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dos pacientes sem CA&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> O campo de canceriza&#231;&#227;o cut&#226;neo &#40;CCC&#41; &#233; caracterizado por m&#250;ltiplas CA e&#47;ou CEC <span class="elsevierStyleItalic">in situ</span>&#44; ocorrendo em &#225;rea cronicamente exposta &#224; radia&#231;&#227;o ultravioleta&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">O tratamento das CA e do CCC visa melhorar a qualidade de vida dos pacientes&#44; erradicar les&#245;es&#44; prevenir a emerg&#234;ncia de malignidades cut&#226;neas e evitar recidivas&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> As op&#231;&#245;es terap&#234;uticas podem ser direcionadas para o tratamento de les&#245;es individuais &#40;terapias destrutivas&#41; ou do CCC&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;7</span></a> Uma vez que as atipias que predisp&#245;em o surgimento de neoplasias malignas ocorrem mesmo em &#225;reas sem les&#245;es clinicamente vis&#237;veis&#44; &#233; recomend&#225;vel tratar todo o CCC e&#44; nesse contexto&#44; os tratamentos t&#243;picos s&#227;o as op&#231;&#245;es mais utilizadas&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">5&#8208;FU &#233; an&#225;logo de pirimidina com a&#231;&#227;o antitumoral descrita primariamente em 1957&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> e h&#225; mais de 50 anos &#233; usado para tratamento de les&#245;es cut&#226;neas pr&#233;&#8208;malignas e malignas&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Sua a&#231;&#227;o decorre principalmente da inibi&#231;&#227;o da timidilato sintase e&#44; como interfere no processo de replica&#231;&#227;o celular&#44; c&#233;lulas com alto &#237;ndice mit&#243;tico s&#227;o mais suscet&#237;veis ao seu efeito citot&#243;xico&#44; enquanto c&#233;lulas normais aparentam ser bem menos sens&#237;veis a esses efeitos&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> As rea&#231;&#245;es adversas locais s&#227;o um empecilho &#224; ader&#234;ncia completa ao tratamento&#44; que costuma durar de 14 a 28 dias&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A colchicina &#40;COL&#41; &#233; um dos f&#225;rmacos mais antigos ainda em uso na atualidade&#46; &#201; alcaloide natural extra&#237;do do cormo da planta <span class="elsevierStyleItalic">Colchicum autumnale</span> e outras esp&#233;cies do g&#234;nero <span class="elsevierStyleItalic">Colchicum</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> O uso para tratamento de CA foi descrito em 1968 por Marshall e se fundamenta na a&#231;&#227;o antimit&#243;tica do f&#225;rmaco&#44; uma vez que compromete a composi&#231;&#227;o dos microt&#250;bulos e a divis&#227;o celular&#46; Em 2000&#44; o primeiro ensaio cl&#237;nico que avaliou a efic&#225;cia da COL para tratamento das CA evidenciou <span class="elsevierStyleItalic">clearance</span> total de 70&#37; nas CA do couro cabeludo de pacientes tratados com COL ap&#243;s 60 dias&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A busca por novas op&#231;&#245;es de tratamento&#44; que ofere&#231;am maior toler&#226;ncia&#44; ader&#234;ncia&#44; efic&#225;cia e&#47;ou seguran&#231;a que as existentes&#44; &#233; desej&#225;vel&#46; Apesar de d&#233;cadas terem se passado desde os primeiros relatos de seu uso para tratamento de CA&#44; h&#225; poucos ensaios cl&#237;nicos publicados que permitam estabelecer a efic&#225;cia e a seguran&#231;a da COL para tratamento de CA e CCC&#46; Al&#233;m disso&#44; n&#227;o h&#225; estudo comparando COL a 5&#8208;FU no tratamento para CCC&#46; Este estudo&#44; ent&#227;o&#44; tem por objetivo avaliar a efic&#225;cia do creme de COL 0&#44;5&#37; <span class="elsevierStyleItalic">versus</span> creme de 5&#8208;FU 5&#37; no tratamento do CCC em pacientes imunocompetentes com m&#250;ltiplas CA nos antebra&#231;os&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ensaio