#226;neas em pacientes com COVID&#8208;19 s&#227;o fundamentais para melhor compreens&#227;o do seu significado fisiopatol&#243;gico em rela&#231;&#227;o &#224; doen&#231;a &#40;causadas diretamente pela infec&#231;&#227;o viral decorrentes de complica&#231;&#245;es da doen&#231;a sist&#234;mica&#41;&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Vale ressaltar a import&#226;ncia da exclus&#227;o dos poss&#237;veis diagn&#243;sticos diferenciais diante de um paciente com COVID&#8208;19 que apresente les&#245;es de pele&#44; antes que se atribua o quadro cut&#226;neo exclusivamente &#224; infec&#231;&#227;o viral&#46; Quadros de urtic&#225;ria espont&#226;nea&#44; demais infec&#231;&#245;es virais&#44; farmacodermias&#44; entre outros&#44; devem ser considerados na investiga&#231;&#227;o desses pacientes&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">A contribui&#231;&#227;o da dermatologia &#224; pandemia de COVID&#8208;19 parece ir al&#233;m das manifesta&#231;&#245;es cut&#226;neas&#46; A estreita rela&#231;&#227;o entre andr&#243;genos e o curso da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 abre um promissor campo de pesquisa sobre seus fatores progn&#243;sticos e protetores&#44; especialmente no tocante ao uso sist&#234;mico dos antiandr&#243;genos&#44; amplamente prescritos na dermatologia&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">A pandemia tem proporcionado uma excelente oportunidade para os dermatologistas aprenderem e contribu&#237;rem&#46; Infelizmente&#44; ela ainda n&#227;o acabou&#46; Como a ci&#234;ncia &#233; um processo din&#226;mico&#44; h&#225; a esperan&#231;a de que mais estudos sejam desenvolvidos para que respostas possam ser encontradas e as incertezas resolvidas&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Suporte financeiro</span><p id="par0295" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Contribui&#231;&#227;o dos autores</span><p id="par0300" class="elsevierStylePara elsevierViewall">Camila Arai Seque&#58; Concep&#231;&#227;o e desenho do estudo&#59; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o final da vers&#227;o do manuscrito&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">Milvia Maria Sim&#245;es e Silva Enokihara&#58; Concep&#231;&#227;o e desenho do estudo&#59; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o final da vers&#227;o do manuscrito&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">Adriana Maria Porro&#58; Concep&#231;&#227;o e desenho do estudo&#59; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o final da vers&#227;o do manuscrito&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Jane Tomimori&#58; Concep&#231;&#227;o e desenho do estudo&#59; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; an&#225;lise estat&#237;stica&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o final da vers&#227;o do manuscrito&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflito de interesses</span><p id="par0320" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:17 [
        0 => array:3 [
          "identificador" => "xres1658798"
          "titulo" => "Resumo"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1474341"
          "titulo" => "Palavras&#8208;chave"
        ]
        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introdu&#231;&#227;o"
        ]
        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Frequ&#234;ncia das manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19"
        ]
        4 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Fisiopatologia"
        ]
        5 => array:3 [
          "identificador" => "sec0020"
          "titulo" => "Grandes s&#233;ries nacionais e internacionais"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Espanha"
            ]
            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Fran&#231;a"
            ]
            2 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "EUA&#47;internacional &#40;31 pa&#237;ses&#41;"
            ]
            3 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "It&#225;lia"
            ]
            4 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Reino Unido"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Estudos prospectivos"
        ]
        7 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Revis&#245;es sistem&#225;ticas"
        ]
        8 => array:3 [
          "identificador" => "sec0060"
          "titulo" => "Principais manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Erup&#231;&#227;o maculopapular"
            ]
            1 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Eritema p&#233;rnio &#40;EP&#41; s&#237;mile"
            ]
            2 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Les&#245;es urticariformes"
            ]
            3 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Erup&#231;&#245;es v&#233;sico&#8208;bolhosas"
            ]
            4 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Livedo&#44; p&#250;rpura&#44; necrose"
            ]
          ]
        ]
        9 => array:3 [
          "identificador" => "sec0090"
          "titulo" => "Outras manifesta&#231;&#245;es"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Acometimento de mucosas"
            ]
            1 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Efl&#250;vio tel&#243;geno e COVID&#8208;19"
            ]
            2 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Relatos dos casos"
            ]
          ]
        ]
        10 => array:3 [
          "identificador" => "sec0110"
          "titulo" => "Histopatologia das manifesta&#231;&#245;es cut&#226;neas da COVID&#8208;19"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0115"
              "titulo" => "Erup&#231;&#245;es m&#225;culo&#8208;papulares"
            ]
            1 => array:2 [
              "identificador" => "sec0120"
              "titulo" => "Eritema p&#233;rnio &#40;EP&#41; s&#237;mile"
            ]
            2 => array:2 [
              "identificador" => "sec0125"
              "titulo" => "Erup&#231;&#245;es urticariformes"
            ]
            3 => array:2 [
              "identificador" => "sec0130"
              "titulo" => "Erup&#231;&#245;es vesiculares"
            ]
            4 => array:2 [
              "identificador" => "sec0135"
              "titulo" => "Livedo&#44; p&#250;rpura"
            ]
          ]
        ]
        11 => array:2 [
          "identificador" => "sec0140"
          "titulo" => "Andr&#243;genos e COVID&#8208;19"
        ]
        12 => array:2 [
          "identificador" => "sec0145"
          "titulo" => "Considera&#231;&#245;es finais"
        ]
        13 => array:2 [
          "identificador" => "sec0150"
          "titulo" => "Suporte financeiro"
        ]
        14 => array:2 [
          "identificador" => "sec0155"
          "titulo" => "Contribui&#231;&#227;o dos autores"
        ]
        15 => array:2 [
          "identificador" => "sec0160"
          "titulo" => "Conflito de interesses"
        ]
        16 => array:1 [
          "titulo" => "Refer&#234;ncias"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-08-05"
    "fechaAceptado" => "2021-08-22"
    "PalabrasClave" => array:1 [
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras&#8208;chave"
          "identificador" => "xpalclavsec1474341"
          "palabras" => array:3 [
            0 => "COVID&#8208;19"
            1 => "Dermatologia"
            2 => "Pele"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neste artigo s&#227;o abordados os principais aspectos das manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19&#44; baseados em revis&#227;o da literatura publicada at&#233; a presente data&#46; Desde o in&#237;cio da pandemia&#44; j&#225; s&#227;o mais de 1&#46;500 artigos sobre o tema&#46; Com rela&#231;&#227;o &#224; fisiopatologia&#44; acredita&#8208;se que os mesmos mecanismos respons&#225;veis pela doen&#231;a nos principais &#243;rg&#227;os&#8208;alvo atuem tamb&#233;m na pele&#44; embora ainda n&#227;o estejam totalmente elucidados&#46; A real frequ&#234;ncia das manifesta&#231;&#245;es dermatol&#243;gicas ainda &#233; incerta&#8208;pode variar de 0&#44;2 a 45&#37;&#59; nas revis&#245;es sistem&#225;ticas&#44; o valor &#233; pr&#243;ximo a 6&#37;&#46; Estudos pioneiros com grandes s&#233;ries de casos conduzidos em pa&#237;ses europeus e os EUA trazem as primeiras informa&#231;&#245;es sobre quais seriam as principais manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19 e prop&#245;em classifica&#231;&#245;es quanto &#224; apresenta&#231;&#227;o cl&#237;nica e fisiopatologia&#44; bem como a frequ&#234;ncia das manifesta&#231;&#245;es&#46; Embora n&#227;o haja consenso&#44; as erup&#231;&#245;es maculopapulares s&#227;o tidas como os quadros mais frequentes&#44; seguidos das les&#245;es do tipo eritema p&#233;rnio &#40;EP&#41; s&#237;mile&#46; Manifesta&#231;&#245;es como urtic&#225;ria&#44; quadros vesiculares e livedo&#47;p&#250;rpura&#47;necrose s&#227;o raras&#46; O tempo de surgimento&#44; a gravidade&#44; a necessidade de tratamento espec&#237;fico e o progn&#243;stico s&#227;o vari&#225;veis conforme o padr&#227;o de apresenta&#231;&#227;o clinica&#46; A crescente descri&#231;&#227;o histopatol&#243;gica dos quadros cut&#226;neos pode contribuir para o diagn&#243;stico&#44; bem como para a compreens&#227;o da fisiopatologia&#46; Ainda no campo dermatol&#243;gico&#44; a rela&#231;&#227;o entre COVID&#8208;19 e andr&#243;genos tem sido cada vez mais estudada&#46; Apesar de todo conhecimento gerado&#44; o significado biol&#243;gico real das manifesta&#231;&#245;es cut&#226;neas ainda &#233; incerto&#46; Assim&#44; a exclus&#227;o dos principais diagn&#243;sticos diferenciais &#233; fundamental para a correla&#231;&#227;o entre manifesta&#231;&#227;o cut&#226;nea e COVID&#8208;19&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Como citar este artigo&#58; Seque CA&#44; Enokihara MMSS&#44; Porro AM&#44; Tomimori J&#46; Skin manifestations associated with COVID&#8208;19&#46; An Bras Dermatol&#46; 2022&#59;97&#58;75&#8211;88&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Trabalho realizado no Departamento de Dermatologia da Universidade Federal de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#44; Brasil&#46;</p>"
      ]
    ]
    "multimedia" => array:9 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 948
            "Ancho" => 750
            "Tamanyo" => 67900
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Exantema em paciente com COVID&#8208;19&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 700
            "Ancho" => 1250
            "Tamanyo" => 67904
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Les&#245;es vesico&#8208;bolhosas em paciente com COVID&#8208;19&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 976
            "Ancho" => 2090
            "Tamanyo" => 121896
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Livedo racemoso&#44; p&#250;rpura e necrose de extremidades em paciente com COVID&#8208;19&#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" => 568
            "Ancho" => 1650
            "Tamanyo" => 145471
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Achados histopatol&#243;gicos de exantema em paciente com COVID&#8208;19&#46; &#40;A&#41;&#44; Presen&#231;a de vasculite leucocitocl&#225;stica dos vasos capilares da derme superficial e eritrodiapedese &#40;Hematoxilina &#38; eosina&#44; 100&#215;&#41;&#46; &#40;B&#41;&#44; Em detalhe vasos capilares contendo neutr&#243;filos &#237;ntegros e degenerados destruindo parcialmente a parede&#44; hem&#225;cias extravasadas e a presen&#231;a de material amorfo eosinof&#237;lico no l&#250;men vascular sugestivo de trombo de fibrina &#40;Hematoxilina &#38; eosina&#44; 400&#215;&#41;&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabela 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pontos&#8208;chave&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">O primeiro relato na literatura de manifesta&#231;&#227;o cut&#226;nea associada &#224; COVID&#8208;19 ocorreu em 23&#47;03&#47;20&#46; Desde ent&#227;o&#44; h&#225; mais de 1&#46;500 publica&#231;&#245;es sobre o tema&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">A frequ&#234;ncia das manifesta&#231;&#245;es cut&#226;neas varia entre 0&#44;2&#37; a 45&#37;&#44; sendo pr&#243;xima a 6&#37; no estudos de revis&#227;o sistem&#225;tica&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">As manifesta&#231;&#245;es mais descritas s&#227;o as erup&#231;&#245;es m&#225;culo&#8208;papulares&#44; seguidas das les&#245;es eritema p&#233;rnio &#40;EP&#41; s&#237;mile&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">Quadros urticariformes&#44; vesiculares e do espectro livedo&#8208;p&#250;rpura&#8208;necrose s&#227;o menos frequentes&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">As les&#245;es de pele habitualmente s&#227;o concomitantes aos sintomas gerais&#46; No entanto&#44; urtic&#225;rias e ves&#237;culas podem preced&#234;&#8208;los&#44; enquanto EP&#8208;s&#237;mile e livedo&#8208;p&#250;rpura&#8208;necrose surgem tardiamente&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">Os principais diagn&#243;sticos diferenciais s&#227;o rea&#231;&#245;es medicamentosas e outras infec&#231;&#245;es virais&#44; que devem ser exclu&#237;dos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824204.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">C&#225;psula com os principais pontos&#8208;chave</p>"
        ]
      ]
      5 => 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:3 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nd&#44; dado n&#227;o dispon&#237;vel&#46;</p>"
          "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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Autor&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">Pa&#237;s&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">Frequ&#234;ncia&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&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">Forma de avalia&#231;&#227;o&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">Guan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">3</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">China&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;2&#37;&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">1099&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&#227;o presencial &#40;banco de dados&#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">Recalcati et al&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">4</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">It&#225;lia&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">20&#44;4&#37;&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">88&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">Presencial por dermatologista&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">Matar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">5</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">Fran&#231;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">1&#37;&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">756&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">Autoexame por entrevista telef&#244;nica&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">Rerknimitr et al&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">6</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">Tail&#226;ndia&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&#37;&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">183&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">Autoexame por entrevista telef&#244;nica&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">Solak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">7</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">Turquia&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">18&#44;3&#37;&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">382&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">Autoexame por entrevista telef&#244;nica&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">Gaspari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">8</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">It&#225;lia&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&#44;4&#37;&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">Nd&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">Presencial por dermatologista&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">Tammaro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">9</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">It&#225;lia&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&#44;5&#37;&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">130&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">Presencial por dermatologista&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">Tamai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">10</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">Jap&#227;o&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&#44;3&#37;&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">69&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">Presencial por dermatologista&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">De Giorgi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">31</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">It&#225;lia&#47;China&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&#44;8&#37;&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">678&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">Presencial &#40;n&#227;o especifica avaliador&#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">Rehktman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">32</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">EUA&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">11&#44;8&#37;&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">296&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">Presencial por estudantes de medicina&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">M&#233;ndez&#8208;Maestro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">30</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">Espanha&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">18&#44;7&#37;&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">75&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">Presencial por dermatologista&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">Nuno&#8208;Gonzales et al&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">34</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">Espanha&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&#44;65&#37;&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">666&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">Presencial por dermatologista&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">Jamshindi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">36</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"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</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">5&#44;95&#37;&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">1847&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"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824202.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Estudo de metan&#225;lise&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Frequ&#234;ncia das manifesta&#231;&#245;es dermatol&#243;gicas na COVID&#8208;19</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabela 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">EP&#8208;s&#237;mile&#44; eritema p&#233;rnio s&#237;mile&#46;</p>"
          "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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Autor&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">Pa&#237;s&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&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">Casos confirmados&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">Erup&#231;&#227;o maculopapular&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">Urticari&#8208;forme&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">EP&#8208;s&#237;mile&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">Vesiculo&#8208;bolhosa&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">Livedo&#8208;p&#250;pura&#8208;necrose&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">Galvan&#8208;Casas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">26</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">Espanha&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">375&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">234 &#40;62&#44;4&#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">47&#37;&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">19&#37;&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">19&#37;&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">9&#37;&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&#37;&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">Masson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">27</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">Fran&#231;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">277&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">25 &#40;9&#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">9&#37;&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">9&#37;&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">75&#37;&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&#37;&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&#37;&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">Freeman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">28</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">EUA &#43;31 pa&#237;ses&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">716&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">171 &#40;23&#44;8&#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">45&#37;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</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">16&#37;&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">18&#37;&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">11&#37;&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&#44;4&#37;&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">Manzano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">29</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">It&#225;lia&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">200&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">120 &#40;62&#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">25&#44;7&#37;&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">10&#44;2&#37;&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">24&#44;6&#37;&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&#44;5&#37;&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">9&#37;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&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">Visconti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">30</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">Reino Unido&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">11544&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">694 &#40;6&#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">41&#44;2&#37;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</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">30&#37;&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">23&#44;1&#37;&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"><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824203.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Incluem erup&#231;&#227;o morbiliforme&#44; eritema m&#225;culo&#8208;papular e p&#225;pulo&#8208;escamoso&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Incluem p&#250;rpura&#47;vasculite&#44; livedo reticular&#47;racemoso&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Incluem erup&#231;&#227;o eritemato&#8208;papulosa e eritemato&#8208;vesiculosa&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Grandes s&#233;ries nacionais e internacionais sobre as manifesta&#231;&#245;es cut&#226;neas</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Tabela 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "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">Quadro dermatol&#243;gico&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">Frequ&#234;ncia&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">Faixa et&#225;ria&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">Quadro sist&#234;mico&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">Surgimento das les&#245;es<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&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">Erup&#231;&#227;o maculopapular&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">Exantema&#44; <span class="elsevierStyleItalic">rash</span>&#44; p&#225;pulo&#8208;escamoso&#44; pitir&#237;ase r&#243;sea s&#237;mile&#44; eritema multiforme s&#237;mile&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">9&#37;&#8211;47&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Adultos&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">Leve&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&#8211;14 dias&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">Pseudo eritema p&#233;rnio&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">M&#225;culas viol&#225;ceas nas extremidades em temperaturas amenas&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">18&#37;&#8211;75&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Crian&#231;as e jovens&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">Leve ou assintom&#225;tico&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">Ap&#243;s 10&#8211;14 dias&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">Urtic&#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">Indistinto das demais formas de urtic&#225;ria&#44; angioedema &#233; raro&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">9&#37;&#8211;30&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Adultos&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">Leve&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">Pr&#233; ou 0&#8211;14 dias&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">V&#233;sico&#8208;bolhosas&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">Varicela s&#237;mile&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">9&#37;&#8211;15&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Adultos&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">Leve a moderado&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">Pr&#233; ou 0&#8211;7 dias&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">Livedo&#44; p&#250;rpura&#44; necrose&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">Livedo reticular fixo&#44; racemoso&#59; p&#250;rpura&#44; vasculite&#59; necrose de extremidades&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&#37;&#8211;9&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Idosos&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">Grave&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">Ap&#243;s 10&#8211;14 dias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824205.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Em rela&#231;&#227;o ao in&#237;cio dos sintomas gerais da COVID&#8208;19&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Principais caracter&#237;sticas das manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Tabela 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SDRIFE&#44; s<span class="elsevierStyleItalic">ymmetrical drug&#8208;related intertriginous and flexural exanthema</span>&#59; NET&#44; necr&#243;lise epid&#233;rmica t&#243;xica&#59; PEGA&#44; pustulose exantem&#225;tica generalizada aguda&#46;</p>"
          "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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Urticariformes&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">Vasculites e p&#250;rpuras&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">Farmacodermias s&#237;mile&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">Topografias espec&#237;ficas&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&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">Urtic&#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">Vasculite leucocitocl&#225;stica&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">Eritema multiforme&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">Ungueal &#40;<span class="elsevierStyleItalic">red half&#8208;moon sign&#41;</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">Pitir&#237;ase r&#243;sea s&#237;mile&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">Urtic&#225;ria vasculite&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">Vasculite por IgA&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">SDRIFE&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">Eritrodisestesia palmoplantar&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">Doen&#231;a de Grover&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">Angioedema&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">Granulomatose eosinof&#237;lica com poliange&#237;te&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">NET&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">Erup&#231;&#227;o folicular&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">S&#237;ndrome de Melkersson&#8208;Rosenthal&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">Granulomatose com poliange&#237;te&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">PEGA&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">Exantema unilateral&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">S&#237;ndrome de Gianotti&#8208;Crosti&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">P&#250;rpura de Schamberg&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><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">Livedo Unilateral&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">Eritema anular centr&#237;fugo&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">P&#250;rpura fulminans&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><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">Eritema nodoso&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="" 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="" 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="" 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">Liquen plano anular&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="" 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="" 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="" 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">Les&#227;o sarco&#237;dea&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="" 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="" 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="" 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">Granuloma anular&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="" 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="" 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="" 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">Alop&#233;cia areata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824201.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Condi&#231;&#245;es dermatol&#243;gicas associadas &#224; COVID&#8208;19 &#8211; Relatos de casos</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Refer&#234;ncias"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:90 [
            0 => array:3 [
              "identificador" => "bib0455"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermatology and COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2020.15276"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA&#46;"
                        "fecha" => "2020"
                        "volumen" => "324"
                        "paginaInicial" => "1133"
                        "paginaFinal" => "1134"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0460"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19 can present with a rash and be mistaken for dengue"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "82"
                        "paginaInicial" => "177"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0465"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical Characteristics of Coronavirus Disease 2019 in China"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa2002032"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med&#46;"
                        "fecha" => "2020"
                        "volumen" => "382"
                        "paginaInicial" => "1708"
                        "paginaFinal" => "1720"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0470"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations in COVID&#8208;19&#58; a first perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "212"
                        "paginaFinal" => "213"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0475"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations in SARS&#8208;CoV&#8208;2 infection &#40;COVID&#8208;19&#41;&#58; a French experience and a systematic review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "686"
                        "paginaFinal" => "689"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0480"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skin manifestations in COVID&#8208;19&#58; The tropics experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "47"
                        "paginaInicial" => "444"
                        "paginaFinal" => "446"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0485"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous symptoms of patients diagnosed with COVID&#8208;19 in one province&#58; a cross&#8208;sectional survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.16678"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "105"
                        "paginaFinal" => "106"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19 skin eruptions&#58; incidence in hospitalized patients in Bologna"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15509"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "512"
                        "paginaFinal" => "513"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations in COVID&#8208;19&#58; the experiences of Barcelona and Rome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "306"
                        "paginaFinal" => "307"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Three cases of COVID&#8208;19 patients presenting with erythema"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/1346-8138.15532"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "47"
                        "paginaInicial" => "1175"
                        "paginaFinal" => "1178"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lack of skin manifestations in COVID&#8208;19 hospitalized patients during the second epidemic wave in Spain&#58; a possible association with a novel SARS&#8208;CoV&#8208;2 variant a cross sectional study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "183"
                        "paginaFinal" => "185"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Potential interactions of SARS&#8208;CoV&#8208;2 with human cell receptors in the skin&#58; Understanding the enigma for a lower frequency of skin lesions compared to other tissues"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/exd.14186"
                      "Revista" => array:6 [
                        "tituloSerie" => "Exp Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "29"
                        "paginaInicial" => "936"
                        "paginaFinal" => "944"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0515"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations of SARS&#8208;CoV&#8208;2 a two&#8208;center&#44; prospective&#44; case&#8208;controlled study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2021.03.064"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "85"
                        "paginaInicial" => "202"
                        "paginaFinal" => "204"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Angiotensin&#8208;converting enzyme 2 &#40;ACE2&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/path.5471"
                      "Revista" => array:6 [
                        "tituloSerie" => "SARS&#8208;CoV&#8208;2 and the pathophysiology of coronavirus disease 2019 &#40;COVID&#8208;19&#41;&#46; J Pathol&#46;"
                        "fecha" => "2020"
                        "volumen" => "251"
                        "paginaInicial" => "228"
                        "paginaFinal" => "248"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0525"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SARS&#8208;CoV&#8208;2 PCR testing of skin for COVID&#8208;19 diagnostics&#58; a case report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(20)31760-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet&#46;"
                        "fecha" => "2020"
                        "volumen" => "396"
                        "paginaInicial" => "598"
                        "paginaFinal" => "599"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0530"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID&#8208;19 infection&#58; A report of five cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.trsl.2020.04.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Transl Res&#46;"
                        "fecha" => "2020"
                        "volumen" => "220"
                        "paginaInicial" => "1"
                        "paginaFinal" => "13"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0535"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SARS&#8208;CoV&#8208;2 endothelial infection causes COVID&#8208;19 chilblains&#58; histopathological&#44; immunohistochemical and ultrastructural study of seven paediatric cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19327"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "729"
                        "paginaFinal" => "737"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0540"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Are the cutaneous manifestations during or due to SARS&#8208;CoV&#8208;2 infection&#47;COVID&#8208;19 frequent or not&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00011-020-01370-w"
                      "Revista" => array:6 [
                        "tituloSerie" => "Revision of possible pathophysiologic mechanisms&#46; Inflamm Res&#46;"
                        "fecha" => "2020"
                        "volumen" => "69"
                        "paginaInicial" => "745"
                        "paginaFinal" => "756"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0545"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations in COVID&#8208;19&#58; Lessons learned from current evidence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "57"
                        "paginaFinal" => "60"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0550"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lessons from dermatology about inflammatory responses in Covid&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Rev Med Virol&#46;"
                        "fecha" => "2020"
                        "volumen" => "30"
                        "paginaInicial" => "2130"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0555"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pernio during the COVID&#8208;19 pandemic and review of inflammation patterns and mechanisms of hypercoagulability"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.06.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "898"
                        "paginaFinal" => "899"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0560"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The differing pathophysiologies that underlie COVID&#8208;19&#8208;associated perniosis and thrombotic retiform purpura&#58; a case series"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19415"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "141"
                        "paginaFinal" => "150"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0565"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19 chilblain&#8208;like lesion&#58; immunohistochemical demonstration of SARS&#8208;CoV&#8208;2 spike protein in blood vessel endothelium and sweat gland epithelium in a polymerase chain reaction&#8208;negative patient"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19338"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "778"
                        "paginaFinal" => "780"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0570"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Absence of SARS&#8208;CoV&#8208;2 RNA detection in tissue samples of COVID&#8208;19&#8208;related cutaneous lesions analyzed by real&#8208;time RT&#8208;PCR"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.16914"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "318"
                        "paginaFinal" => "321"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0575"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19&#8208;associated cutaneous manifestations&#58; does human herpesvirus 6 play an aetiological role&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19806"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "1187"
                        "paginaFinal" => "1190"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0580"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification of the cutaneous manifestations of COVID&#8208;19&#58; a rapid prospective nationwide consensus study in Spain with 375 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19163"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "71"
                        "paginaFinal" => "77"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0585"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chilblains is a common cutaneous finding during the COVID&#8208;19 pandemic&#58; A retrospective nationwide study from France"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.04.161"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "667"
                        "paginaFinal" => "670"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0590"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The spectrum of COVID&#8208;19&#8208;associated dermatologic manifestations&#58; An international registry of 716 patients from 31 countries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.06.1016"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "1118"
                        "paginaFinal" => "1129"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0595"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The clinical spectrum of COVID&#8208;19&#8208;associated cutaneous manifestations&#58; An Italian multicenter study of 200 adult patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2021.01.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "84"
                        "paginaInicial" => "1356"
                        "paginaFinal" => "1363"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0600"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnostic value of cutaneous manifestation of SARS&#8208;CoV&#8208;2 infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "880"
                        "paginaFinal" => "887"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0605"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations related to coronavirus disease 2019 &#40;COVID&#8208;19&#41;&#58; A prospective study from China and Italy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.05.073"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "674"
                        "paginaFinal" => "675"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0610"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eruptions and related clinical course among 296 hospitalized adults with confirmed COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "84"
                        "paginaInicial" => "946"
                        "paginaFinal" => "952"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0615"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skin manifestations in patients hospitalized with confirmed COVID&#8208;19 disease&#58; a cross&#8208;sectional study in a tertiary hospital"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15180"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1353"
                        "paginaFinal" => "1357"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0620"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of mucocutaneous manifestations in 666 patients with COVID&#8208;19 in a field hospital in Spain&#58; oral and palmoplantar findings"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19564"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "184"
                        "paginaFinal" => "185"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0625"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Absence of specific cutaneous manifestations of severe acute respiratory syndrome coronavirus 2 in a reference center in Brazil"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "84"
                        "paginaInicial" => "67"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0630"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skin Manifestations in COVID&#8208;19 Patients&#58; Are They Indicators for Disease Severity&#63;&#46; A Systematic Review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3389/fmed.2021.723019"
                      "Revista" => array:4 [
                        "tituloSerie" => "Front Med &#40;Lausanne&#41;&#46;"
                        "fecha" => "2021"
                        "volumen" => "8"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0635"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Time of Onset of Selected Skin Lesions Associated with COVID&#8208;19&#58; A Systematic Review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s13555-021-00526-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Ther &#40;Heidelb&#41;&#46;"
                        "fecha" => "2021"
                        "volumen" => "11"
                        "paginaInicial" => "695"
                        "paginaFinal" => "705"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0640"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermatologic manifestations of COVID&#8208;19&#58; a comprehensive systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15168"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "418"
                        "paginaFinal" => "450"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0645"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Exanthema and eosinophilia in COVID&#8208;19 patients&#58; has viral infection a role in drug induced exanthemas&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "561"
                        "paginaFinal" => "563"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0650"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Characterization of acute acral skin lesions in nonhospitalized patients&#58; A case series of 132 patients during the COVID&#8208;19 outbreak"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "61"
                        "paginaFinal" => "63"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0655"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pernio&#8208;like skin lesions associated with COVID&#8208;19&#58; A case series of 318 patients from 8 countries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.05.109"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "486"
                        "paginaFinal" => "492"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0660"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chilblain&#8208;like acral lesions during the COVID&#8208;19 pandemic &#40;&#8220;COVID toes&#8221;&#41;&#58; Histologic&#44; immunofluorescence&#44; and immunohistochemical study of 17 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.05.145"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "870"
                        "paginaFinal" => "875"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0665"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Most chilblains observed during the COVID&#8208;19 outbreak occur in patients who are negative for COVID&#8208;19 on polymerase chain reaction and serology testing"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19377"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "866"
                        "paginaFinal" => "874"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0670"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Do we have serological evidence that chilblain&#8208;like lesions are related to SARS&#8208;CoV&#8208;2&#63;&#46; A review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0675"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chilblains and COVID&#8208;19&#58; why SARS&#8208;CoV&#8208;2 endothelial infection is questioned"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19489"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "1152"
                        "paginaFinal" => "1153"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0680"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticaria and COVID&#8208;19&#58; A review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0685"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Varicella&#8208;like exanthema as a specific COVID&#8208;19&#8208;associated skin manifestation&#58; Multicenter case series of 22 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.04.044"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "280"
                        "paginaFinal" => "285"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0690"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral manifestations of COVID&#8208;19 disease&#58; A review article"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2021"
                        "volumen" => "34"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0695"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SARS&#8208;CoV&#8208;2&#8208;induced telogen effluvium&#58; a multicentric study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "181"
                        "paginaFinal" => "183"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0700"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Race&#44; ethnicity and comorbidities are critical factors in the diagnosis of telogen effluvium during the COVID&#8208;19 pandemic"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2021.03.099"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "85"
                        "paginaInicial" => "209"
                        "paginaFinal" => "211"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0705"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.04.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "498"
                        "paginaFinal" => "499"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0710"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticarial vasculitis in COVID&#8208;19 infection&#58; a vasculopathy&#8208;related symptom&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "566"
                        "paginaFinal" => "568"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0715"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Angioedema and urticaria in a COVID&#8208;19 patient&#58; A case report and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.07.042"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "1091"
                        "paginaFinal" => "1094"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0720"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pityriasis rosea in otherwise asymptomatic confirmed COVID&#8208;19&#8208;positive patients&#58; A report of 2 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.10.035"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2021"
                        "volumen" => "7"
                        "paginaInicial" => "93"
                        "paginaFinal" => "94"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0725"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SARS&#8208;CoV&#8208;2 spike protein positivity in pityriasis rosea&#8208;like and urticaria&#8208;like rashes of COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                           …1
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19833"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "1194"
                        "paginaFinal" => "1195"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0730"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The clinics of HHV&#8208;6 infection in COVID&#8208;19 pandemic&#58; Pityriasis rosea and Kawasaki disease"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0735"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Widespread cutaneous small vessel vasculitis secondary to COVID&#8208;19 infection"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15106"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1278"
                        "paginaFinal" => "1279"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0740"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Leucocytoclastic vasculitis in a patient with COVID&#8208;19 with positive SARS&#8208;CoV&#8208;2 PCR in skin biopsy"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "BMJ Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "13"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0745"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Possible association between IgA vasculitis and COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2021"
                        "volumen" => "34"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0750"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New Onset Granulomatosis with Polyangiitis Associated with COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Case Rep Dermatol Med&#46;"
                        "fecha" => "2021"
                        "volumen" => "2021"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0755"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic granulomatosis with polyangiitis mimicking coronavirus disease 2019&#58; a case report"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "557"
                        "paginaFinal" => "559"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0760"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Schamberg&#8208;like purpuric eruptions and tonsillitis in mild COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0765"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Purpura fulminans as the presenting manifestation of COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/postgradmedj-2020-139202"
                      "Revista" => array:5 [
                        "tituloSerie" => "Postgrad Med J&#46;"
                        "fecha" => "2021"
                        "volumen" => "97"
                        "paginaInicial" => "473"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0770"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Atypical erythema multiforme palmar plaques lesions due to Sars&#8208;Cov&#8208;2"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "373"
                        "paginaFinal" => "375"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0775"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute Generalized Exanthematous Pustulosis &#40;AGEP&#41; in 12 Patients Treated for SARS&#8208;CoV&#8208;2 Positive Pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/DAD.0000000000001819"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol&#46;"
                        "fecha" => "2021"
                        "volumen" => "43"
                        "paginaInicial" => "342"
                        "paginaFinal" => "348"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0780"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development of toxic epidermal necrolysis in a coronavirus disease 2019 patient with recurrence of positive SARS&#8208;CoV&#8208;2 viral RNA"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "48"
                        "paginaInicial" => "144"
                        "paginaFinal" => "145"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0785"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SDRIFE&#8208;like rash associated with COVID&#8208;19&#44; clinicopathological correlation"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ajd.13444"
                      "Revista" => array:6 [
                        "tituloSerie" => "Australas J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "62"
                        "paginaInicial" => "88"
                        "paginaFinal" => "89"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0790"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The red half&#8208;moon nail sign&#58; a novel manifestation of coronavirus infection"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "663"
                        "paginaFinal" => "665"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0795"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Palmoplantar erythrodysesthesia&#58; a diagnostic sign of COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.16965"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "247"
                        "paginaFinal" => "249"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0800"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Follicular eruption as a cutaneous manifestation in COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "BMJ Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "13"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0805"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Unilateral laterothoracic exanthem in association with coronavirus disease 2019"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.07.020"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "900"
                        "paginaFinal" => "901"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0810"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Unilateral livedo reticularis in a COVID&#8208;19 patient&#58; Case with fatal outcome"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.10.033"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2021"
                        "volumen" => "7"
                        "paginaInicial" => "120"
                        "paginaFinal" => "121"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0815"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pression&#8208;induced facial ulcers by prone position for COVID&#8208;19 mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0820"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Papular&#8208;purpuric exanthem in a COVID&#8208;19 patient&#58; clinical and dermoscopic description"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "570"
                        "paginaFinal" => "572"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0825"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermoscopy of chilblain&#8208;like lesions during the COVID&#8208;19 outbreak&#58; A multicenter study on 10 patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.07.058"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "1749"
                        "paginaFinal" => "1751"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0830"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Herpes zoster ophthalmicus in COVID&#8208;19 patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15240"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1545"
                        "paginaFinal" => "1546"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0835"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Grover&#8208;like skin eruption&#58; another cutaneous manifestation in a COVID&#8208;19 patient"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15104"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1290"
                        "paginaFinal" => "1292"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0840"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Tas&#807;l&#305;dere N&#46; Melkersson&#8208;Rosenthal Syndrome Induced by COVID&#8208;19&#46; Am J Emerg Med"
                        "fecha" => "2021"
                        "volumen" => "41"
                        "paginaInicial" => "262"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0845"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Erythema nodosum&#8208;like rash in a COVID&#8208;19 patient&#58; A case report"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajem.2020.07.063"
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Emerg Med&#46;"
                        "fecha" => "2021"
                        "volumen" => "40"
                        "paginaInicial" => "227"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0850"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sarcoid&#8208;like reaction in a patient recovering from coronavirus disease 19 pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.07.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "915"
                        "paginaFinal" => "917"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0855"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An Isolated Peculiar Gianotti&#8208;Crosti Rash in the Course of a COVID&#8208;19 Episode"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2340/00015555-3614"
                      "Revista" => array:4 [
                        "tituloSerie" => "Acta Derm Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "100"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib0860"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Seborrheic dermatitis in COVID&#8208;19&#58; a case report"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15256"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1543"
                        "paginaFinal" => "1544"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib0865"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Annular lichen planus associated with coronavirus SARS&#8208;CoV&#8208;2 disease &#40;COVID&#8208;19&#41;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15338"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "246"
                        "paginaFinal" => "247"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib0870"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Erythema annulare centrifugum with anosmia and ageusia in a SARS&#8208;CoV&#8208;2 exposed patient successfully treated with doxycycline"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15356"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "384"
                        "paginaFinal" => "386"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib0875"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Granuloma annulare triggered by SARS&#8208;CoV&#8208;2 infection&#58; Immunohistochemical staining"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2021"
                        "volumen" => "34"
                        "paginaInicial" => "14897"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib0880"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19&#58; association with rapidly progressive forms of alopecia areata"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15317"
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "127"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            86 => array:3 [
              "identificador" => "bib0885"
              "etiqueta" => "87"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical and Histopathological Features and Potential Pathological Mechanisms of Skin Lesions in COVID&#8208;19&#58; Review of the Literature"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3390/dermatopathology7010002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatopathology &#40;Basel&#41;&#46;"
                        "fecha" => "2020"
                        "volumen" => "7"
                        "paginaInicial" => "3"
                        "paginaFinal" => "16"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            87 => array:3 [
              "identificador" => "bib0890"
              "etiqueta" => "88"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severe acute respiratory syndrome coronavirus 2 &#40;SARS&#8208;CoV&#8208;2&#41; infection is likely to be androgen mediated"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.04.032"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "308"
                        "paginaFinal" => "309"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            88 => array:3 [
              "identificador" => "bib0895"
              "etiqueta" => "89"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anti&#8208;androgens may protect against severe COVID&#8208;19 outcomes&#58; results from a prospective cohort study of 77 hospitalized men"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.17067"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "13"
                        "paginaFinal" => "15"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            89 => array:3 [
              "identificador" => "bib0900"
              "etiqueta" => "90"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "5&#8208;alpha&#8208;reductase inhibitors are associated with reduced frequency of COVID&#8208;19 symptoms in males with androgenetic alopecia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "243"
                        "paginaFinal" => "246"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "pt"
  "url" => "/26662752/0000009700000001/v1_202202030913/S2666275221002800/v1_202202030913/pt/main.assets"
  "Apartado" => array:4 [
    "identificador" => "81730"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Revis&#227;o"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/26662752/0000009700000001/v1_202202030913/S2666275221002800/v1_202202030913/pt/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275221002800?idApp=UINPBA00008Z"
]
Compartilhar
Informação da revista

Estatísticas

Siga este link para acessar o texto completo do artigo

Revisão
Manifestações cutâneas associadas à COVID‐19
Camila Arai Seque
Autor para correspondência
camilaseque@yahoo.com

Autor para correspondência.