cl&#237;nico randomizado&#44; aberto&#44; autocontrolado&#44; comparando creme de COL 0&#44;5&#37; <span class="elsevierStyleItalic">versus</span> creme de 5&#8208;FU 5&#37;&#44; realizado no Ambulat&#243;rio de Dermatologia do Instituto Lauro de Souza Lima &#40;ILSL&#41; em Bauru&#47;SP&#46; O estudo foi aprovado pelo comit&#234; de &#233;tica institucional &#40;n&#176; 3&#46;751&#46;592&#41;&#44; registrado no Registro Brasileiro de Ensaios Cl&#237;nicos &#40;<a href="https://ensaiosclinicos.gov.br/rg/RBR-487ctp">https&#58;&#47;&#47;ensaiosclinicos&#46;gov&#46;br&#47;rg&#47;RBR&#8208;487ctp</a>&#41; e financiado pelo Fundo de Apoio &#224; Dermatologia &#40;FUNADERM&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ap&#243;s concord&#226;ncia e assinatura do termo de consentimento&#44; foram inclu&#237;dos 45 pacientes imunocompetentes&#44; de ambos os sexos&#44; com mais de 18 anos e com diagn&#243;stico cl&#237;nico de tr&#234;s a dez CA em cada antebra&#231;o&#44; que n&#227;o tivessem realizado quaisquer tratamentos para CA ou CCC nos &#250;ltimos seis meses&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Os crit&#233;rios de exclus&#227;o definidos foram&#58; dermatoses extensas afetando um dos antebra&#231;os&#44; hipersensibilidade ou alergia sabida a alguma das subst&#226;ncias estudadas&#44; imunossupress&#227;o por medicamentos e&#47;ou doen&#231;as&#44; gesta&#231;&#227;o&#44; amamenta&#231;&#227;o e uso de retinoides&#44; anti&#8208;inflamat&#243;rios ou qualquer outro tratamento t&#243;pico na regi&#227;o avaliada&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os participantes foram randomizados para definir em qual antebra&#231;o receberiam 5&#8208;FU ou COL&#44; em aloca&#231;&#227;o de 1&#58;1&#44; gerada por simula&#231;&#227;o computacional &#40;randomiza&#231;&#227;o em bloco&#41;&#46; A randomiza&#231;&#227;o foi executada por pesquisador n&#227;o envolvido na avalia&#231;&#227;o dos pacientes&#44; com aloca&#231;&#227;o sequencial&#44; e a inclus&#227;o e avalia&#231;&#227;o dos pacientes foi realizada por outro pesquisador&#46; Cada indiv&#237;duo foi submetido aos dois tratamentos&#44; um em cada antebra&#231;o&#46; 5&#8208;FU foi aplicado 2&#215;&#47;dia por 21 dias&#44; e COL 2&#215;&#47;dia por sete dias&#46; Os pacientes tamb&#233;m receberam filtro solar para uso regular em ambos os antebra&#231;os durante todo o per&#237;odo do estudo&#46; A aplica&#231;&#227;o das medica&#231;&#245;es e do filtro solar foi realizada pelos pr&#243;prios pacientes&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Na inclus&#227;o&#44; cada participante recebeu um pacote correspondente ao seu grupo de randomiza&#231;&#227;o&#44; contendo&#58; 1&#41; tr&#234;s tubos de 15<span class="elsevierStyleHsp" style=""></span>g de creme de 5&#8208;FU 5&#37; &#40;Efurix&#174;&#44; Valeant&#41;&#59; 2&#41; um frasco resistente &#224; luz <span class="elsevierStyleItalic">airless</span> de 20<span class="elsevierStyleHsp" style=""></span>g &#40;libera&#231;&#227;o de 1<span class="elsevierStyleHsp" style=""></span>g por <span class="elsevierStyleItalic">pump</span>&#41; de creme de COL 0&#44;5&#37; &#40;produto manipulado&#44; Pharm&#225;cia Spec&#237;fica Ltda&#46;&#41;&#59; 3&#41; dois tubos de 200<span class="elsevierStyleHsp" style=""></span>mL de filtro solar &#40;Protetor Solar Corporal Neutrogena&#174; Sun Fresh FPS30&#41;&#59; 4&#41; folha com orienta&#231;&#245;es de uso&#44; telefone para contato e com ilustra&#231;&#227;o demonstrando &#225;rea e lado em que cada medica&#231;&#227;o deveria ser utilizada&#44; al&#233;m do modo de uso de acordo com grupo de randomiza&#231;&#227;o&#46; Todas as embalagens das medica&#231;&#245;es foram etiquetadas em &#8220;direito&#8221; ou &#8220;esquerdo&#8221; &#40;com ilustra&#231;&#227;o do antebra&#231;o correspondente&#41; e com a forma de uso de cada f&#225;rmaco&#44; obedecendo &#224; randomiza&#231;&#227;o dos antebra&#231;os&#44; para