, Milvia Maria Simões e Silva Enokihara, Adriana Maria Porro, Jane Tomimori
Departamento de Dermatologia, Universidade Federal de São Paulo, São Paulo, SP, Brasil
Lido
28173
Vezes
que se leu este artigo
4816
Total PDF
23357
Total HTML
Compartilhar estatísticas
 array:24 [
  "pii" => "S2666275221002800"
  "issn" => "26662752"
  "doi" => "10.1016/j.abdp.2021.08.001"
  "estado" => "S300"
  "fechaPublicacion" => "2022-01-01"
  "aid" => "485"
  "copyright" => "Sociedade Brasileira de Dermatologia"
  "copyrightAnyo" => "2021"
  "documento" => "article"
  "crossmark" => 1
  "licencia" => "http://creativecommons.org/licenses/by/4.0/"
  "subdocumento" => "rev"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "en" => array:19 [
      "pii" => "S0365059621002774"
      "issn" => "03650596"
      "doi" => "10.1016/j.abd.2021.08.002"
      "estado" => "S300"
      "fechaPublicacion" => "2022-01-01"
      "aid" => "485"
      "copyright" => "Sociedade Brasileira de Dermatologia"
      "documento" => "article"
      "crossmark" => 1
      "licencia" => "http://creativecommons.org/licenses/by/4.0/"
      "subdocumento" => "rev"
      "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">Review</span>"
        "titulo" => "Skin manifestations associated with COVID-19"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => "en"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "75"
            "paginaFinal" => "88"
          ]
        ]
        "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" => 976
                "Ancho" => 2090
                "Tamanyo" => 120941
              ]
            ]
            "detalles" => array:1 [
              0 => array:3 [
                "identificador" => "at0015"
                "detalle" => "Figure "
                "rol" => "short"
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Livedo racemosa&#44; purpura and necrosis of the extremities in a patient with COVID-19&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Camila Arai Seque, Milvia Maria Sim&#245;es e Silva Enokihara, Adriana Maria Porro, Jane Tomimori"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "Camila Arai"
                "apellidos" => "Seque"
              ]
              1 => array:2 [
                "nombre" => "Milvia Maria Sim&#245;es e Silva"
                "apellidos" => "Enokihara"
              ]
              2 => array:2 [
                "nombre" => "Adriana Maria"
                "apellidos" => "Porro"
              ]
              3 => array:2 [
                "nombre" => "Jane"
                "apellidos" => "Tomimori"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "pt" => array:9 [
          "pii" => "S2666275221002800"
          "doi" => "10.1016/j.abdp.2021.08.001"
          "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/S2666275221002800?idApp=UINPBA00008Z"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059621002774?idApp=UINPBA00008Z"
      "url" => "/03650596/0000009700000001/v1_202201230559/S0365059621002774/v1_202201230559/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2666275221002666"
    "issn" => "26662752"
    "doi" => "10.1016/j.abdp.2021.11.010"
    "estado" => "S300"
    "fechaPublicacion" => "2022-01-01"
    "aid" => "469"
    "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
    ]
    "pt" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Dermatologia Tropical&#47;Infectoparasit&#225;ria</span>"
      "titulo" => "Caso exuberante de leishmaniose cut&#226;nea verrucosa"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => "pt"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "89"
          "paginaFinal" => "92"
        ]
      ]
      "contieneResumen" => array:1 [
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0020"
          "etiqueta" => "Figura 4"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr4.jpeg"
              "Alto" => 685
              "Ancho" => 750
              "Tamanyo" => 61558
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Resposta satisfat&#243;ria imediatamente ap&#243;s o tratamento com milfetosina&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Jana Regis Novaes, Luise Ribeiro Daltro, Thiago Amparo Ferreira, Paulo Roberto Lima Machado"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Jana Regis"
              "apellidos" => "Novaes"
            ]
            1 => array:2 [
              "nombre" => "Luise Ribeiro"
              "apellidos" => "Daltro"
            ]
            2 => array:2 [
              "nombre" => "Thiago Amparo"
              "apellidos" => "Ferreira"
            ]
            3 => array:2 [
              "nombre" => "Paulo Roberto Lima"
              "apellidos" => "Machado"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S0365059621002609"
        "doi" => "10.1016/j.abd.2020.11.011"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059621002609?idApp=UINPBA00008Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275221002666?idApp=UINPBA00008Z"
    "url" => "/26662752/0000009700000001/v1_202202030913/S2666275221002666/v1_202202030913/pt/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2666275221002770"
    "issn" => "26662752"
    "doi" => "10.1016/j.abdp.2021.11.020"
    "estado" => "S300"
    "fechaPublicacion" => "2022-01-01"
    "aid" => "483"
    "copyright" => "Sociedade Brasileira de Dermatologia"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by/4.0/"
    "subdocumento" => "rev"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "pt" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Revis&#227;o</span>"
      "titulo" => "Psor&#237;ase pustulosa generalizada &#40;von Zumbusch&#41;"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => "pt"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "63"
          "paginaFinal" => "74"
        ]
      ]
      "contieneResumen" => array:1 [
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0025"
          "etiqueta" => "Figura 5"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr5.jpeg"
              "Alto" => 665
              "Ancho" => 905
              "Tamanyo" => 119501
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Quadro eruptivo de psor&#237;ase pustulosa generalizada&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ricardo Romiti, Andr&#233; Lu&#237;s da Silva Hirayama, Marcelo Arnone, Renata Ferreira Magalh&#227;es"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Ricardo"
              "apellidos" => "Romiti"
            ]
            1 => array:2 [
              "nombre" => "Andr&#233; Lu&#237;s da Silva"
              "apellidos" => "Hirayama"
            ]
            2 => array:2 [
              "nombre" => "Marcelo"
              "apellidos" => "Arnone"
            ]
            3 => array:2 [
              "nombre" => "Renata Ferreira"
              "apellidos" => "Magalh&#227;es"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S0365059621002750"
        "doi" => "10.1016/j.abd.2021.05.011"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059621002750?idApp=UINPBA00008Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275221002770?idApp=UINPBA00008Z"
    "url" => "/26662752/0000009700000001/v1_202202030913/S2666275221002770/v1_202202030913/pt/main.assets"
  ]
  "pt" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Revis&#227;o</span>"
    "titulo" => "Manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "75"
        "paginaFinal" => "88"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Camila Arai Seque, Milvia Maria Sim&#245;es e Silva Enokihara, Adriana Maria Porro, Jane Tomimori"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "Camila Arai"
            "apellidos" => "Seque"
            "email" => array:1 [
              0 => "camilaseque@yahoo.com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "Milvia Maria Sim&#245;es e Silva"
            "apellidos" => "Enokihara"
          ]
          2 => array:2 [
            "nombre" => "Adriana Maria"
            "apellidos" => "Porro"
          ]
          3 => array:2 [
            "nombre" => "Jane"
            "apellidos" => "Tomimori"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Departamento de Dermatologia&#44; Universidade Federal de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#44; Brasil"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Autor para correspond&#234;ncia&#46;"
          ]
        ]
      ]
    ]
    "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" => 700
            "Ancho" => 1250
            "Tamanyo" => 67904
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Les&#245;es vesico&#8208;bolhosas em paciente com COVID&#8208;19&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">No in&#237;cio da pandemia de COVID&#8208;19&#44; a dermatologia j&#225; parecia ter um papel importante dentre as manifesta&#231;&#245;es cl&#237;nicas dessa nova doen&#231;a&#46; Desde mar&#231;o de 2020&#44; mais de 1&#46;500 artigos correlacionando &#8220;dermatologia&#8221; e &#8220;COVID&#8208;19&#8221; foram publicados&#46; Nunca uma quantidade t&#227;o grande de informa&#231;&#245;es foi gerada em t&#227;o pouco tempo na comunidade cient&#237;fica&#44; inclusive dermatol&#243;gica&#46; Embora os primeiros relatos sejam escassos&#44; possivelmente em raz&#227;o da incapacidade de se realizarem exame dermatol&#243;gico completo&#44; registro fotogr&#225;fico&#44; an&#225;lise histopatol&#243;gica e&#47;ou imuno&#8208;histoqu&#237;mica e tamb&#233;m pela baixa presen&#231;a do especialista na assist&#234;ncia direta a esses pacientes&#44; pesquisas subsequentes trouxeram importantes contribui&#231;&#245;es sobre o envolvimento cut&#226;neo na COVID&#8208;19&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">1</span></a> Neste documento s&#227;o revisadas as principais publica&#231;&#245;es at&#233; o momento &#40;30&#47;04&#47;21&#41; sobre diferentes aspectos das manifesta&#231;&#245;es dermatol&#243;gicas da COVID&#8208;19&#44; segundo as metodologias adotadas nessas pesquisas&#46; Utilizamos como base de dados o Pubmed&#44; segundo as seguintes palavras chaves&#58; COVID&#8208;19&#44; SARS&#8208;CoV&#8208;2&#44; &#8220;<span class="elsevierStyleItalic">dermatology</span>&#8221;&#44; &#8220;<span class="elsevierStyleItalic">skin</span>&#8221;<span class="elsevierStyleItalic">&#46;</span> As informa&#231;&#245;es iniciais est&#227;o reunidas na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Frequ&#234;ncia das manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19</span><p id="par0010" class="elsevierStylePara elsevierViewall">Embora o primeiro relato de um quadro dermatol&#243;gico possivelmente associado a COVID&#8208;19 na literatura tenha sido publicado em 22&#47;03&#47;2020 por Joob e Wiwanitkit<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">2</span></a> no Journal of the American Academy of Dermatology &#40;JAAD&#41;&#44; j&#225; no final de 2019 Guan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">3</span></a> fizeram a primeira cita&#231;&#227;o sobre a frequ&#234;ncia de manifesta&#231;&#245;es cut&#226;neas&#46; Dentre os 1&#46;099 pacientes com infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 descritos&#44; 0&#44;2&#37; apresentaram <span class="elsevierStyleItalic">rash&#46;</span></p><p id="par0015" class="elsevierStylePara elsevierViewall">O primeiro artigo com foco principal na frequ&#234;ncia das manifesta&#231;&#245;es cut&#226;neas&#44; publicado por Recalcati<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">4</span></a> em 26&#47;03&#47;20&#44; relatou que entre 88 casos avaliados por dermatologistas&#44; 20&#44;4&#37; apresentaram les&#245;es de pele&#46; Desde ent&#227;o&#44; a estimativa de tal frequ&#234;ncia tem sido amplamente vari&#225;vel&#44; em diferentes pa&#237;ses&#44; com dados obtidos por diferentes metodologias&#46; Matar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">5</span></a> na Fran&#231;a&#44; Reknimitr et al&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">6</span></a> na Tail&#226;ndia e Solak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">7</span></a> na Turquia mostraram frequ&#234;ncias de 1&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>756&#41;&#44; 15&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>183&#41; e 18&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>382&#41;&#44; respectivamente&#44; por meio da coleta a dist&#226;ncia em entrevista telef&#244;nica ap&#243;s avalia&#231;&#227;o realizada pelo pr&#243;prio paciente &#40;autoexame&#41;&#46; Frequ&#234;ncias mais baixas foram registradas por Gaspari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">8</span></a> na It&#225;lia &#40;1&#44;4&#37;&#41;&#44; Tammaro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">9</span></a> tamb&#233;m na It&#225;lia &#40;1&#44;5&#37; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>130&#41; e Tamai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">10</span></a> no Jap&#227;o &#40;4&#44;3&#37; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>69&#41; em avalia&#231;&#227;o presencial dos pacientes realizada por dermatologista &#8211; fator fundamental para maior sensibilidade na detec&#231;&#227;o de les&#245;es de pele e acur&#225;cia em atribu&#237;&#8208;las &#224; COVID&#8208;19&#46; Pela metodologia mais adequada&#44; acredita&#8208;se que a real frequ&#234;ncia esteja pr&#243;xima &#224;s relatadas por esses &#250;ltimos estudos&#46; As principais cr&#237;ticas aos trabalhos iniciais s&#227;o a avalia&#231;&#227;o a dist&#226;ncia&#44; avalia&#231;&#227;o pelo pr&#243;prio paciente ou por profissionais de sa&#250;de n&#227;o dermatologistas&#44; inclus&#227;o de casos suspeitos de COVID&#8208;19 &#40;n&#227;o confirmados&#41; e a n&#227;o exclus&#227;o de afec&#231;&#245;es cut&#226;neas comuns&#44; como outras infec&#231;&#245;es virais e rea&#231;&#245;es adversas a medicamentos&#46; O significado biol&#243;gico real de tais manifesta&#231;&#245;es ainda parece incerto&#46; Mais dados sobre frequ&#234;ncia ser&#227;o citados adiante&#44; nos t&#243;picos &#8220;Estudos prospectivos&#8221; e &#8220;Revis&#245;es sistem&#225;ticas&#8221; e resumidos na <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Curiosamente&#44; um estudo espanhol mostrou que a frequ&#234;ncia de manifesta&#231;&#245;es dermatol&#243;gicas foi ainda menor na segunda onda da epidemia naquele pa&#237;s&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">11</span></a> Poss&#237;veis explica&#231;&#245;es s&#227;o&#58; melhor conhecimento sobre a doen&#231;a propiciou tratamento precoce e com medica&#231;&#245;es mais assertivas&#44; o que reduziu a propor&#231;&#227;o de casos graves e rea&#231;&#245;es adversas a medicamentos &#40;um dos principais diagn&#243;sticos diferenciais&#41;&#59; maior aplica&#231;&#227;o de medidas preventivas e testes diagn&#243;sticos para exclus&#227;o de outras infec&#231;&#245;es virais&#59; novas muta&#231;&#245;es com maior diversidade de virul&#234;ncia e antigenicidade&#46; Al&#233;m disso&#44; a aparente baixa frequ&#234;ncia de les&#245;es dermatol&#243;gicas em compara&#231;&#227;o &#224;s manifesta&#231;&#245;es cl&#237;nicas &#8220;cl&#225;ssicas&#8221; podem ser explicadas pela menor express&#227;o de receptores virais na pele em rela&#231;&#227;o a outros &#243;rg&#227;os&#8208;alvo e pela presen&#231;a de proteases de membrana com a&#231;&#227;o protetora &#224; pele&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Por fim&#44; um recente estudo austr&#237;aco com metodologia caso&#8208;controle n&#227;o mostrou signific&#226;ncia estat&#237;stica entre a presen&#231;a de les&#245;es de pele no grupo dos pacientes com COVID&#8208;19 confirmados &#40;casos&#41; e no grupo n&#227;o COVID &#40;controles&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">13</span></a> Sugere&#8208;se que as les&#245;es de pele s&#227;o menos espec&#237;ficas do que outros sinais cl&#237;nicos&#44; n&#227;o s&#227;o boas pistas diagn&#243;sticas&#44; devem ser avaliadas com crit&#233;rio e ser atribu&#237;das &#224; COVID&#8208;19 apenas depois de exclu&#237;dos outros diagn&#243;sticos diferenciais&#44; como rea&#231;&#245;es adversas a medicamentos e outras infec&#231;&#245;es virais&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Fisiopatologia</span><p id="par0030" class="elsevierStylePara elsevierViewall">Os mecanismos pelos quais o SARS&#8208;CoV&#8208;2 causa doen&#231;a nos diversos &#243;rg&#227;os&#44; incluindo a pele&#44; s&#227;o bastante complexos e n&#227;o totalmente elucidados&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">O risco de um &#243;rg&#227;o desenvolver infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 &#233; determinado pela presen&#231;a dos receptores funcionais virais da enzima conversora de angiotensina&#8208;2 &#40;ACE2&#41; e transmembrana <span class="elsevierStyleItalic">protease serine</span> 2 &#40;TMPRSS2&#41; expressos nas c&#233;lulas locais&#46; A ACE2 &#233; encontrada principalmente em c&#233;lulas epiteliais alveolares&#44; o que explica a alta vulnerabilidade dos pulm&#245;es &#224; COVID&#8208;19&#46; Alguns estudos mostraram que a ACE2 &#233; detect&#225;vel na camada basal da epiderme&#44; bem como nos fol&#237;culos capilares&#46; No entanto&#44; a presen&#231;a de SARS&#8208;CoV&#8208;2 em amostras de pele foi relacionada com a express&#227;o da ACE2 nas c&#233;lulas endoteliais de capilares cut&#226;neos&#44; n&#227;o em queratin&#243;citos e melan&#243;citos&#44;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">14</span></a> o que faz com que o v&#237;rus n&#227;o consiga penetrar e infectar direta e primariamente a pele&#46; O acometimento cut&#226;neo &#233; indireto&#44; ou seja&#44; ocorre por infec&#231;&#227;o das c&#233;lulas endoteliais dos vasos d&#233;rmicos&#46; A presen&#231;a do SARS&#8208;CoV&#8208;2 nas les&#245;es de pele j&#225; foi confirmada por t&#233;cnica de rea&#231;&#227;o em cadeia da polimerase &#40;PCR&#41; em tecido com baixa replica&#231;&#227;o&#44; mesmo em paciente com PCR no <span class="elsevierStyleItalic">swab</span> nasal e sorologias negativas&#44; mostrando que a pele pode ser um &#243;rg&#227;o infectado&#44; eventualmente at&#233; diagn&#243;stico&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">15</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A primeira e maior evid&#234;ncia sobre a fisiopatologia das les&#245;es cut&#226;neas na COVID&#8208;19 foi publicada por Magro et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">16</span></a> ainda no in&#237;cio da pandemia &#40;15&#47;04&#47;20&#41;&#46; Por meio de t&#233;cnicas de histopatologia e imuno&#8208;histoqu&#237;mica de componentes do complemento e da prote&#237;na <span class="elsevierStyleItalic">spike viral</span>&#44; o trabalho de Magro mostra que o processo fisiopatol&#243;gico respons&#225;vel pelo acometimento pulmonar pode ocorrer tamb&#233;m na pele&#44; tanto s&#227; como lesada&#44; al&#233;m de comprovar a presen&#231;a viral nesses &#243;rg&#227;os&#46; Da mesma maneira&#44; Colmenero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">17</span></a> tamb&#233;m identificaram part&#237;culas virais no endot&#233;lio de les&#245;es do tipo eritema p&#233;rnio em crian&#231;as&#44; o que sustenta a rela&#231;&#227;o causal entre o acometimento cut&#226;neo e a presen&#231;a viral&#46; O dano endotelial induzido pelo SARS&#8208;CoV&#8208;2 na pele pode ser um dos mecanismos&#8208;chave na patog&#234;nese&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Sabe&#8208;se que a fisiopatologia da COVID&#8208;19 &#233; multifatorial e envolve resposta imune inata&#44; humoral&#44; hipercoagulabilidade&#44; ativa&#231;&#227;o monoc&#237;tica&#47;macrof&#225;gica&#44; aumento expressivo de citocinas &#40;&#8220;tempestade de citocinas&#8221;&#41;&#44; entre outros&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">18</span></a> De maneira bastante simplificada&#44; as manifesta&#231;&#245;es cut&#226;neas t&#234;m sido divididas em duas formas quanto &#224; fisiopatologia&#58; &#40;1&#41; inflamat&#243;ria&#44; como resposta imune aos nucleot&#237;dios virais&#44; e &#40;2&#41; vascular&#44; secund&#225;ria aos fen&#244;menos de vasculite&#44; vasculopatia e trombose&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">19</span></a> Sobre a resposta inflamat&#243;ria&#44; as infec&#231;&#245;es virais est&#227;o relacionadas com o desencadear de respostas imunes inatas e adaptativas&#46; O sistema monoc&#237;tico&#8208;macr&#243;fago produz uma resposta imune exacerbada&#44; gerando processo inflamat&#243;rio sist&#234;mico intenso&#46; A ativa&#231;&#227;o viral de mast&#243;citos e bas&#243;filos poderia justificar les&#245;es como urtic&#225;ria e exantemas&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">20</span></a> Com rela&#231;&#227;o aos mecanismos vasculares&#44; as les&#245;es mais estudadas s&#227;o do tipo eritema p&#233;rnio&#44; em analogia &#224; fisiopatologia de doen&#231;as j&#225; conhecidas&#44; como eritema p&#233;rnio &#8220;cl&#225;ssico&#8221; &#40;desencadeado pelo frio&#41;&#44; &#8220;l&#250;pico&#8221; e outras entidades vasculares&#44; como a vasculopatia livedoide&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">21</span></a> Acredita&#8208;se que o eritema p&#233;rnio associado &#224; COVID&#8208;19 decorra tamb&#233;m de uma rea&#231;&#227;o imune exagerada com sinaliza&#231;&#227;o via interferon tipo I&#44; importante para a erradica&#231;&#227;o viral&#44; por&#233;m com resposta generalizada altamente inflamat&#243;ria&#46; J&#225; nos quadros de p&#250;rpura retiforme dos pacientes graves&#44; a trombose vascular na pele e em outros &#243;rg&#227;os estaria associada a uma resposta m&#237;nima de interferon&#44; possibilitando a replica&#231;&#227;o viral excessiva com libera&#231;&#227;o de prote&#237;nas virais que se localizam no endot&#233;lio extrapulmonar e desencadeiam extensa ativa&#231;&#227;o do complemento&#46;<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Controv&#233;rsias quanto &#224; fisiopatologia e &#224; presen&#231;a de part&#237;culas virais desencadeando les&#245;es cut&#226;neas baseiam&#8208;se em estudos que constatam a aus&#234;ncia dessas part&#237;culas em pesquisa&#44; por t&#233;cnica de PCR nos fragmentos obtidos por bi&#243;psia de les&#245;es de pele&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">24</span></a> Al&#233;m disso&#44; recentemente&#44; sugere&#8208;se que o SARS&#8208;CoV&#8208;2 poderia causar a reativa&#231;&#227;o de outros v&#237;rus latentes&#44; como o HHV&#8208;6&#44; e que este seria o real respons&#225;vel por algumas manifesta&#231;&#245;es cut&#226;neas inicialmente atribu&#237;das &#224; COVID&#8208;19&#44;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">25</span></a> como os exantemas e quadros pitir&#237;ase r&#243;sea s&#237;mile&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Grandes s&#233;ries nacionais e internacionais</span><p id="par0055" class="elsevierStylePara elsevierViewall">Logo ap&#243;s os primeiros relatos de casos isolados de manifesta&#231;&#245;es cut&#226;neas em pacientes com COVID&#8208;19&#44; principalmente com a chegada da pandemia na Europa&#44; alguns pa&#237;ses realizaram estudos com colabora&#231;&#227;o nacional e internacional sob lideran&#231;a de suas respectivas sociedades acad&#234;micas&#46; Surgem&#44; ent&#227;o&#44; os primeiros estudos com grandes s&#233;ries de casos sobre as manifesta&#231;&#245;es cut&#226;neas mais prevalentes&#44; incluindo sugest&#245;es de classifica&#231;&#245;es em grupos&#44; conforme o padr&#227;o cl&#237;nico e mecanismos fisiopatol&#243;gicos&#46; Tais estudos foram fundamentais na compreens&#227;o inicial da rela&#231;&#227;o entre dermatologia e COVID&#8208;19&#44; e s&#227;o refer&#234;ncias importantes at&#233; o presente momento&#46; Os principais dados desses estudos est&#227;o reunidos na <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Espanha</span><p id="par0060" class="elsevierStylePara elsevierViewall">A primeira grande s&#233;rie retrospectiva foi publicada em 29&#47;04&#47;20 por Galv&#225;n&#8208;Casas et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">26</span></a> amplamente divulgada&#44; contendo um atlas dermatol&#243;gico&#46; Com o apoio da Academia Espa&#241;ola de Dermatolog&#237;a y Venereolog&#237;a&#44; dermatologistas de toda a Espanha inclu&#237;ram imagens de les&#245;es de pele de 375 pacientes com COVID&#8208;19 &#40;suspeitos ou confirmados&#41;&#44; agrupados em cinco padr&#245;es principais&#58; erup&#231;&#245;es maculopapulares &#40;47&#37;&#41;&#44; urticariformes &#40;19&#37;&#41;&#44; EP&#8208;s&#237;mile &#40;19&#37;&#41;&#44; vesico&#8208;bolhosas &#40;9&#37;&#41;&#44; e livedo&#47;necrose &#40;6&#37;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">O padr&#227;o mais encontrado foi de erup&#231;&#245;es maculopapulares&#44; com in&#237;cio concomitante aos sintomas gerais e dura&#231;&#227;o m&#233;dia de 8&#44;6 dias&#44; em semelhan&#231;a aos quadros urticariformes&#46; Ambos n&#227;o foram considerados &#250;teis para o diagn&#243;stico da COVID&#8208;19 por serem manifesta&#231;&#245;es inespec&#237;ficas&#44; comuns a outras afec&#231;&#245;es frequentes&#44; como rea&#231;&#245;es adversas a medicamentos e outras infec&#231;&#245;es virais&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">As les&#245;es EP&#8208;s&#237;mile ocorreram em pacientes mais jovens com quadros sist&#234;micos leves&#44; de surgimento tardio &#40;m&#233;dia 12&#44;7 dias do in&#237;cio dos sintomas gerais&#41; e dura&#231;&#227;o prolongada&#46; Apenas 1 dos 71 casos relatava EP pr&#233;vio&#46; Teriam valor como marcador epidemiol&#243;gico e n&#227;o diagn&#243;stico&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As les&#245;es vesiculares surgiram antes dos sintomas gerais em 15&#37; dos casos dessa s&#233;rie&#44; com dura&#231;&#227;o m&#233;dia de 10&#44;4 dias e relativa especificidade diagn&#243;stica&#44; j&#225; que s&#227;o manifesta&#231;&#245;es cut&#226;neas n&#227;o relatadas nos exantemas virais&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Livedo&#47;necrose incluem uma gama vari&#225;vel de apresenta&#231;&#245;es relacionadas com a COVID&#8208;19 ou &#224;s suas complica&#231;&#245;es&#44; como estado de hipercoagulabilidade e dano vascular&#46; Est&#227;o associadas com faixa et&#225;ria elevada e maior mortalidade&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Embora haja grande m&#233;rito pelo pioneirismo e expressivo n&#250;mero de casos&#44; a inclus&#227;o de pacientes n&#227;o confirmados para COVID&#8208;19 &#40;suspeitos&#41;&#44; em sua maioria ambulatoriais&#44; avaliados por registro fotogr&#225;fico&#44; sem an&#225;lise histol&#243;gica ou exclus&#227;o dos principais diagn&#243;sticos diferenciais &#233; uma limita&#231;&#227;o do estudo&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fran&#231;a</span><p id="par0090" class="elsevierStylePara elsevierViewall">Em 04&#47;05&#47;20&#44; de Masson et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">27</span></a> com apoio da Soci&#233;t&#233; Fran&#231;aise de Dermatologie&#44; publicaram um estudo retrospectivo observacional em forma de carta que incluiu imagens de manifesta&#231;&#245;es cut&#226;neas de 277 pacientes com COVID&#8208;19 &#40;252 suspeitos e 25 confirmados&#41; de cl&#237;nicas privadas de toda a Fran&#231;a&#46; Surpreendentemente&#44; as les&#245;es EP&#8208;s&#237;mile corresponderam &#224; grande maioria dos casos &#40;75&#37;&#41;&#44; relatadas inclusive como manifesta&#231;&#227;o &#250;nica da doen&#231;a&#46; Estudo histol&#243;gico realizado em tr&#234;s casos mostrou dermatite de interface liquenoide com a presen&#231;a de microtrombos&#46; Outros padr&#245;es cut&#226;neos encontrados foram&#58; vesicular &#40;15&#37;&#41;&#44; urticariforme &#40;9&#37;&#41;&#44; morbiliforme &#40;9&#37;&#41;&#44; petequial &#40;3&#37;&#41;&#44; livedo reticular &#40;1&#37;&#41;&#44; outros &#40;15&#37;&#41;&#46; Alguns pacientes foram contabilizados em mais de uma categoria&#46; Vale lembrar que os franceses foram os primeiros a descrever as les&#245;es EP&#8208;s&#237;mile relacionadas com a COVID&#8208;19&#44; o que poderia ser um vi&#233;s para a alta frequ&#234;ncia apresentada nesse estudo&#44; n&#227;o reprodut&#237;vel nos demais trabalhos semelhantes&#46; Al&#233;m disso&#44; a elevada preval&#234;ncia das les&#245;es EP&#8208;s&#237;mile provavelmente reflete&#8208;se na grande porcentagem de casos n&#227;o confirmados inclu&#237;dos na an&#225;lise&#44; uma vez que tais les&#245;es predominam em quadros oligo ou assintom&#225;ticos da COVID&#8208;19&#44; que habitualmente s&#227;o pouco testados quanto &#224; confirma&#231;&#227;o laboratorial da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">EUA&#47;internacional &#40;31 pa&#237;ses&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Em colabora&#231;&#227;o com a American Academy of Dermatology e com a International League of Dermatological Societies&#44; Freeman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">28</span></a> coletaram dados de 716 casos de 31 pa&#237;ses por meio de registro eletr&#244;nico&#44; resultados publicados em 02&#47;07&#47;20&#46; Dermatologistas forneceram dados de 54&#37; dos casos &#40;89&#37; de todos os registros eram provenientes dos EUA&#41;&#46; Apenas 34 pacientes hisp&#226;nicos&#47;latinos e 13 afro&#8208;americanos foram inclu&#237;dos&#44; comprometendo a diversidade racial necess&#225;ria para a compreens&#227;o das manifesta&#231;&#245;es cut&#226;neas&#46; Apenas 171 pacientes eram COVID&#8208;19 confirmados&#44; com as seguintes manifesta&#231;&#245;es e suas frequ&#234;ncias&#58; morbiliforme &#40;22&#37;&#41;&#44; EP&#8208;s&#237;mile &#40;18&#37;&#41;&#44; urticariforme &#40;16&#37;&#41;&#44; eritema macular &#40;13&#37;&#41;&#44; vesicular &#40;11&#37;&#41;&#44; papuloescamoso &#40;9&#44;9&#37;&#41; e p&#250;rpura retiforme &#40;6&#44;4&#37;&#41;&#46; A maioria das manifesta&#231;&#245;es cut&#226;neas teve in&#237;cio concomitante aos sintomas gerais&#46; No entanto&#44; em 12&#37; as les&#245;es de pele foram os primeiros sintomas da doen&#231;a&#44; mostrando a poss&#237;vel import&#226;ncia das les&#245;es cut&#226;neas como marcador para o diagn&#243;stico precoce da COVID&#8208;19&#46; Com rela&#231;&#227;o &#224; gravidade&#44; as les&#245;es EP&#8208;s&#237;mile associaram&#8208;se a quadros sist&#234;micos mais leves e os casos com p&#250;rpura retiforme estavam 100&#37; hospitalizados&#46; Estudo histopatol&#243;gico foi realizado em 14 casos confirmados&#46; As limita&#231;&#245;es apresentadas pelo pr&#243;prio estudo foram&#58; vi&#233;s do avaliador&#44; impossibilidade de estimar frequ&#234;ncia&#47;preval&#234;ncia das manifesta&#231;&#245;es cut&#226;neas&#44; baixa taxa de casos COVID&#8208;19 confirmados &#40;25&#37;&#41; e pouca diversidade &#233;tnica&#44; apesar da aparente alta representatividade por 31 pa&#237;ses&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">It&#225;lia</span><p id="par0100" class="elsevierStylePara elsevierViewall">Em semelhan&#231;a &#224; Espanha e Fran&#231;a&#44; em 18&#47;01&#47;21 a Societ&#224; Italiana di Dermatologia medica&#44; chirurgica&#44; estetica e delle Malattie Sessualmente Trasmesse tamb&#233;m coordenou um estudo nacional que reuniu dados de 200 pacientes com manifesta&#231;&#245;es cut&#226;neas&#46; Um dos crit&#233;rios de inclus&#227;o para Marzano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">29</span></a> foi a presen&#231;a de les&#245;es de pele relacionada com a COVID&#8208;19&#44; confirmada por um dermatologista experiente&#59; 62&#37; apresentavam diagn&#243;stico confirmado de COVID&#8208;19&#46; Os principais padr&#245;es identificados foram&#58; erup&#231;&#227;o maculopapular&#47;exantema morbiliforme &#40;25&#44;7&#37;&#41;&#44; EP&#8208;s&#237;mile &#40;24&#44;6&#37;&#41;&#44; erup&#231;&#227;o papulovesicular &#40;15&#44;5&#37;&#41;&#44; urticariforme &#40;10&#44;2&#37;&#41;&#44; p&#250;rpura&#47;vasculite &#40;6&#44;9&#37;&#41;&#44; livedo reticular&#47;racemoso &#40;2&#44;1&#37;&#41; e outros &#40;15&#37;&#41;&#44; que inclu&#237;ram pitir&#237;ase r&#243;sea s&#237;mile&#44; eritema multiforme s&#237;mile&#44; eritema nodoso s&#237;mile&#44; paniculite e angioedema&#46; N&#227;o foram identificadas les&#245;es mucosas&#46; O quadro cut&#226;neo surgiu&#44; em m&#233;dia&#44; 14 dias ap&#243;s o in&#237;cio dos sintomas sist&#234;micos e durou&#44; em m&#233;dia&#44; 12 dias&#46; As les&#245;es EP&#8208;s&#237;mile apresentaram dura&#231;&#227;o maior em rela&#231;&#227;o aos demais padr&#245;es&#44; ocorreram em faixa et&#225;ria mais jovem e representaram menor risco de desenvolver doen&#231;a sist&#234;mica grave &#8211; todos fatores com signific&#226;ncia estat&#237;stica&#46; A idade m&#233;dia dos grupos livedo reticular&#47;racemoso e erup&#231;&#227;o maculopapular&#47;exantema morbiliforme tamb&#233;m foi maior &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; Uma limita&#231;&#227;o do estudo &#233; a aus&#234;ncia de confirma&#231;&#227;o diagn&#243;stica da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 em 36&#44;5&#37; da amostra&#44; por fatores econ&#244;micos que limitaram a ampla testagem diagn&#243;stica na It&#225;lia e em diversos outros pa&#237;ses&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Reino Unido</span><p id="par0105" class="elsevierStylePara elsevierViewall">Por fim&#44; o estudo populacional mais recente&#44; com n&#250;meros bastante expressivos&#44; cujos resultados geraram muita repercuss&#227;o&#44; foi publicado em 14&#47;01&#47;21 por Visconti et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">30</span></a> com dados de todo o Reino Unido e desenho distinto das publica&#231;&#245;es citadas anteriormente&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">O primeiro bra&#231;o do estudo coletou dados de 336&#46;847 usu&#225;rios do aplicativo &#8220;COVID <span class="elsevierStyleItalic">Symptom Study</span>&#8221;&#44; em que indiv&#237;duos forneceram informa&#231;&#245;es epidemiol&#243;gicas&#44; laboratoriais e cl&#237;nicas&#44; dentre elas acerca da presen&#231;a ou n&#227;o de les&#245;es de pele identificadas pelo pr&#243;prio usu&#225;rio&#46; Apenas 2&#46;021 &#40;7&#44;4&#37;&#41; usu&#225;rios apresentavam confirma&#231;&#227;o laboratorial de COVID&#8208;19&#59; desses&#44; 178 &#40;8&#44;8&#37;&#41; relataram les&#245;es cut&#226;neas&#46; A preval&#234;ncia foi ligeiramente maior entre as mulheres&#46; Al&#233;m disso&#44; a preval&#234;ncia de les&#245;es na pele foi significativamente maior entre os que testaram positivo para SARS&#8208;CoV&#8208;2 em compara&#231;&#227;o aos que testaram negativo&#44; o que justificaria a inclus&#227;o do acometimento cut&#226;neo na lista dos sintomas de suspei&#231;&#227;o da COVID&#8208;19&#44; por seu fator preditivo diagn&#243;stico&#44; independentemente da frequ&#234;ncia com que ocorra&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">O segundo bra&#231;o do estudo procurou investigar com detalhes as manifesta&#231;&#245;es cut&#226;neas por meio de question&#225;rio dirigido aos usu&#225;rios que as relataram e o compartilhamento de fotos&#46; Dentre os 11&#46;544 question&#225;rios respondidos&#44; apenas 694 &#40;6&#37;&#41; apresentavam diagn&#243;stico confirmado de COVID&#8208;19&#46; Nesse grupo&#44; embora a maioria tenha referido in&#237;cio das les&#245;es cut&#226;neas juntamente ou logo ap&#243;s os sintomas gerais&#44; 17&#37; relataram que as les&#245;es de pele surgiram antes dos sintomas sist&#234;micos&#44; e em 21&#37; o quadro cut&#226;neo foi o &#250;nico sintoma&#46; No entanto&#44; o estudo n&#227;o trouxe informa&#231;&#245;es adicionais detalhadas sobre tais constata&#231;&#245;es&#46; N&#227;o houve descri&#231;&#227;o sobre quais foram as manifesta&#231;&#245;es cut&#226;neas ocorridas previamente aos sintomas gerais e quanto tempo antes elas surgiram&#46; Tampouco especificou quais foram as les&#245;es de pele consideradas pelo pr&#243;prio indiv&#237;duo como manifesta&#231;&#227;o &#250;nica da COVID&#8208;19 ou esclareceu o motivo pelo qual foi realizada a confirma&#231;&#227;o laboratorial da doen&#231;a na aus&#234;ncia de qualquer sintoma suspeito&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nesse mesmo bra&#231;o do estudo&#44; 2&#46;328 usu&#225;rios compartilharam fotos das les&#245;es cut&#226;neas&#44; 260 imagens foram selecionadas de modo randomizado para an&#225;lise por dermatologistas e&#44; dessas&#44; 30 foram descartadas por n&#227;o serem atribu&#237;veis &#224; infec&#231;&#227;o pelo SARS&#8208;CoV&#8208;2 &#8211; p&#46; ex&#46;&#44; acne&#44; molusco contagioso&#44; herpes&#8208;z&#243;ster&#44; eczema&#44; dermatite perioral&#44; impetigo&#44; dermatofitose &#8211;&#44; o que mostra a limita&#231;&#227;o do pr&#243;prio usu&#225;rio como avaliador das les&#245;es de pele&#46; As imagens finais foram avaliadas por quatro dermatologistas experientes&#46; A apresenta&#231;&#227;o dermatol&#243;gica mais frequente foi erup&#231;&#245;es papulosas &#40;41&#44;2&#37; incluindo eritemato&#8208;papulosas e eritemato&#8208;vesiculosas&#41;&#44; urticariformes &#40;30&#37;&#41; e acrais &#40;23&#44;1&#37;&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">At&#233; o momento&#44; essa &#233; a primeira e &#250;nica publica&#231;&#227;o de impacto que afirma a frequ&#234;ncia e a relev&#226;ncia das les&#245;es cut&#226;neas como &#250;nica manifesta&#231;&#227;o da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2&#46; Portanto&#44; s&#227;o necess&#225;rios cautela e estudos mais aprofundados sobre o tema para compreendermos sua real import&#226;ncia e impacto no diagn&#243;stico da COVID&#8208;19&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">A natureza do estudo apresenta quatro principais limita&#231;&#245;es&#58; dados baseados na autoavalia&#231;&#227;o&#44; n&#227;o representativos da popula&#231;&#227;o geral&#44; desconsiderou manifesta&#231;&#245;es dermatol&#243;gicas raras e a impossibilidade de excluir diagn&#243;stico diferenciais importantes&#44; como rea&#231;&#227;o adversa a medicamentos&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Estudos prospectivos</span><p id="par0135" class="elsevierStylePara elsevierViewall">S&#227;o poucos estudos prospectivos sobre manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19 publicados at&#233; o momento&#46; Tal metodologia ofereceria informa&#231;&#245;es mais fidedignas sobre a real preval&#234;ncia das les&#245;es cut&#226;neas e os padr&#245;es identificados&#44; especialmente por meio da busca ativa de les&#245;es cut&#226;neas pelo especialista&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Ainda assim&#44; diferentes preval&#234;ncias&#44; propor&#231;&#245;es e classifica&#231;&#245;es de manifesta&#231;&#245;es cut&#226;neas diagnosticadas por dermatologistas em pacientes com infec&#231;&#227;o confirmada por SARS&#8208;CoV&#8208;2 de maneira prospectiva foram relatadas&#46; De Giorgi et at&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">31</span></a> avaliaram 678 pacientes em hospitais na It&#225;lia e na China com frequ&#234;ncia de 7&#44;8&#37; de presen&#231;a de les&#245;es cut&#226;neas &#8211; 44&#37; identificadas ao diagn&#243;stico de COVID&#8208;19 e 56&#37; nos dias subsequentes&#44; em m&#233;dia ap&#243;s 11&#44;7 dias&#46; O achado mais frequente foi o exantema &#40;70&#37;&#41;&#44; seguido de les&#245;es urticariformes &#40;26&#37;&#41; e vesiculares &#40;4&#37;&#41;&#46; Todos os casos de exantema melhoraram espontaneamente em dois a cinco dias&#46; Rehktman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">32</span></a> avaliaram 296 pacientes em dois hospitais em Nova York&#44; com frequ&#234;ncia de 11&#44;8&#37; de les&#245;es cut&#226;neas nas seguintes propor&#231;&#245;es&#58; &#250;lceras &#40;37&#44;1&#37;&#41;&#44; p&#250;rpura &#40;25&#44;7&#37;&#41;&#44; necrose &#40;14&#44;3&#37;&#41;&#44; eritema inespec&#237;fico &#40;11&#44;4&#37;&#41;&#44; erup&#231;&#227;o morbiliforme &#40;11&#44;4&#37;&#41;&#44; EP&#8208;s&#237;mile &#40;11&#44;4&#37;&#41; e ves&#237;culas &#40;2&#44;9&#37;&#41;&#46; J&#225; M&#233;ndez&#8208;Maestro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">33</span></a> avaliaram 75 pacientes em hospital espanhol&#44; dos quais 14 &#40;18&#44;7&#37;&#41; apresentavam les&#245;es de pele possivelmente associada &#224; COVID&#8208;19&#58; EP&#8208;s&#237;mile &#40;42&#44;8&#37;&#41;&#44; erup&#231;&#227;o maculopapular &#40;28&#44;6&#37;&#41;&#44; urticariforme &#40;14&#44;3&#37;&#41;&#44; livedo reticular s&#237;mile &#40;7&#44;15&#37;&#41; e vesicular &#40;7&#44;15&#37;&#41;&#46; Por fim&#44; Nuno&#8208;Gonzales et al&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">34</span></a> avaliaram 666 pacientes&#44; tamb&#233;m em ambiente hospitalar na Espanha&#44; e relataram a alt&#237;ssima frequ&#234;ncia de 45&#44;65&#37; de les&#245;es mucocut&#226;neas&#46; No entanto&#44; o estudo incluiu altera&#231;&#245;es bastante inespec&#237;ficas tanto mucosas &#40;p&#46; ex&#46;&#44; papilite&#44; glossite&#44; estomatite&#44; despapila&#231;&#227;o&#44; mucosite&#41; como cut&#226;neas &#40;p&#46; ex&#46;&#44; descama&#231;&#227;o e m&#225;culas eritemato&#8208;acastanhada palmoplantares&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">No Brasil&#44; at&#233; o momento n&#227;o h&#225; dados sobre a preval&#234;ncia de les&#245;es cut&#226;neas&#46; Avancini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">35</span></a> relataram que dentre os 86 pacientes internados em um centro de refer&#234;ncia com infec&#231;&#227;o confirmada por SARS&#8208;CoV&#8208;2 para os quais foi solicitada avalia&#231;&#227;o da equipe de dermatologia&#44; em nenhum foi poss&#237;vel atribuir correla&#231;&#227;o direta entre as les&#245;es de pele e a COVID&#8208;19&#44; uma vez que o perfil de dermatoses encontrado se assemelhou ao per&#237;odo pr&#233;&#8208;pandemia&#46; Cinco pacientes apresentaram exantema indistingu&#237;vel de rea&#231;&#227;o medicamentosa e um apresentou les&#245;es EP&#8208;s&#237;mile&#44; por&#233;m com antecedente pessoal de l&#250;pus eritematoso sist&#234;mico&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Revis&#245;es sistem&#225;ticas</span><p id="par0150" class="elsevierStylePara elsevierViewall">A grande quantidade de publica&#231;&#245;es em um curto per&#237;odo de tempo tornou poss&#237;vel que j&#225; no final de 2020 surgissem os primeiros estudos de revis&#245;es sistem&#225;ticas sobre as manifesta&#231;&#245;es cut&#226;neas da COVID&#8208;19&#44; com o intuito de reunir e compilar os resultados at&#233; ent&#227;o&#44; produzindo dados com maior evid&#234;ncia cientifica&#46; Ainda assim&#44; as conclus&#245;es s&#227;o divergentes&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Em dois artigos de revis&#227;o sistem&#225;tica&#44; a preval&#234;ncia de les&#245;es de pele em pacientes com COVID&#8208;19 foi bastante semelhante&#58; 5&#44;69 e 5&#44;95&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">36</span></a> No entanto&#44; mesmo os estudos de metan&#225;lise ainda diferem sobre quais seriam as manifesta&#231;&#245;es cut&#226;neas mais frequentes&#46; A maioria das revis&#245;es sistem&#225;ticas encontrou maior frequ&#234;ncia das erup&#231;&#245;es maculopapulares&#58; 37&#44;1&#37;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">36</span></a> e 48&#37;&#44; seguida das les&#245;es vasculares &#40;incluindo EP&#8208;s&#237;mile&#41;&#58; 23&#37; e 33&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">37</span></a> No entanto&#44; outros afirmam que o padr&#227;o mais comum seria o de les&#245;es EP&#8208;s&#237;mile &#40;51&#44;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">38</span></a> Os quadros urticariformes&#44; vesiculares e livedo&#47;necrose s&#227;o tidos como mais raros&#46;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">36&#8211;38</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Em sua revis&#227;o sistem&#225;tica&#44; Jamshidi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">36</span></a> concentraram&#8208;se nos fatores progn&#243;sticos associados aos diferentes padr&#245;es de manifesta&#231;&#245;es cut&#226;neas&#46; As erup&#231;&#245;es maculopapulares associam&#8208;se a quadros leves de COVID&#8208;19 em 48&#37; dos casos&#44; assim como os padr&#245;es urticariforme e EP&#8208;s&#237;mile&#46; Pacientes com les&#245;es vasculares do espectro livedo&#44; p&#250;rpura e necrose apresentaram a maior mortalidade &#40;18&#44;2&#37;&#41; e aqueles com les&#245;es urticariformes&#44; a menor &#40;2&#44;2&#37;&#41;&#46; Sobre o tempo de surgimento das manifesta&#231;&#245;es cut&#226;neas&#44; em sua grande maioria &#40;92&#37;&#41; ocorrem em at&#233; quatro semanas do in&#237;cio dos sintomas gerais da COVID&#8208;19&#44; especialmente nos primeiros dias e at&#233; duas semanas nos casos dos exantemas e urtic&#225;rias&#46; J&#225; as les&#245;es EP&#8208;s&#237;mile s&#227;o mais tardias e surgem entre a segunda e quarta semanas&#44; assim como as p&#250;rpuras e a necrose&#46; Em 8 a 10&#37;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">37</span></a> dos casos as manifesta&#231;&#245;es cut&#226;neas podem preceder&#44; em m&#233;dia&#44; por tr&#234;s dias os sintomas cl&#237;nicos &#8211; s&#227;o&#44; portanto&#44; possivelmente &#250;teis como indicadores para o diagn&#243;stico precoce da COVID&#8208;19&#46; &#201; importante ressaltar que quase a totalidade dos estudos inclu&#237;dos nas revis&#245;es sistem&#225;ticas &#233; origin&#225;ria da Europa e dos EUA&#44; com raros relatos da &#193;sia e Am&#233;rica Latina &#40;pela escassez de dados publicados&#41;&#44; o que poderia gerar um vi&#233;s&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Principais manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Erup&#231;&#227;o maculopapular</span><p id="par0165" class="elsevierStylePara elsevierViewall">Na maioria dos estudos &#233; considerada a manifesta&#231;&#227;o cut&#226;nea mais frequente na COVID&#8208;19&#46; Engloba quadros de exantema &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#44; <span class="elsevierStyleItalic">rash&#44;</span> p&#225;pulas difusas&#44; pitir&#237;ase r&#243;sea s&#237;mile&#44; eritema multiforme s&#237;mile&#44; entre outros&#46; Habitualmente&#44; surge nos primeiros dias de sintomas gerais da infec&#231;&#227;o viral ou em at&#233; duas semanas&#44; embora haja relatos espor&#225;dicos de surgimento tardio &#40;ap&#243;s um m&#234;s&#41;&#46; Correlaciona&#8208;se com quadros sist&#234;micos leves e tem melhora espont&#226;nea em sete a dez dias&#44;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">26</span></a> sem necessidade de tratamento espec&#237;fico&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Embora sejam manifesta&#231;&#245;es frequentes&#44; s&#227;o altamente inespec&#237;ficas uma vez que outras infec&#231;&#245;es virais s&#227;o causas comuns de exantemas&#44; bem como as rea&#231;&#245;es adversas a medicamentos&#46; Discute&#8208;se na literatura a necessidade de excluir tais diagn&#243;sticos diferenciais antes de atribuirmos o quadro cut&#226;neo unicamente &#224; COVID&#8208;19&#44; mesmo em casos confirmados da doen&#231;a&#46; Outro fator de confus&#227;o &#233; a reativa&#231;&#227;o viral que ocorre nos casos de farmacodermia&#44; como a ativa&#231;&#227;o de HHV&#8208;6 nos quadros <span class="elsevierStyleItalic">drug reaction with eosinofilia and systemic symptoms</span> &#40;DRESS&#41;<span class="elsevierStyleItalic">&#46;</span> Uma hip&#243;tese seria que a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 levaria a uma reativa&#231;&#227;o