diminuir o risco de confus&#227;o entre os tratamentos&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Para cada paciente&#44; o estudo teve 90 dias de dura&#231;&#227;o&#44; com tr&#234;s avalia&#231;&#245;es&#58; 1&#41; D0 &#8208; inclus&#227;o&#44; contagem de CA em cada antebra&#231;o&#44; escala de fotoenvelhecimento de antebra&#231;os &#40;EFA&#41; e escala de gravidade das CA &#40;EGCA&#41;&#59; 2&#41; D14 &#8208; avalia&#231;&#227;o de tolerabilidade e efeitos adversos&#59; 3&#41; D90 &#8208; contagem de CA&#44; EFA e EGCA &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Para a avalia&#231;&#227;o e tratamento&#44; foi definida a face dorsal de cada antebra&#231;o&#44; como a &#225;rea delimitada por linha imagin&#225;ria que liga os processos estiloides da ulna e do r&#225;dio&#44; a borda medial do antebra&#231;o&#44; borda lateral do antebra&#231;o e uma linha que une o epic&#244;ndilo lateral &#224; fossa antecubital &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Ap&#243;s marca&#231;&#227;o das CA com caneta&#44; foi realizada contagem e confirma&#231;&#227;o da contagem para cada antebra&#231;o&#44; pelo mesmo avaliador &#40;A&#46;S&#46;T&#46;&#41; em ambas as avalia&#231;&#245;es&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A EFA &#233; uma escala validada&#44; que mensura o grau de envelhecimento dos antebra&#231;os por meio do n&#250;mero de CA superficiais e hipertr&#243;ficas&#44; quantidade e gravidade de rugas&#44; lentigos solares&#44; p&#250;rpuras vis&#237;veis&#44; cicatrizes atr&#243;ficas estelares&#44; elastose e perda de elasticidade&#46; Cada crit&#233;rio tem um peso e&#44; ao final da avalia&#231;&#227;o&#44; os valores s&#227;o somados resultando em n&#250;mero que varia de 0 a 192&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">A EGCA permite avaliar resposta a modalidades terap&#234;uticas para CCC de maneira qualitativa&#44; e &#233; complementar &#224; contagem de CA&#46; Di&#226;metro em mil&#237;metros&#44; grau de hiperceratose e exulcera&#231;&#227;o de cada CA s&#227;o par&#226;metros considerados&#44; e o valor final da EGCA &#233; dado pela somat&#243;ria da pontua&#231;&#227;o de todas as CA na &#225;rea avaliada&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">O desfecho prim&#225;rio avaliado foi a taxa de <span class="elsevierStyleItalic">clearance</span> completo de CA em cada antebra&#231;o&#46; Os desfechos secund&#225;rios foram <span class="elsevierStyleItalic">clearance</span> parcial &#40;redu&#231;&#227;o &#8805; 50&#37; da contagem de CA&#41;&#44; redu&#231;&#227;o na contagem de CA&#44; melhora da EFA&#44; redu&#231;&#227;o da EGCA e avalia&#231;&#227;o dos efeitos adversos&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A compara&#231;&#227;o dos efeitos adversos provocados por terapias t&#243;picas com posologias distintas em um mesmo paciente pode ser complexa&#44; uma vez que o &#225;pice das rea&#231;&#245;es locais ocorre em momentos diferentes&#46; O creme de COL teve seu uso avaliado&#44; na maioria dos estudos&#44; no esquema de 2&#215;&#47;dia por 10 dias&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16&#8211;18</span></a> Ensaios cl&#237;nicos pr&#233;vios com COL t&#243;pica realizados pelo nosso grupo de pesquisa revelaram que os &#250;ltimos dias de tratamento levaram a rea&#231;&#245;es locais mais acentuadas&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16&#44;17</span></a> No presente estudo&#44; adotamos curso mais curto&#44; de sete dias&#44; de modo a avaliar se a redu&#231;&#227;o do per&#237;odo de tratamento demonstraria a mesma efic&#225;cia&#44; mas com menos efeitos adversos&#46; De outro modo&#44; a posologia usual do creme de 5&#8208;FU 5&#37; para o tratamento de CA &#233; de 2&#215;&#47;dia por duas a quatro semanas&#44; e os efeitos adversos s&#227;o mais intensos quanto mais prolongado o esquema terap&#234;utico&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Diante