de v&#237;rus latentes&#44; como o HHV&#8208;6&#44; e assim predisporia a um quadro de rea&#231;&#227;o adversa a medicamentos&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">25&#44;39</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Eritema p&#233;rnio &#40;EP&#41; s&#237;mile</span><p id="par0175" class="elsevierStylePara elsevierViewall">Sem d&#250;vida&#44; s&#227;o as manifesta&#231;&#245;es mais relatadas em grandes s&#233;ries de casos na literatura&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">40&#44;41</span></a> Com a chegada da pandemia de COVID&#8208;19 na Europa&#44; observou&#8208;se uma explos&#227;o de casos semelhantes ao eritema p&#233;rnio &#8220;cl&#225;ssico&#8221;&#44; por&#233;m com caracter&#237;sticas peculiares&#44; distintas da forma cl&#225;ssica&#58; predom&#237;nio em crian&#231;as e jovens&#44; em &#233;poca de temperaturas amenas &#40;primavera&#41;&#44; sem antecedente pessoal de eritema p&#233;rnio&#44; colagenoses ou outras condi&#231;&#245;es predisponentes&#46; Foi descrito&#44; ent&#227;o&#44; o EP&#8208;s&#237;mile associado &#224; COVID&#8208;19&#46; Desde ent&#227;o&#44; h&#225; in&#250;meras publica&#231;&#245;es sobre o tema&#44; inclusive mostrando a presen&#231;a do <span class="elsevierStyleItalic">spike viral</span> nas les&#245;es cut&#226;neas&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">17</span></a> mesmo em pacientes com PCR negativo &#40;<span class="elsevierStyleItalic">swab</span>&#41;&#46; O EP&#8208;s&#237;mile &#233; mais frequente em crian&#231;as e adultos jovens&#44; saud&#225;veis&#44; oligo ou assintom&#225;ticos para COVID&#8208;19&#44; e pode ser a &#250;nica manifesta&#231;&#227;o da doen&#231;a&#46; Portanto&#44; na presen&#231;a dessas les&#245;es&#44; sugere&#8208;se que a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 seja investigada&#46; Surge em m&#233;dia ap&#243;s 10 a 14 dias dos sintomas gerais&#44; duram em m&#233;dia 14 dias&#44; com melhora espont&#226;nea&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">41</span></a> A maioria dos pacientes &#40;em algumas s&#233;ries&#44; at&#233; a totalidade&#41; apresentam pesquisa viral por PCR &#40;<span class="elsevierStyleItalic">swab</span>&#41; negativa&#46; Tal fato poderia ser explicado pela baixa carga viral encontrada habitualmente nos quadros oligo ou assintom&#225;ticos de COVID&#8208;19 nas crian&#231;as e nos est&#225;gios mais tardios da doen&#231;a &#40;ap&#243;s 10 a 14 dias do in&#237;cio dos sintomas&#41;&#46; Por outro lado&#44; a aus&#234;ncia de positividade de PCR&#44; portanto&#44; da confirma&#231;&#227;o laboratorial da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2&#44; levanta a d&#250;vida se esses pacientes realmente foram infectados&#46; Estudos de imuno&#8208;histoqu&#237;mica e imunofluoresc&#234;ncia podem contribuir para elucidar a rela&#231;&#227;o entre o EP&#8208;s&#237;mile e a COVID&#8208;19&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">42</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Recentemente&#44; a rela&#231;&#227;o entre o EP&#8208;s&#237;mile e a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 tem sido bastante questionada na literatura&#46; Uma das principais controv&#233;rsias &#233; justamente a aus&#234;ncia de comprova&#231;&#227;o de infec&#231;&#227;o pelo SARS&#8208;CoV&#8208;2 nesses pacientes&#46; Foram publicadas s&#233;ries de casos de EP&#8208;s&#237;mile em que n&#227;o havia nenhuma evid&#234;ncia epidemiol&#243;gica&#44; cl&#237;nica ou laboratorial que corroborasse para o diagn&#243;stico de COVID&#8208;19&#44;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">43</span></a> ou mesmo sorol&#243;gica&#44; que poderia contribuir para a fisiopatologia do EP&#8208;s&#237;mile&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">44</span></a> Embora a presen&#231;a do <span class="elsevierStyleItalic">spike viral</span> nas les&#245;es de EP&#8208;s&#237;mile j&#225; tenha sido mostrada por t&#233;cnicas de imuno&#8208;histoqu&#237;mica&#44; e inclusive a estrutura viral completa identificada por microscopia eletr&#244;nica&#44; esses foram relatos pontuais na literatura &#8211; a grande maioria das publica&#231;&#245;es sobre EP&#8208;s&#237;mile n&#227;o conta com essa evid&#234;ncia&#46; Sobre a fisiopatologia&#44; no in&#237;cio da pandemia as les&#245;es EP&#8208;s&#237;mile&#44; livedo&#44; p&#250;rpura e necrose foram interpretadas como fases de um mesmo espectro de acometimento cut&#226;neo&#46; Atualmente&#44; acredita&#8208;se que elas tenham mecanismos fisiopatol&#243;gicos distintos&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Les&#245;es urticariformes</span><p id="par0185" class="elsevierStylePara elsevierViewall">As infec&#231;&#245;es&#44; inclusive virais&#44; s&#227;o fatores desencadeantes j&#225; conhecidos de les&#245;es urticariformes&#46; Nesse sentido&#44; a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 poderia ser um novo fator desencadeante&#46; S&#227;o relatados quadros de urtic&#225;ria associados &#224; COVID&#8208;19 em pacientes sem relatos pr&#233;vios da doen&#231;a&#46; Um estudo em uma cl&#237;nica privada relatou aumento da incid&#234;ncia dos casos de urtic&#225;ria diagnosticados durante a pandemia&#44; por&#233;m n&#227;o foi realizada investiga&#231;&#227;o quanto &#224; presen&#231;a de COVID&#8208;19 nesses pacientes&#46; Clinicamente&#44; as les&#245;es s&#227;o disseminadas&#44; indistintas das demais causas&#44; e o angioedema &#233; raro&#46; Estima&#8208;se que em 10&#37; dos pacientes o quadro cut&#226;neo possa preceder em alguns dias os sintomas gerais de COVID&#8208;19 e que&#44; portanto&#44; a detec&#231;&#227;o das les&#245;es de pele poderia favorecer o diagn&#243;stico precoce da infec&#231;&#227;o&#46; Por&#233;m&#44; em sua grande maioria&#44; as les&#245;es urticariformes surgem concomitantemente aos demais sintomas&#46; N&#227;o h&#225; predile&#231;&#227;o por faixa et&#225;ria e associa&#8208;se a quadros sist&#234;micos leves&#44; com baixa mortalidade&#46; &#201; relatada melhora espont&#226;nea em sete dias&#44; ou com uso de anti&#8208;histam&#237;nicos e&#47;ou corticoide sist&#234;mico em baixa dose&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Erup&#231;&#245;es v&#233;sico&#8208;bolhosas</span><p id="par0190" class="elsevierStylePara elsevierViewall">Embora raras&#44; as erup&#231;&#245;es vesico&#8208;bolhosas s&#227;o consideradas padr&#227;o espec&#237;fico de les&#227;o cut&#226;nea associada &#224; COVID&#8208;19&#44; uma vez que n&#227;o s&#227;o comumente observadas nos exantemas virais e por farmacodemia &#40;principais diagn&#243;sticos diferenciais&#41;&#46; S&#227;o quadros de ves&#237;culas ou bolhas localizadas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41; ou disseminadas&#44; que podem acometer regi&#227;o palmoplantar&#44; poupando mucosas&#46; T&#234;m in&#237;cio cerca de tr&#234;s dias ap&#243;s os sintomas gerais e perduram por 7 a 14 dias&#44; com melhora espont&#226;nea&#46; Associam&#8208;se a quadro sist&#234;mico leve a moderado&#46; Em uma s&#233;rie de casos&#44; tentou&#8208;se isolar o agente viral por t&#233;cnica de PCR do conte&#250;do da bolha&#44; sem sucesso&#46; &#201; fundamental excluir outras infec&#231;&#245;es virais&#44; especialmente a herp&#233;tica&#44; uma vez que j&#225; foi relatado um caso de herpes disseminado com pneumonia em paciente com COVID&#8208;19&#44; mostrando a import&#226;ncia do diagn&#243;stico diferencial&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">47</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Livedo&#44; p&#250;rpura&#44; necrose</span><p id="par0195" class="elsevierStylePara elsevierViewall">As manifesta&#231;&#245;es cut&#226;neas vasculares associadas &#224; COVID&#8208;19 compreendem um amplo espectro&#44; que varia desde livedo reticular transit&#243;rio a fixo&#44; livedo racemoso&#44; p&#250;rpuras e necrose de extremidades &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46; S&#227;o manifesta&#231;&#245;es raras associadas a quadros sist&#234;micos graves&#44; que ocorrem de maneira tardia em pacientes idosos&#44; internados em ambiente de terapia intensiva&#44; com m&#250;ltiplas comorbidades e altera&#231;&#245;es laboratoriais &#40;exemplo&#58; coagulopatias&#44; eleva&#231;&#227;o de D&#8208;d&#237;mero&#41;&#46; Frequentemente&#44; associam&#8208;se a outros eventos tromb&#243;ticos como trombose venosa profunda&#44; acidente vascular encef&#225;lico &#40;AVE&#41; isqu&#234;mico e coagula&#231;&#227;o intravascular disseminada&#44; que s&#227;o respons&#225;veis pela elevada mortalidade nesae grupo&#46; Assim&#44; os achados cut&#226;neos em pacientes com doen&#231;a potencialmente fatal s&#227;o bastante espec&#237;ficos e distintos do perfil ambulatorial&#46; Isso acontece pois provavelmente os mesmos mecanismos microangiop&#225;ticos e tromb&#243;ticos ocorrem simultaneamente nos principais &#243;rg&#227;os&#8208;alvo&#44; como pulm&#227;o e rim e na pele&#46; Desse modo&#44; o tratamento das les&#245;es cut&#226;neas consiste no tratamento da pr&#243;pria doen&#231;a de base&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">16&#44;22&#44;26</span></a> Um resumo das principais caracter&#237;sticas das manifesta&#231;&#245;es dermatol&#243;gicas acima descritas encontra&#8208;se na <a class="elsevierStyleCrossRef" href="#tbl0020">tabela 4</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Outras manifesta&#231;&#245;es</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Acometimento de mucosas</span><p id="par0200" class="elsevierStylePara elsevierViewall">Les&#245;es orais durante o curso da COVID&#8208;19 tamb&#233;m foram descritas e reunidas em artigos de revis&#227;o&#46; Sabe&#8208;se que o SARS&#8208;CoV&#8208;2 pode ser detectado na saliva por t&#233;cnica de PCR &#8211; inclusive&#44; atualmente&#44; para fins diagn&#243;sticos&#46; Al&#233;m disso&#44; o ACE2 &#40;receptor funcional viral no organismo&#41; est&#225; presente na mucosa oral&#44; com maior densidade no dorso da l&#237;ngua e gl&#226;ndulas salivares menores&#44; o que justificaria a presen&#231;a de les&#245;es mucosas&#46; Disgeusia foi o primeiro sintoma oral reconhecido na COVID&#8208;19&#44; com frequ&#234;ncia amplamente vari&#225;vel de 5 a 88&#37;&#46; Posteriormente&#44; foram tamb&#233;m descritas in&#250;meras les&#245;es orais&#44; das quais as mais frequentes foram&#58; enantema&#44; pet&#233;quias&#44; les&#245;es aftoides ou &#250;lceras&#44; herpetiformes&#44; candid&#237;ase e les&#245;es orais associadas a doen&#231;a de Kawasaki&#46; Geralmente s&#227;o sintom&#225;ticas &#40;dor&#44; queima&#231;&#227;o ou prurido&#41; e surgem quatro dias antes ou at&#233; 12 semanas ap&#243;s os sintomas gerais&#46; O tratamento depende do padr&#227;o de les&#227;o encontrado&#46; Higiene oral inadequada&#44; imunossupress&#227;o&#44; reativa&#231;&#227;o de v&#237;rus latentes &#40;p&#46; ex&#46;&#44; herpes&#8208;v&#237;rus&#41;&#44; infec&#231;&#245;es oportunistas&#44; estresse&#44; trauma secund&#225;rio a intuba&#231;&#227;o&#44; resposta hiperinflamat&#243;ria da COVID&#8208;19 s&#227;o fatores predisponentes&#46; S&#227;o necess&#225;rios mais estudos para definir quais manifesta&#231;&#245;es orais est&#227;o diretamente ligadas &#224; infec&#231;&#227;o pelo SARS&#8208;CoV&#8208;2 e quais s&#227;o indiretas&#44; devido &#224; presen&#231;a de outras afec&#231;&#245;es mucosas que&#44; nestes casos&#44; ocorrem no contexto da COVID&#8208;19&#46; Nesse sentido&#44; &#233; fundamental a investiga&#231;&#227;o para excluir tais condi&#231;&#245;es&#46; Sugere&#8208;se que manifesta&#231;&#245;es induzidas pelas altera&#231;&#245;es vasculares e microtrombos&#44; como pet&#233;quias e &#250;lceras&#44; e o enantema &#40;em semelhan&#231;a ao exantema viral&#41; possam estar associadas diretamente &#224; fisiopatologia do SARS&#8208;CoV&#8208;2&#46;<a class="elsevierStyleCrossRefs" href="#bib0620"><span class="elsevierStyleSup">34&#8211;48</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Efl&#250;vio tel&#243;geno e COVID&#8208;19</span><p id="par0205" class="elsevierStylePara elsevierViewall">Amplamente e h&#225; muito tempo conhecido na Dermatologia&#44; o efl&#250;vio tel&#243;geno &#40;ET&#41; pode ser desencadeado por altera&#231;&#245;es metab&#243;licas&#44; nutricionais&#44; medicamentosas e in&#250;meras condi&#231;&#245;es sist&#234;micas&#44; entre elas as infec&#231;&#245;es&#46; Na COVID&#8208;19&#44; cogita&#8208;se que as citocinas inflamat&#243;rias liberadas e o uso de medica&#231;&#245;es&#44; como a heparina&#44; possam estar envolvidas no mecanismo do ET&#46; H&#225; relato de aumento da incid&#234;ncia do ET em quase tr&#234;s vezes durante a pandemia&#46; Estima&#8208;se que 10&#37; dos pacientes com COVID&#8208;19 evoluam com ET nas semanas e meses subsequentes &#224; infec&#231;&#227;o&#44; especialmente nos pacientes com comorbidades&#44; mas podem ocorrer inclusive nos quadros subcl&#237;nicos&#46; At&#233; o momento&#44; as informa&#231;&#245;es sobre o in&#237;cio&#44; evolu&#231;&#227;o e progn&#243;stico do ET associado a COVID&#8208;19 s&#227;o indistintas do ET por outras causas j&#225; conhecidas&#46; N&#227;o h&#225; nenhuma peculiaridade ou caracter&#237;stica espec&#237;fica no ET induzido pela infec&#231;&#227;o por SARS&#8208;CoV&#8208;2&#46; Portanto&#44; a abordagem&#44; o tratamento e o seguimento desses pacientes devem ser os mesmas adotados para o ET na pr&#225;tica dermatol&#243;gica&#46;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">49&#44;50</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Relatos dos casos</span><p id="par0210" class="elsevierStylePara elsevierViewall">Al&#233;m das manifesta&#231;&#245;es mais descritas e agrupadas em &#8220;padr&#245;es&#8221; nas grandes s&#233;ries de casos&#44; estudos prospectivos e de revis&#227;o sistem&#225;tica&#44; existem in&#250;meros relatos de casos isolados na literatura sobre diversos quadros cut&#226;neos possivelmente associados &#224; COVID&#8208;19&#46; Em fun&#231;&#227;o da limita&#231;&#227;o metodol&#243;gica inerente &#224;s publica&#231;&#245;es do tipo relato de casos&#44; n&#227;o se pode afirmar o real papel da infec&#231;&#227;o pelo SARS&#8208;CoV&#8208;2 nessas entidades &#8211; ou seja&#44; se s&#227;o de fato atribu&#237;veis &#224; COVID&#8208;19 ou n&#227;o&#46; As condi&#231;&#245;es isoladamente associadas &#224; COVID&#8208;19 publicadas em relatos de casos encontram&#8208;se reunidas na <a class="elsevierStyleCrossRef" href="#tbl0025">tabela 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Os primeiros relatos foram de casos de urtic&#225;ria&#44; inclusive precedendo os sintomas cl&#237;nicos&#44;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">51</span></a> urtic&#225;ria vasculite<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">52</span></a> e angioedema&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">53</span></a> Casos de pitir&#237;ase r&#243;sea ou les&#245;es pitir&#237;ase r&#243;sea s&#237;mile<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">54</span></a>&#44; sendo que um relato mostrou a presen&#231;a do SARS&#8208;CoV&#8208;2 por t&#233;cnicas imuno&#8208;histoqu&#237;micas&#44;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">55</span></a> e outro apontou para o poss&#237;vel papel da reativa&#231;&#227;o do HHV&#8208;6 e outros v&#237;rus nesses quadros&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">56</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">H&#225; tamb&#233;m relatos de vasculites de pequenos vasos associadas &#224; COVID&#8208;19&#44;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">57</span></a> vasculite leucocitocl&#225;stica&#44;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">58</span></a> vasculite por IgA&#44;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">59</span></a> granulomatose com poliange&#237;te &#40;antes chamada de doen&#231;a de Wegener&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">60</span></a> granulomatose eosinof&#237;lica com poliange&#237;te &#40;antes chamada de s&#237;ndrome de Churg&#8208;Strauss&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">61</span></a> p&#250;rpura de Schamberg<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">62</span></a> e p&#250;rpura fulminans&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">63</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Sobre os quadros que se assemelham a farmacodermias&#44; foram descritos pacientes com COVID&#8208;19 e eritema multiforme&#44;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">64</span></a> s&#233;rie de casos de pustulose exantem&#225;tica generalizada aguda &#40;PEGA&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">65</span></a> relatos de necr&#243;lise epid&#233;rmica t&#243;xica &#40;NET&#41;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">66</span></a> e SDRIFE &#40;<span class="elsevierStyleItalic">symmetrical drug&#8208;related intertriginous and flexural exanthema</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">67</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">H&#225; tamb&#233;m relatos de caso em topografias espec&#237;ficas &#8211; acometimento ungueal&#44; com descri&#231;&#227;o do &#8220;<span class="elsevierStyleItalic">red half&#8208;moon sign</span>&#8221;&#59;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">68</span></a> acometimento palmoplantar com eritrodisestesia&#59;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">69</span></a> erup&#231;&#227;o folicular&#44;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">70</span></a> exantema unilateral&#44;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">71</span></a> livedo reticular unilateral<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">72</span></a> e &#250;lceras de press&#227;o em localiza&#231;&#245;es n&#227;o usuais &#40;como esterno&#44; joelhos&#41; por prona&#231;&#227;o prolongada&#46;<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">73</span></a> Foram publicadas descri&#231;&#245;es dermatosc&#243;picas de erup&#231;&#227;o papular purp&#250;rica<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">74</span></a> e les&#245;es EP&#8208;s&#237;mile&#46;<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">75</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">H&#225; ainda relatos de herpes&#8208;z&#243;ster<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">76</span></a> e relatos isolados de quadros semelhantes a doen&#231;a de Grover&#44;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">77</span></a> s&#237;ndrome de Melkersson&#8208;Rosenthal&#44;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">78</span></a> eritema nodoso&#44;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">79</span></a> les&#227;o sarco&#237;dea&#44;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">80</span></a> s&#237;ndrome de Gianotti&#8208;Crosti&#44;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">81</span></a> dermatite seborreica&#44;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">82</span></a> l&#237;quen plano anular&#44;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">83</span></a> eritema anular centr&#237;fugo&#44;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">84</span></a> granuloma anular<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">85</span></a> e alopecia areata rapidamente progressiva&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">86</span></a></p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Histopatologia das manifesta&#231;&#245;es cut&#226;neas da COVID&#8208;19</span><p id="par0240" class="elsevierStylePara elsevierViewall">Alguns estudos trazem as primeiras descri&#231;&#245;es sobre as altera&#231;&#245;es histopatol&#243;gicas e imuno&#8208;histoqu&#237;micas das les&#245;es de pele associadas &#224; COVID&#8208;19&#44; com o intuito de colaborar para a compreens&#227;o dos mecanismos fisiopatol&#243;gicos das manifesta&#231;&#245;es&#46; A seguir&#44; ser&#227;o brevemente citadas as principais altera&#231;&#245;es histol&#243;gicas dos padr&#245;es cut&#226;neos mais descritos&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">87</span></a></p><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Erup&#231;&#245;es m&#225;culo&#8208;papulares</span><p id="par0245" class="elsevierStylePara elsevierViewall">Dermatite perivascular superficial com discreta linfocitose&#44; vasos trombosados com debris neutrof&#237;licos e eosinof&#237;licos&#59; dermatite de interface&#44; infiltrado linfoc&#237;tico perivascular superficial e profundo&#44; com ou sem vasculite &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Eritema p&#233;rnio &#40;EP&#41; s&#237;mile</span><p id="par0250" class="elsevierStylePara elsevierViewall">Na epiderme&#44; presen&#231;a de paraqueratose e hiperqueratose&#44; com queratin&#243;citos apopt&#243;ticos e&#44; eventualmente&#44; necrose epid&#233;rmica&#46; Infiltrado linfoc&#237;tico denso na derme superficial e profunda&#44; tamb&#233;m na hipoderme&#44; com padr&#227;o perivascular e sinais de ativa&#231;&#227;o endotelial&#46; Por vezes&#44; infiltrado linfoc&#237;tico &#233;crino semelhante ao observado na hidradenite &#233;crina linfoc&#237;tica&#46; Outros achados frequentes s&#227;o&#58; eritrodiapedese&#44; edema na derme papilar com forma&#231;&#227;o de bolha subepid&#233;rmica e aumento do dep&#243;sito de mucina intersticial&#46; Raramente h&#225; presen&#231;a de microtrombos vasculares nos capilares da derme superficial e v&#234;nulas d&#233;rmicas&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Erup&#231;&#245;es urticariformes</span><p id="par0255" class="elsevierStylePara elsevierViewall">Infiltrado linfoc&#237;tico perivascular com alguns eosin&#243;filos e edema na derme superficial&#44; eventualmente com dermatite de interface vacuolar e necrose de queratin&#243;citos&#44; com padr&#227;o semelhante ao do eritema multiforme&#46; Na urtic&#225;ria vasculite h&#225; extravasamento de hem&#225;cias com infiltrado neutrof&#237;lico perivascular&#44; macr&#243;fagos&#44; necrose e dep&#243;sito de fibrina&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Erup&#231;&#245;es vesiculares</span><p id="par0260" class="elsevierStylePara elsevierViewall">Acantose&#44; ves&#237;culas por degenera&#231;&#227;o vacuolar da camada basal com c&#233;lulas disquerat&#243;ticas&#44; multinucleadas &#40;sugestivas de inclus&#227;o viral&#41; sem infiltrado inflamat&#243;rio&#46; Nesses casos&#44; &#233; fundamental o diagn&#243;stico diferencial com as dermatoviroses herp&#233;ticas&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Livedo&#44; p&#250;rpura</span><p id="par0265" class="elsevierStylePara elsevierViewall">Vasculopatia tromb&#243;tica com extensa deposi&#231;&#227;o de C5b&#8208;9 e C4d &#40;t&#233;cnica imuno&#8208;histoqu&#237;mica&#41; na microvasculatura&#46;</p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Andr&#243;genos e COVID&#8208;19</span><p id="par0270" class="elsevierStylePara elsevierViewall">Durante toda a pandemia observou&#8208;se que a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 afetava mais homens do que mulheres&#46; Os homens t&#234;m duas vezes mais chance de serem admitidos em unidades de terapia intensiva &#40;UTI&#41;&#46; A associa&#231;&#227;o entre a via dos andr&#243;genos e a infectividade do SARS&#8208;CoV&#8208;2 j&#225; foi descrita&#46; Portanto&#44; tal predisposi&#231;&#227;o &#224; infec&#231;&#227;o mediada pelos andr&#243;genos poderia justificar as altas taxas de interna&#231;&#227;o e mortalidade concentradas nos homens&#46; Assim&#44; a express&#227;o androg&#234;nica em forma de alopecia &#40;alop&#233;cia androgen&#233;tica &#8211; AGA&#41; poderia&#44; por si s&#243;&#44; ser um fator de risco para a COVID&#8208;19&#44; e j&#225; foi relatada alta frequ&#234;ncia de AGA entre homens internados&#46; Al&#233;m disso&#44; o uso de anti&#8208;andr&#243;genos poderia ser um fator protetor e&#47;ou terap&#234;utico na evolu&#231;&#227;o desses pacientes&#46; Nesse sentido&#44; estudo publicado mostrou que homens com AGA ou hiperplasia prost&#225;tica benigna em uso sist&#234;mico de inibidor de 5&#8208;alfa&#8208;redutase que contra&#237;ram COVID&#8208;19 apresentaram redu&#231;&#227;o importante dos sintomas no contexto ambulatorial&#46; Em estudo caso&#8208;controle em ambiente hospitalar&#44; homens em uso de inibidor de 5&#8208;alfa&#8208;redutase tiveram menor chance de serem admitidos em UTI&#44; sugerindo tal efeito protetor&#46; No entanto&#44; ainda &#233; incerto se a introdu&#231;&#227;o de antiandr&#243;genos ap&#243;s a infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 teria algum benef&#237;cio&#46; Aparentemente&#44; os dermatologistas deveriam encorajar seus pacientes com AGA a manterem o uso de antiandr&#243;genos durante a pandemia&#46; Esse &#233;&#44; sem d&#250;vida&#44; um campo de pesquisa bastante promissor&#46;<a class="elsevierStyleCrossRefs" href="#bib0890"><span class="elsevierStyleSup">88&#8211;90</span></a></p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Considera&#231;&#245;es finais</span><p id="par0275" class="elsevierStylePara elsevierViewall">Embora o n&#250;mero de publica&#231;&#245;es em um curto intervalo de tempo seja expressivo e crescente&#44; ainda h&#225; muitas perguntas desafiadoras sobre as manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19&#46; A verdadeira frequ&#234;ncia dos achados cut&#226;neos &#233; amplamente vari&#225;vel &#40;0&#44;2 a 45&#37;&#41; na literatura&#59; os estudos de revis&#227;o sistem&#225;tica apontam para frequ&#234;ncia pr&#243;xima a 6&#37;&#46; As manifesta&#231;&#245;es dermatol&#243;gicas mais encontradas foram as erup&#231;&#245;es maculopapulares&#44; seguidas das les&#245;es EP&#8208;s&#237;mile&#46; No entanto&#44; h&#225; publica&#231;&#245;es que trazem as les&#245;es EP&#8208;s&#237;mile como as manifesta&#231;&#245;es mais prevalentes&#46; Os quadros de erup&#231;&#245;es urticariforme&#44; vesicular e livedo&#44; al&#233;m de p&#250;rpura e necrose s&#227;o menos descritos&#46; Quanto ao tempo de surgimento&#44; as les&#245;es cut&#226;neas s&#227;o habitualmente concomitantes aos sintomas gerais e raramente podem preced&#234;&#8208;los&#44; como nos casos de urtic&#225;ria e les&#245;es vesiculares&#46; O EP&#8208;s&#237;mile pode surgir tardiamente ou&#44; inclusive&#44; ser a &#250;nica manifesta&#231;&#227;o cl&#237;nica de COVID&#8208;19&#46; Os quadros vasculares como livedo&#44; p&#250;rpura e necrose s&#227;o igualmente tardios&#44; por&#233;m associados a maior gravidade e pior progn&#243;stico&#46; Estudos histopatol&#243;gicos e de imuno&#8208;histoqu&#237;mica dos diferentes padr&#245;es de les&#245;es cut&#226;neas em pacientes com COVID&#8208;19 s&#227;o fundamentais para melhor compreens&#227;o do seu significado fisiopatol&#243;gico em rela&#231;&#227;o &#224; doen&#231;a &#40;causadas diretamente pela infec&#231;&#227;o viral decorrentes de complica&#231;&#245;es da doen&#231;a sist&#234;mica&#41;&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Vale ressaltar a import&#226;ncia da exclus&#227;o dos poss&#237;veis diagn&#243;sticos diferenciais diante de um paciente com COVID&#8208;19 que apresente les&#245;es de pele&#44; antes que se atribua o quadro cut&#226;neo exclusivamente &#224; infec&#231;&#227;o viral&#46; Quadros de urtic&#225;ria espont&#226;nea&#44; demais infec&#231;&#245;es virais&#44; farmacodermias&#44; entre outros&#44; devem ser considerados na investiga&#231;&#227;o desses pacientes&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">A contribui&#231;&#227;o da dermatologia &#224; pandemia de COVID&#8208;19 parece ir al&#233;m das manifesta&#231;&#245;es cut&#226;neas&#46; A estreita rela&#231;&#227;o entre andr&#243;genos e o curso da infec&#231;&#227;o por SARS&#8208;CoV&#8208;2 abre um promissor campo de pesquisa sobre seus fatores progn&#243;sticos e protetores&#44; especialmente no tocante ao uso sist&#234;mico dos antiandr&#243;genos&#44; amplamente prescritos na dermatologia&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">A pandemia tem proporcionado uma excelente oportunidade para os dermatologistas aprenderem e contribu&#237;rem&#46; Infelizmente&#44; ela ainda n&#227;o acabou&#46; Como a ci&#234;ncia &#233; um processo din&#226;mico&#44; h&#225; a esperan&#231;a de que mais estudos sejam desenvolvidos para que respostas possam ser encontradas e as incertezas resolvidas&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Suporte financeiro</span><p id="par0295" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Contribui&#231;&#227;o dos autores</span><p id="par0300" class="elsevierStylePara elsevierViewall">Camila Arai Seque&#58; Concep&#231;&#227;o e desenho do estudo&#59; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o final da vers&#227;o do manuscrito&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">Milvia Maria Sim&#245;es e Silva Enokihara&#58; Concep&#231;&#227;o e desenho do estudo&#59; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o final da vers&#227;o do manuscrito&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">Adriana Maria Porro&#58; Concep&#231;&#227;o e desenho do estudo&#59; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o final da vers&#227;o do manuscrito&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Jane Tomimori&#58; Concep&#231;&#227;o e desenho do estudo&#59; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; an&#225;lise estat&#237;stica&#59; reda&#231;&#227;o do artigo e revis&#227;o cr&#237;tica do conte&#250;do&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; aprova&#231;&#227;o final da vers&#227;o do manuscrito&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflito de interesses</span><p id="par0320" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:17 [
        0 => array:3 [
          "identificador" => "xres1658798"
          "titulo" => "Resumo"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1474341"
          "titulo" => "Palavras&#8208;chave"
        ]
        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introdu&#231;&#227;o"
        ]
        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Frequ&#234;ncia das manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19"
        ]
        4 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Fisiopatologia"
        ]
        5 => array:3 [
          "identificador" => "sec0020"
          "titulo" => "Grandes s&#233;ries nacionais e internacionais"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Espanha"
            ]
            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Fran&#231;a"
            ]
            2 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "EUA&#47;internacional &#40;31 pa&#237;ses&#41;"
            ]
            3 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "It&#225;lia"
            ]
            4 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Reino Unido"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Estudos prospectivos"
        ]
        7 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Revis&#245;es sistem&#225;ticas"
        ]
        8 => array:3 [
          "identificador" => "sec0060"
          "titulo" => "Principais manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Erup&#231;&#227;o maculopapular"
            ]
            1 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Eritema p&#233;rnio &#40;EP&#41; s&#237;mile"
            ]
            2 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Les&#245;es urticariformes"
            ]
            3 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Erup&#231;&#245;es v&#233;sico&#8208;bolhosas"
            ]
            4 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Livedo&#44; p&#250;rpura&#44; necrose"
            ]
          ]
        ]
        9 => array:3 [
          "identificador" => "sec0090"
          "titulo" => "Outras manifesta&#231;&#245;es"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Acometimento de mucosas"
            ]
            1 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Efl&#250;vio tel&#243;geno e COVID&#8208;19"
            ]
            2 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Relatos dos casos"
            ]
          ]
        ]
        10 => array:3 [
          "identificador" => "sec0110"
          "titulo" => "Histopatologia das manifesta&#231;&#245;es cut&#226;neas da COVID&#8208;19"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0115"
              "titulo" => "Erup&#231;&#245;es m&#225;culo&#8208;papulares"
            ]
            1 => array:2 [
              "identificador" => "sec0120"
              "titulo" => "Eritema p&#233;rnio &#40;EP&#41; s&#237;mile"
            ]
            2 => array:2 [
              "identificador" => "sec0125"
              "titulo" => "Erup&#231;&#245;es urticariformes"
            ]
            3 => array:2 [
              "identificador" => "sec0130"
              "titulo" => "Erup&#231;&#245;es vesiculares"
            ]
            4 => array:2 [
              "identificador" => "sec0135"
              "titulo" => "Livedo&#44; p&#250;rpura"
            ]
          ]
        ]
        11 => array:2 [
          "identificador" => "sec0140"
          "titulo" => "Andr&#243;genos e COVID&#8208;19"
        ]
        12 => array:2 [
          "identificador" => "sec0145"
          "titulo" => "Considera&#231;&#245;es finais"
        ]
        13 => array:2 [
          "identificador" => "sec0150"
          "titulo" => "Suporte financeiro"
        ]
        14 => array:2 [
          "identificador" => "sec0155"
          "titulo" => "Contribui&#231;&#227;o dos autores"
        ]
        15 => array:2 [
          "identificador" => "sec0160"
          "titulo" => "Conflito de interesses"
        ]
        16 => array:1 [
          "titulo" => "Refer&#234;ncias"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-08-05"
    "fechaAceptado" => "2021-08-22"
    "PalabrasClave" => array:1 [
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras&#8208;chave"
          "identificador" => "xpalclavsec1474341"
          "palabras" => array:3 [
            0 => "COVID&#8208;19"
            1 => "Dermatologia"
            2 => "Pele"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neste artigo s&#227;o abordados os principais aspectos das manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19&#44; baseados em revis&#227;o da literatura publicada at&#233; a presente data&#46; Desde o in&#237;cio da pandemia&#44; j&#225; s&#227;o mais de 1&#46;500 artigos sobre o tema&#46; Com rela&#231;&#227;o &#224; fisiopatologia&#44; acredita&#8208;se que os mesmos mecanismos respons&#225;veis pela doen&#231;a nos principais &#243;rg&#227;os&#8208;alvo atuem tamb&#233;m na pele&#44; embora ainda n&#227;o estejam totalmente elucidados&#46; A real frequ&#234;ncia das manifesta&#231;&#245;es dermatol&#243;gicas ainda &#233; incerta&#8208;pode variar de 0&#44;2 a 45&#37;&#59; nas revis&#245;es sistem&#225;ticas&#44; o valor &#233; pr&#243;ximo a 6&#37;&#46; Estudos pioneiros com grandes s&#233;ries de casos conduzidos em pa&#237;ses europeus e os EUA trazem as primeiras informa&#231;&#245;es sobre quais seriam as principais manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19 e prop&#245;em classifica&#231;&#245;es quanto &#224; apresenta&#231;&#227;o cl&#237;nica e fisiopatologia&#44; bem como a frequ&#234;ncia das manifesta&#231;&#245;es&#46; Embora n&#227;o haja consenso&#44; as erup&#231;&#245;es maculopapulares s&#227;o tidas como os quadros mais frequentes&#44; seguidos das les&#245;es do tipo eritema p&#233;rnio &#40;EP&#41; s&#237;mile&#46; Manifesta&#231;&#245;es como urtic&#225;ria&#44; quadros vesiculares e livedo&#47;p&#250;rpura&#47;necrose s&#227;o raras&#46; O tempo de surgimento&#44; a gravidade&#44; a necessidade de tratamento espec&#237;fico e o progn&#243;stico s&#227;o vari&#225;veis conforme o padr&#227;o de apresenta&#231;&#227;o clinica&#46; A crescente descri&#231;&#227;o histopatol&#243;gica dos quadros cut&#226;neos pode contribuir para o diagn&#243;stico&#44; bem como para a compreens&#227;o da fisiopatologia&#46; Ainda no campo dermatol&#243;gico&#44; a rela&#231;&#227;o entre COVID&#8208;19 e andr&#243;genos tem sido cada vez mais estudada&#46; Apesar de todo conhecimento gerado&#44; o significado biol&#243;gico real das manifesta&#231;&#245;es cut&#226;neas ainda &#233; incerto&#46; Assim&#44; a exclus&#227;o dos principais diagn&#243;sticos diferenciais &#233; fundamental para a correla&#231;&#227;o entre manifesta&#231;&#227;o cut&#226;nea e COVID&#8208;19&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Como citar este artigo&#58; Seque CA&#44; Enokihara MMSS&#44; Porro AM&#44; Tomimori J&#46; Skin manifestations associated with COVID&#8208;19&#46; An Bras Dermatol&#46; 2022&#59;97&#58;75&#8211;88&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Trabalho realizado no Departamento de Dermatologia da Universidade Federal de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#44; Brasil&#46;</p>"
      ]
    ]
    "multimedia" => array:9 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 948
            "Ancho" => 750
            "Tamanyo" => 67900
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Exantema em paciente com COVID&#8208;19&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 700
            "Ancho" => 1250
            "Tamanyo" => 67904
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Les&#245;es vesico&#8208;bolhosas em paciente com COVID&#8208;19&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 976
            "Ancho" => 2090
            "Tamanyo" => 121896
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Livedo racemoso&#44; p&#250;rpura e necrose de extremidades em paciente com COVID&#8208;19&#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" => 568
            "Ancho" => 1650
            "Tamanyo" => 145471
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Achados histopatol&#243;gicos de exantema em paciente com COVID&#8208;19&#46; &#40;A&#41;&#44; Presen&#231;a de vasculite leucocitocl&#225;stica dos vasos capilares da derme superficial e eritrodiapedese &#40;Hematoxilina &#38; eosina&#44; 100&#215;&#41;&#46; &#40;B&#41;&#44; Em detalhe vasos capilares contendo neutr&#243;filos &#237;ntegros e degenerados destruindo parcialmente a parede&#44; hem&#225;cias extravasadas e a presen&#231;a de material amorfo eosinof&#237;lico no l&#250;men vascular sugestivo de trombo de fibrina &#40;Hematoxilina &#38; eosina&#44; 400&#215;&#41;&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabela 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pontos&#8208;chave&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">O primeiro relato na literatura de manifesta&#231;&#227;o cut&#226;nea associada &#224; COVID&#8208;19 ocorreu em 23&#47;03&#47;20&#46; Desde ent&#227;o&#44; h&#225; mais de 1&#46;500 publica&#231;&#245;es sobre o tema&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">A frequ&#234;ncia das manifesta&#231;&#245;es cut&#226;neas varia entre 0&#44;2&#37; a 45&#37;&#44; sendo pr&#243;xima a 6&#37; no estudos de revis&#227;o sistem&#225;tica&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">As manifesta&#231;&#245;es mais descritas s&#227;o as erup&#231;&#245;es m&#225;culo&#8208;papulares&#44; seguidas das les&#245;es eritema p&#233;rnio &#40;EP&#41; s&#237;mile&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">Quadros urticariformes&#44; vesiculares e do espectro livedo&#8208;p&#250;rpura&#8208;necrose s&#227;o menos frequentes&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">As les&#245;es de pele habitualmente s&#227;o concomitantes aos sintomas gerais&#46; No entanto&#44; urtic&#225;rias e ves&#237;culas podem preced&#234;&#8208;los&#44; enquanto EP&#8208;s&#237;mile e livedo&#8208;p&#250;rpura&#8208;necrose surgem tardiamente&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">Os principais diagn&#243;sticos diferenciais s&#227;o rea&#231;&#245;es medicamentosas e outras infec&#231;&#245;es virais&#44; que devem ser exclu&#237;dos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824204.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">C&#225;psula com os principais pontos&#8208;chave</p>"
        ]
      ]
      5 => 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:3 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nd&#44; dado n&#227;o dispon&#237;vel&#46;</p>"
          "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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Autor&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">Pa&#237;s&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">Frequ&#234;ncia&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&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">Forma de avalia&#231;&#227;o&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">Guan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">3</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">China&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;2&#37;&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">1099&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&#227;o presencial &#40;banco de dados&#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">Recalcati et al&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">4</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">It&#225;lia&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">20&#44;4&#37;&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">88&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">Presencial por dermatologista&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">Matar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">5</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">Fran&#231;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">1&#37;&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">756&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">Autoexame por entrevista telef&#244;nica&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">Rerknimitr et al&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">6</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">Tail&#226;ndia&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&#37;&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">183&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">Autoexame por entrevista telef&#244;nica&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">Solak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">7</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">Turquia&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">18&#44;3&#37;&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">382&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">Autoexame por entrevista telef&#244;nica&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">Gaspari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">8</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">It&#225;lia&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&#44;4&#37;&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">Nd&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">Presencial por dermatologista&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">Tammaro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">9</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">It&#225;lia&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&#44;5&#37;&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">130&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">Presencial por dermatologista&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">Tamai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">10</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">Jap&#227;o&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&#44;3&#37;&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">69&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">Presencial por dermatologista&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">De Giorgi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">31</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">It&#225;lia&#47;China&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&#44;8&#37;&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">678&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">Presencial &#40;n&#227;o especifica avaliador&#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">Rehktman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">32</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">EUA&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">11&#44;8&#37;&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">296&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">Presencial por estudantes de medicina&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">M&#233;ndez&#8208;Maestro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">30</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">Espanha&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">18&#44;7&#37;&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">75&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">Presencial por dermatologista&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">Nuno&#8208;Gonzales et al&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">34</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">Espanha&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&#44;65&#37;&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">666&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">Presencial por dermatologista&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">Jamshindi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">36</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"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</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">5&#44;95&#37;&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">1847&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"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824202.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Estudo de metan&#225;lise&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Frequ&#234;ncia das manifesta&#231;&#245;es dermatol&#243;gicas na COVID&#8208;19</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabela 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">EP&#8208;s&#237;mile&#44; eritema p&#233;rnio s&#237;mile&#46;</p>"