do exposto&#44; foi estabelecido curso de tratamento de sete dias para COL&#44; de 21 dias para 5&#8208;FU e a avalia&#231;&#227;o de efeitos adversos foi realizada ap&#243;s 14 dias do in&#237;cio dos tratamentos&#44; momento considerado oportuno para n&#227;o supervalorizar a ocorr&#234;ncia de rea&#231;&#245;es locais por nenhuma das terapias&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A amostra foi dimensionada a fim de detectar 30&#37; ou mais de diferen&#231;a na taxa de <span class="elsevierStyleItalic">clearance</span> completo de CA &#40;D90&#41; entre os grupos &#40;p&#46; ex&#46;&#44; 16&#37; <span class="elsevierStyleItalic">vs&#46;</span> 46&#37;&#41;&#46; Adotou&#8208;se o poder de 0&#44;85&#59; alfa de 0&#44;05 e estimativa de <span class="elsevierStyleItalic">dropout</span> de at&#233; 20&#37;&#44; resultando 45 pacientes &#40;90 antebra&#231;os&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Todos os pacientes inclu&#237;dos no estudo e randomizados fizeram parte da popula&#231;&#227;o ITT &#40;<span class="elsevierStyleItalic">intention to treat</span>&#41;&#46; <span class="elsevierStyleItalic">Clearance</span> de CA&#44; a EFA e a EGCA dos antebra&#231;os foram comparados por tempo e grupos &#40;ao longo do tempo&#41; usando o modelo linear generalizado de efeitos mistos&#44; estrutura de covari&#226;ncia robusta&#44; covari&#226;ncia matriz autorregressiva tipo 1&#44; compara&#231;&#227;o <span class="elsevierStyleItalic">post&#8208;hoc</span> de &#352;id&#225;k&#44; e ajuste de probabilidade gama ou binomial negativa&#44; quando indicado&#46; Os casos faltantes tiveram seus valores imputados pelo modelo misto&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">O tamanho do efeito foi calculado como a diferen&#231;a nas m&#233;dias de cada vari&#225;vel em D0 e D90&#44; e o intervalo de confian&#231;a usando a t&#233;cnica de <span class="elsevierStyleItalic">bootstrap</span> com 1&#46;000 reamostras&#46; Os dados foram analisados no IBM SPSS 25<span class="elsevierStyleHsp" style=""></span>v&#46; A signific&#226;ncia foi definida como p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="par0105" class="elsevierStylePara elsevierViewall">De maio de 2021 a abril de 2022 foram inclu&#237;dos 45 pacientes eleg&#237;veis&#44; submetidos a tratamento com creme de 5&#8208;FU 5&#37; em um antebra&#231;o e creme de COL 0&#44;5&#37; no antebra&#231;o contralateral &#40;total de 90 antebra&#231;os&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Os principais dados cl&#237;nicos e demogr&#225;ficos dos 45 participantes na inclus&#227;o &#40;D0&#41; est&#227;o expostos na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46; Houve predomin&#226;ncia de mulheres &#40;62&#37;&#41;&#59; a idade m&#233;dia dos participantes foi de 67&#44;3 anos&#59; fototipo II foi o mais comum &#40;69&#37;&#41;&#59; e a maioria dos pacientes tinha antecedente pessoal de c&#226;ncer de pele &#40;60&#37;&#41; e intensa exposi&#231;&#227;o solar pr&#233;via &#40;64&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">No que concerne aos desfechos cl&#237;nicos&#44; 15 antebra&#231;os tratados com 5&#8208;FU apresentaram <span class="elsevierStyleItalic">clearance</span> completo das CA em D90 &#40;37&#37;&#59; 95&#37; IC 24&#37;&#8208;49&#37;&#41;&#44; enquanto entre os tratados com COL&#44; sete alcan&#231;aram esse desfecho &#40;17&#37;&#59; 95&#37; IC 7&#37;&#8208;27&#37;&#41;&#44; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;077&#41;&#46; J&#225; o <span class="elsevierStyleItalic">clearance</span> parcial &#40;redu&#231;&#227;o &#8805; 50&#37; no n&#250;mero de CA&#41; foi obtido por 35 dos antebra&#231;os 5&#8208;FU &#40;85&#37;&#59; 95&#37; IC 76&#37;&#8211;93&#37;&#41; e por 32 dos COL &#40;78&#37;&#59; 95&#37; IC 66&#37;&#8211;88&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;508&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Em D90&#44; houve