          "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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Autor&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">Pa&#237;s&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&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">Casos confirmados&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">Erup&#231;&#227;o maculopapular&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">Urticari&#8208;forme&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">EP&#8208;s&#237;mile&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">Vesiculo&#8208;bolhosa&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">Livedo&#8208;p&#250;pura&#8208;necrose&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">Galvan&#8208;Casas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">26</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">Espanha&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">375&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">234 &#40;62&#44;4&#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">47&#37;&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">19&#37;&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">19&#37;&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">9&#37;&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&#37;&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">Masson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">27</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">Fran&#231;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">277&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">25 &#40;9&#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">9&#37;&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">9&#37;&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">75&#37;&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&#37;&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&#37;&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">Freeman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">28</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">EUA &#43;31 pa&#237;ses&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">716&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">171 &#40;23&#44;8&#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">45&#37;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</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">16&#37;&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">18&#37;&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">11&#37;&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&#44;4&#37;&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">Manzano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">29</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">It&#225;lia&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">200&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">120 &#40;62&#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">25&#44;7&#37;&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">10&#44;2&#37;&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">24&#44;6&#37;&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&#44;5&#37;&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">9&#37;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&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">Visconti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">30</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">Reino Unido&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">11544&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">694 &#40;6&#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">41&#44;2&#37;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</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">30&#37;&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">23&#44;1&#37;&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"><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824203.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Incluem erup&#231;&#227;o morbiliforme&#44; eritema m&#225;culo&#8208;papular e p&#225;pulo&#8208;escamoso&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Incluem p&#250;rpura&#47;vasculite&#44; livedo reticular&#47;racemoso&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Incluem erup&#231;&#227;o eritemato&#8208;papulosa e eritemato&#8208;vesiculosa&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Grandes s&#233;ries nacionais e internacionais sobre as manifesta&#231;&#245;es cut&#226;neas</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Tabela 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "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">Quadro dermatol&#243;gico&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">Frequ&#234;ncia&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">Faixa et&#225;ria&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">Quadro sist&#234;mico&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">Surgimento das les&#245;es<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&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">Erup&#231;&#227;o maculopapular&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">Exantema&#44; <span class="elsevierStyleItalic">rash</span>&#44; p&#225;pulo&#8208;escamoso&#44; pitir&#237;ase r&#243;sea s&#237;mile&#44; eritema multiforme s&#237;mile&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">9&#37;&#8211;47&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Adultos&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">Leve&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&#8211;14 dias&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">Pseudo eritema p&#233;rnio&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">M&#225;culas viol&#225;ceas nas extremidades em temperaturas amenas&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">18&#37;&#8211;75&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Crian&#231;as e jovens&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">Leve ou assintom&#225;tico&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">Ap&#243;s 10&#8211;14 dias&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">Urtic&#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">Indistinto das demais formas de urtic&#225;ria&#44; angioedema &#233; raro&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">9&#37;&#8211;30&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Adultos&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">Leve&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">Pr&#233; ou 0&#8211;14 dias&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">V&#233;sico&#8208;bolhosas&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">Varicela s&#237;mile&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">9&#37;&#8211;15&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Adultos&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">Leve a moderado&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">Pr&#233; ou 0&#8211;7 dias&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">Livedo&#44; p&#250;rpura&#44; necrose&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">Livedo reticular fixo&#44; racemoso&#59; p&#250;rpura&#44; vasculite&#59; necrose de extremidades&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&#37;&#8211;9&#37;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">26&#8208;30</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">Idosos&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">Grave&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">Ap&#243;s 10&#8211;14 dias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824205.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Em rela&#231;&#227;o ao in&#237;cio dos sintomas gerais da COVID&#8208;19&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Principais caracter&#237;sticas das manifesta&#231;&#245;es cut&#226;neas associadas &#224; COVID&#8208;19</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Tabela 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SDRIFE&#44; s<span class="elsevierStyleItalic">ymmetrical drug&#8208;related intertriginous and flexural exanthema</span>&#59; NET&#44; necr&#243;lise epid&#233;rmica t&#243;xica&#59; PEGA&#44; pustulose exantem&#225;tica generalizada aguda&#46;</p>"
          "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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Urticariformes&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">Vasculites e p&#250;rpuras&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">Farmacodermias s&#237;mile&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">Topografias espec&#237;ficas&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&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">Urtic&#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">Vasculite leucocitocl&#225;stica&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">Eritema multiforme&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">Ungueal &#40;<span class="elsevierStyleItalic">red half&#8208;moon sign&#41;</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">Pitir&#237;ase r&#243;sea s&#237;mile&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">Urtic&#225;ria vasculite&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">Vasculite por IgA&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">SDRIFE&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">Eritrodisestesia palmoplantar&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">Doen&#231;a de Grover&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">Angioedema&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">Granulomatose eosinof&#237;lica com poliange&#237;te&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">NET&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">Erup&#231;&#227;o folicular&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">S&#237;ndrome de Melkersson&#8208;Rosenthal&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">Granulomatose com poliange&#237;te&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">PEGA&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">Exantema unilateral&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">S&#237;ndrome de Gianotti&#8208;Crosti&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">P&#250;rpura de Schamberg&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><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">Livedo Unilateral&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">Eritema anular centr&#237;fugo&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">P&#250;rpura fulminans&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><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">Eritema nodoso&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="" 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="" 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="" 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">Liquen plano anular&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="" 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="" 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="" 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">Les&#227;o sarco&#237;dea&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="" 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="" 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="" 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">Granuloma anular&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="" 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="" 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="" 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">Alop&#233;cia areata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2824201.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Condi&#231;&#245;es dermatol&#243;gicas associadas &#224; COVID&#8208;19 &#8211; Relatos de casos</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Refer&#234;ncias"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:90 [
            0 => array:3 [
              "identificador" => "bib0455"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermatology and COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2020.15276"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA&#46;"
                        "fecha" => "2020"
                        "volumen" => "324"
                        "paginaInicial" => "1133"
                        "paginaFinal" => "1134"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0460"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19 can present with a rash and be mistaken for dengue"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "82"
                        "paginaInicial" => "177"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0465"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical Characteristics of Coronavirus Disease 2019 in China"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa2002032"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med&#46;"
                        "fecha" => "2020"
                        "volumen" => "382"
                        "paginaInicial" => "1708"
                        "paginaFinal" => "1720"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0470"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations in COVID&#8208;19&#58; a first perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "212"
                        "paginaFinal" => "213"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0475"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations in SARS&#8208;CoV&#8208;2 infection &#40;COVID&#8208;19&#41;&#58; a French experience and a systematic review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "686"
                        "paginaFinal" => "689"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0480"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skin manifestations in COVID&#8208;19&#58; The tropics experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "47"
                        "paginaInicial" => "444"
                        "paginaFinal" => "446"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0485"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous symptoms of patients diagnosed with COVID&#8208;19 in one province&#58; a cross&#8208;sectional survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.16678"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "105"
                        "paginaFinal" => "106"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19 skin eruptions&#58; incidence in hospitalized patients in Bologna"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15509"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "512"
                        "paginaFinal" => "513"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations in COVID&#8208;19&#58; the experiences of Barcelona and Rome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "306"
                        "paginaFinal" => "307"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Three cases of COVID&#8208;19 patients presenting with erythema"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/1346-8138.15532"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "47"
                        "paginaInicial" => "1175"
                        "paginaFinal" => "1178"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lack of skin manifestations in COVID&#8208;19 hospitalized patients during the second epidemic wave in Spain&#58; a possible association with a novel SARS&#8208;CoV&#8208;2 variant a cross sectional study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "183"
                        "paginaFinal" => "185"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Potential interactions of SARS&#8208;CoV&#8208;2 with human cell receptors in the skin&#58; Understanding the enigma for a lower frequency of skin lesions compared to other tissues"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/exd.14186"
                      "Revista" => array:6 [
                        "tituloSerie" => "Exp Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "29"
                        "paginaInicial" => "936"
                        "paginaFinal" => "944"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0515"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations of SARS&#8208;CoV&#8208;2 a two&#8208;center&#44; prospective&#44; case&#8208;controlled study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2021.03.064"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "85"
                        "paginaInicial" => "202"
                        "paginaFinal" => "204"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Angiotensin&#8208;converting enzyme 2 &#40;ACE2&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/path.5471"
                      "Revista" => array:6 [
                        "tituloSerie" => "SARS&#8208;CoV&#8208;2 and the pathophysiology of coronavirus disease 2019 &#40;COVID&#8208;19&#41;&#46; J Pathol&#46;"
                        "fecha" => "2020"
                        "volumen" => "251"
                        "paginaInicial" => "228"
                        "paginaFinal" => "248"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0525"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SARS&#8208;CoV&#8208;2 PCR testing of skin for COVID&#8208;19 diagnostics&#58; a case report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(20)31760-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet&#46;"
                        "fecha" => "2020"
                        "volumen" => "396"
                        "paginaInicial" => "598"
                        "paginaFinal" => "599"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0530"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID&#8208;19 infection&#58; A report of five cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.trsl.2020.04.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Transl Res&#46;"
                        "fecha" => "2020"
                        "volumen" => "220"
                        "paginaInicial" => "1"
                        "paginaFinal" => "13"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0535"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SARS&#8208;CoV&#8208;2 endothelial infection causes COVID&#8208;19 chilblains&#58; histopathological&#44; immunohistochemical and ultrastructural study of seven paediatric cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19327"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "729"
                        "paginaFinal" => "737"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0540"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Are the cutaneous manifestations during or due to SARS&#8208;CoV&#8208;2 infection&#47;COVID&#8208;19 frequent or not&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00011-020-01370-w"
                      "Revista" => array:6 [
                        "tituloSerie" => "Revision of possible pathophysiologic mechanisms&#46; Inflamm Res&#46;"
                        "fecha" => "2020"
                        "volumen" => "69"
                        "paginaInicial" => "745"
                        "paginaFinal" => "756"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0545"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations in COVID&#8208;19&#58; Lessons learned from current evidence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "57"
                        "paginaFinal" => "60"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0550"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lessons from dermatology about inflammatory responses in Covid&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Rev Med Virol&#46;"
                        "fecha" => "2020"
                        "volumen" => "30"
                        "paginaInicial" => "2130"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0555"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pernio during the COVID&#8208;19 pandemic and review of inflammation patterns and mechanisms of hypercoagulability"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.06.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "898"
                        "paginaFinal" => "899"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0560"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The differing pathophysiologies that underlie COVID&#8208;19&#8208;associated perniosis and thrombotic retiform purpura&#58; a case series"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19415"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "141"
                        "paginaFinal" => "150"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0565"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19 chilblain&#8208;like lesion&#58; immunohistochemical demonstration of SARS&#8208;CoV&#8208;2 spike protein in blood vessel endothelium and sweat gland epithelium in a polymerase chain reaction&#8208;negative patient"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19338"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "778"
                        "paginaFinal" => "780"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0570"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Absence of SARS&#8208;CoV&#8208;2 RNA detection in tissue samples of COVID&#8208;19&#8208;related cutaneous lesions analyzed by real&#8208;time RT&#8208;PCR"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.16914"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "318"
                        "paginaFinal" => "321"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0575"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19&#8208;associated cutaneous manifestations&#58; does human herpesvirus 6 play an aetiological role&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19806"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "1187"
                        "paginaFinal" => "1190"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0580"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification of the cutaneous manifestations of COVID&#8208;19&#58; a rapid prospective nationwide consensus study in Spain with 375 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19163"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "71"
                        "paginaFinal" => "77"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0585"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chilblains is a common cutaneous finding during the COVID&#8208;19 pandemic&#58; A retrospective nationwide study from France"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.04.161"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "667"
                        "paginaFinal" => "670"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0590"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The spectrum of COVID&#8208;19&#8208;associated dermatologic manifestations&#58; An international registry of 716 patients from 31 countries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.06.1016"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "1118"
                        "paginaFinal" => "1129"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0595"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The clinical spectrum of COVID&#8208;19&#8208;associated cutaneous manifestations&#58; An Italian multicenter study of 200 adult patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2021.01.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "84"
                        "paginaInicial" => "1356"
                        "paginaFinal" => "1363"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0600"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnostic value of cutaneous manifestation of SARS&#8208;CoV&#8208;2 infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "880"
                        "paginaFinal" => "887"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0605"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations related to coronavirus disease 2019 &#40;COVID&#8208;19&#41;&#58; A prospective study from China and Italy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.05.073"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "674"
                        "paginaFinal" => "675"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0610"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eruptions and related clinical course among 296 hospitalized adults with confirmed COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "84"
                        "paginaInicial" => "946"
                        "paginaFinal" => "952"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0615"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skin manifestations in patients hospitalized with confirmed COVID&#8208;19 disease&#58; a cross&#8208;sectional study in a tertiary hospital"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15180"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1353"
                        "paginaFinal" => "1357"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0620"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of mucocutaneous manifestations in 666 patients with COVID&#8208;19 in a field hospital in Spain&#58; oral and palmoplantar findings"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19564"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "184"
                        "paginaFinal" => "185"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0625"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Absence of specific cutaneous manifestations of severe acute respiratory syndrome coronavirus 2 in a reference center in Brazil"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "84"
                        "paginaInicial" => "67"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0630"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skin Manifestations in COVID&#8208;19 Patients&#58; Are They Indicators for Disease Severity&#63;&#46; A Systematic Review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3389/fmed.2021.723019"
                      "Revista" => array:4 [
                        "tituloSerie" => "Front Med &#40;Lausanne&#41;&#46;"
                        "fecha" => "2021"
                        "volumen" => "8"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0635"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Time of Onset of Selected Skin Lesions Associated with COVID&#8208;19&#58; A Systematic Review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s13555-021-00526-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Ther &#40;Heidelb&#41;&#46;"
                        "fecha" => "2021"
                        "volumen" => "11"
                        "paginaInicial" => "695"
                        "paginaFinal" => "705"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0640"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermatologic manifestations of COVID&#8208;19&#58; a comprehensive systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15168"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "418"
                        "paginaFinal" => "450"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0645"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Exanthema and eosinophilia in COVID&#8208;19 patients&#58; has viral infection a role in drug induced exanthemas&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "561"
                        "paginaFinal" => "563"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0650"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Characterization of acute acral skin lesions in nonhospitalized patients&#58; A case series of 132 patients during the COVID&#8208;19 outbreak"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "61"
                        "paginaFinal" => "63"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0655"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pernio&#8208;like skin lesions associated with COVID&#8208;19&#58; A case series of 318 patients from 8 countries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.05.109"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "486"
                        "paginaFinal" => "492"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0660"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chilblain&#8208;like acral lesions during the COVID&#8208;19 pandemic &#40;&#8220;COVID toes&#8221;&#41;&#58; Histologic&#44; immunofluorescence&#44; and immunohistochemical study of 17 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.05.145"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "870"
                        "paginaFinal" => "875"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0665"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Most chilblains observed during the COVID&#8208;19 outbreak occur in patients who are negative for COVID&#8208;19 on polymerase chain reaction and serology testing"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19377"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "866"
                        "paginaFinal" => "874"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0670"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Do we have serological evidence that chilblain&#8208;like lesions are related to SARS&#8208;CoV&#8208;2&#63;&#46; A review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0675"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chilblains and COVID&#8208;19&#58; why SARS&#8208;CoV&#8208;2 endothelial infection is questioned"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19489"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "183"
                        "paginaInicial" => "1152"
                        "paginaFinal" => "1153"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0680"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticaria and COVID&#8208;19&#58; A review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [ …1]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0685"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Varicella&#8208;like exanthema as a specific COVID&#8208;19&#8208;associated skin manifestation&#58; Multicenter case series of 22 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.04.044"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "280"
                        "paginaFinal" => "285"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0690"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral manifestations of COVID&#8208;19 disease&#58; A review article"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2021"
                        "volumen" => "34"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0695"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SARS&#8208;CoV&#8208;2&#8208;induced telogen effluvium&#58; a multicentric study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "181"
                        "paginaFinal" => "183"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0700"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Race&#44; ethnicity and comorbidities are critical factors in the diagnosis of telogen effluvium during the COVID&#8208;19 pandemic"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2021.03.099"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "85"
                        "paginaInicial" => "209"
                        "paginaFinal" => "211"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0705"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.04.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "498"
                        "paginaFinal" => "499"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0710"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticarial vasculitis in COVID&#8208;19 infection&#58; a vasculopathy&#8208;related symptom&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "566"
                        "paginaFinal" => "568"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0715"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Angioedema and urticaria in a COVID&#8208;19 patient&#58; A case report and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.07.042"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "1091"
                        "paginaFinal" => "1094"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0720"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pityriasis rosea in otherwise asymptomatic confirmed COVID&#8208;19&#8208;positive patients&#58; A report of 2 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.10.035"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2021"
                        "volumen" => "7"
                        "paginaInicial" => "93"
                        "paginaFinal" => "94"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0725"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SARS&#8208;CoV&#8208;2 spike protein positivity in pityriasis rosea&#8208;like and urticaria&#8208;like rashes of COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                           …1
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.19833"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "184"
                        "paginaInicial" => "1194"
                        "paginaFinal" => "1195"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0730"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The clinics of HHV&#8208;6 infection in COVID&#8208;19 pandemic&#58; Pityriasis rosea and Kawasaki disease"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0735"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Widespread cutaneous small vessel vasculitis secondary to COVID&#8208;19 infection"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15106"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1278"
                        "paginaFinal" => "1279"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0740"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Leucocytoclastic vasculitis in a patient with COVID&#8208;19 with positive SARS&#8208;CoV&#8208;2 PCR in skin biopsy"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "BMJ Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "13"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0745"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Possible association between IgA vasculitis and COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2021"
                        "volumen" => "34"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0750"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New Onset Granulomatosis with Polyangiitis Associated with COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Case Rep Dermatol Med&#46;"
                        "fecha" => "2021"
                        "volumen" => "2021"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0755"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic granulomatosis with polyangiitis mimicking coronavirus disease 2019&#58; a case report"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "557"
                        "paginaFinal" => "559"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0760"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Schamberg&#8208;like purpuric eruptions and tonsillitis in mild COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0765"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Purpura fulminans as the presenting manifestation of COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/postgradmedj-2020-139202"
                      "Revista" => array:5 [
                        "tituloSerie" => "Postgrad Med J&#46;"
                        "fecha" => "2021"
                        "volumen" => "97"
                        "paginaInicial" => "473"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0770"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Atypical erythema multiforme palmar plaques lesions due to Sars&#8208;Cov&#8208;2"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "373"
                        "paginaFinal" => "375"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0775"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute Generalized Exanthematous Pustulosis &#40;AGEP&#41; in 12 Patients Treated for SARS&#8208;CoV&#8208;2 Positive Pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/DAD.0000000000001819"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol&#46;"
                        "fecha" => "2021"
                        "volumen" => "43"
                        "paginaInicial" => "342"
                        "paginaFinal" => "348"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0780"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development of toxic epidermal necrolysis in a coronavirus disease 2019 patient with recurrence of positive SARS&#8208;CoV&#8208;2 viral RNA"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "48"
                        "paginaInicial" => "144"
                        "paginaFinal" => "145"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0785"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SDRIFE&#8208;like rash associated with COVID&#8208;19&#44; clinicopathological correlation"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ajd.13444"
                      "Revista" => array:6 [
                        "tituloSerie" => "Australas J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "62"
                        "paginaInicial" => "88"
                        "paginaFinal" => "89"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0790"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The red half&#8208;moon nail sign&#58; a novel manifestation of coronavirus infection"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "663"
                        "paginaFinal" => "665"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0795"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Palmoplantar erythrodysesthesia&#58; a diagnostic sign of COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.16965"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "247"
                        "paginaFinal" => "249"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0800"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Follicular eruption as a cutaneous manifestation in COVID&#8208;19"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "BMJ Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "13"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0805"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Unilateral laterothoracic exanthem in association with coronavirus disease 2019"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.07.020"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "900"
                        "paginaFinal" => "901"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0810"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Unilateral livedo reticularis in a COVID&#8208;19 patient&#58; Case with fatal outcome"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.10.033"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2021"
                        "volumen" => "7"
                        "paginaInicial" => "120"
                        "paginaFinal" => "121"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0815"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pression&#8208;induced facial ulcers by prone position for COVID&#8208;19 mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2020"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0820"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Papular&#8208;purpuric exanthem in a COVID&#8208;19 patient&#58; clinical and dermoscopic description"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "34"
                        "paginaInicial" => "570"
                        "paginaFinal" => "572"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0825"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dermoscopy of chilblain&#8208;like lesions during the COVID&#8208;19 outbreak&#58; A multicenter study on 10 patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.07.058"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "1749"
                        "paginaFinal" => "1751"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0830"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Herpes zoster ophthalmicus in COVID&#8208;19 patients"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15240"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1545"
                        "paginaFinal" => "1546"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0835"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Grover&#8208;like skin eruption&#58; another cutaneous manifestation in a COVID&#8208;19 patient"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15104"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1290"
                        "paginaFinal" => "1292"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0840"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Tas&#807;l&#305;dere N&#46; Melkersson&#8208;Rosenthal Syndrome Induced by COVID&#8208;19&#46; Am J Emerg Med"
                        "fecha" => "2021"
                        "volumen" => "41"
                        "paginaInicial" => "262"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0845"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Erythema nodosum&#8208;like rash in a COVID&#8208;19 patient&#58; A case report"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajem.2020.07.063"
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Emerg Med&#46;"
                        "fecha" => "2021"
                        "volumen" => "40"
                        "paginaInicial" => "227"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0850"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sarcoid&#8208;like reaction in a patient recovering from coronavirus disease 19 pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jdcr.2020.07.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD Case Rep&#46;"
                        "fecha" => "2020"
                        "volumen" => "6"
                        "paginaInicial" => "915"
                        "paginaFinal" => "917"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0855"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An Isolated Peculiar Gianotti&#8208;Crosti Rash in the Course of a COVID&#8208;19 Episode"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2340/00015555-3614"
                      "Revista" => array:4 [
                        "tituloSerie" => "Acta Derm Venereol&#46;"
                        "fecha" => "2020"
                        "volumen" => "100"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib0860"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Seborrheic dermatitis in COVID&#8208;19&#58; a case report"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15256"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "59"
                        "paginaInicial" => "1543"
                        "paginaFinal" => "1544"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib0865"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Annular lichen planus associated with coronavirus SARS&#8208;CoV&#8208;2 disease &#40;COVID&#8208;19&#41;"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15338"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "246"
                        "paginaFinal" => "247"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib0870"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Erythema annulare centrifugum with anosmia and ageusia in a SARS&#8208;CoV&#8208;2 exposed patient successfully treated with doxycycline"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15356"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "384"
                        "paginaFinal" => "386"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib0875"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Granuloma annulare triggered by SARS&#8208;CoV&#8208;2 infection&#58; Immunohistochemical staining"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Dermatol Ther&#46;"
                        "fecha" => "2021"
                        "volumen" => "34"
                        "paginaInicial" => "14897"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib0880"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "COVID&#8208;19&#58; association with rapidly progressive forms of alopecia areata"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ijd.15317"
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2021"
                        "volumen" => "60"
                        "paginaInicial" => "127"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            86 => array:3 [
              "identificador" => "bib0885"
              "etiqueta" => "87"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical and Histopathological Features and Potential Pathological Mechanisms of Skin Lesions in COVID&#8208;19&#58; Review of the Literature"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3390/dermatopathology7010002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatopathology &#40;Basel&#41;&#46;"
                        "fecha" => "2020"
                        "volumen" => "7"
                        "paginaInicial" => "3"
                        "paginaFinal" => "16"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            87 => array:3 [
              "identificador" => "bib0890"
              "etiqueta" => "88"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severe acute respiratory syndrome coronavirus 2 &#40;SARS&#8208;CoV&#8208;2&#41; infection is likely to be androgen mediated"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2020.04.032"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2020"
                        "volumen" => "83"
                        "paginaInicial" => "308"
                        "paginaFinal" => "309"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            88 => array:3 [
              "identificador" => "bib0895"
              "etiqueta" => "89"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anti&#8208;androgens may protect against severe COVID&#8208;19 outcomes&#58; results from a prospective cohort study of 77 hospitalized men"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.17067"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "13"
                        "paginaFinal" => "15"
                        "link" => array:1 [ …1]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            89 => array:3 [
              "identificador" => "bib0900"
              "etiqueta" => "90"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "5&#8208;alpha&#8208;reductase inhibitors are associated with reduced frequency of COVID&#8208;19 symptoms in males with androgenetic alopecia"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2021"
                        "volumen" => "35"
                        "paginaInicial" => "243"
                        "paginaFinal" => "246"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "pt"
  "url" => "/26662752/0000009700000001/v1_202202030913/S2666275221002800/v1_202202030913/pt/main.assets"
  "Apartado" => array:4 [
    "identificador" => "81730"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Revis&#227;o"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/26662752/0000009700000001/v1_202202030913/S2666275221002800/v1_202202030913/pt/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275221002800?idApp=UINPBA00008Z"
]
Informação do artigo
ISSN: 26662752
Idioma original: Português
Dados atualizados diariamente
Ano/Mês Html Pdf Total
2024 Novembro 29 4 33
2024 Outubro 721 121 842
2024 Setembro 802 163 965
2024 Agosto 781 150 931
2024 Julho 735 141 876
2024 Junho 556 100 656
2024 Maio 591 90 681
2024 Abril 634 138 772
2024 Março 807 166 973
2024 Fevereiro 979 130 1109
2024 Janeiro 818 124 942
2023 Dezembro 832 121 953
2023 Novembro 979 151 1130
2023 Outubro 923 147 1070
2023 Setembro 779 152 931
2023 Agosto 720 66 786
2023 Julho 687 90 777
2023 Junho 726 116 842
2023 Maio 863 86 949
2023 Abril 676 115 791
2023 Março 734 155 889
2023 Fevereiro 552 104 656
2023 Janeiro 563 157 720
2022 Dezembro 844 108 952
2022 Novembro 599 136 735
2022 Outubro 474 126 600
2022 Setembro 477 131 608
2022 Agosto 642 149 791
2022 Julho 779 190 969
2022 Junho 645 172 817
2022 Maio 541 139 680
2022 Abril 536 190 726
2022 Março 415 194 609
2022 Fevereiro 444 217 661
2022 Janeiro 336 214 550
2021 Dezembro 138 63 201
Mostrar tudo

Siga este link para acessar o texto completo do artigo

Idiomas
Anais Brasileiros de Dermatologia (Portuguese)
en pt
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.