redu&#231;&#227;o percentual de 75&#37; na contagem de CA para os antebra&#231;os submetidos ao tratamento com 5&#8208;FU &#40;95&#37; IC 66&#37;&#8211;83&#37;&#41; e de 64&#37; nos tratados com COL &#40;95&#37; IC 55&#37;&#8211;72&#37;&#41;&#44; havendo melhora ao longo do tempo para ambos os tratamentos &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; por&#233;m&#44; sem diferen&#231;a entre eles &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;069&#41;&#46; Nenhum participante apresentou piora da contagem de CA&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">A diferen&#231;a intergrupos da melhora da EFA tamb&#233;m n&#227;o foi relevante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;654&#41;&#59; por outro lado&#44; ambos os tratamentos levaram &#224; redu&#231;&#227;o significante da EGCA&#44; e nesse quesito houve superioridade do 5&#8208;FU &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#59; <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">A respeito dos efeitos adversos&#44; este estudo demonstrou que COL provocou mais dor que 5&#8208;FU&#44; al&#233;m de causar mais edema e desencadear descama&#231;&#227;o mais intensa&#46; Em contrapartida&#44; 5&#8208;FU levou &#224; maior forma&#231;&#227;o de crostas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46; Contudo&#44; apenas um participante &#40;2&#44;2&#37;&#41; referiu n&#227;o estar disposto a realizar novamente os tratamentos caso fosse necess&#225;rio&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">N&#227;o houve surgimento de neoplasias malignas nas regi&#245;es tratadas durante o seguimento de 90 dias&#46; No per&#237;odo do estudo&#44; houve quatro <span class="elsevierStyleItalic">dropouts</span>&#44; de modo que 41 participantes &#40;82 antebra&#231;os&#41; passaram por todas as tr&#234;s avalia&#231;&#245;es &#40;D0&#44; D14 e D90&#41;&#46; Os <span class="elsevierStyleItalic">dropouts</span> n&#227;o ocorreram em virtude dos efeitos adversos da interven&#231;&#227;o&#44; mas por n&#227;o comparecimento dos pacientes no dia agendado para a avalia&#231;&#227;o e impossibilidade de reagendamento &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Os participantes faltantes foram contactados e n&#227;o compareceram por motivos ligados &#224; pandemia de COVID&#8208;19&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discuss&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">O presente estudo n&#227;o demonstrou diferen&#231;a quanto &#224; efic&#225;cia no tratamento de CA entre 5&#8208;FU 5&#37; e COL 0&#44;5&#37; nas posologias e tempo de uso testados&#46; Uma vez que 5&#8208;FU &#233; tratamento consagrado e fortemente recomendado para tratamento de CA e CCC&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> esse dado refor&#231;a COL tamb&#233;m como op&#231;&#227;o terap&#234;utica&#44; de custo acess&#237;vel e posologia que facilita a ader&#234;ncia&#44; em que pesem efeitos adversos mais intensos&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Entre os antebra&#231;os tratados com 5&#8208;FU&#44; 37&#37; apresentaram <span class="elsevierStyleItalic">clearance</span> completo das CA&#44; resultado muito semelhante ao encontrado em um ensaio cl&#237;nico randomizado duplo&#8208;cego&#44; com 932 pacientes&#44; em que foi avaliada a efic&#225;cia de creme de 5&#8208;FU 5&#37; seis meses ap&#243;s um curso de tratamento de 2&#215;&#47;dia por quatro semanas na face e orelhas &#40;<span class="elsevierStyleItalic">clearance</span> completo 5&#8208;FU 38&#37; <span class="elsevierStyleItalic">versus</span> placebo 17&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Outro ensaio cl&#237;nico randomizado&#44; envolvendo 602 pacientes&#44; que comparou 5&#8208;FU 5&#37; a outras tr&#234;s op&#231;&#245;es de tratamento para CA na cabe&#231;a&#44; evidenciou <span class="elsevierStyleItalic">clearance</span> &#8805; 75&#37; em 90&#44;6&#37; dos pacientes ap&#243;s tr&#234;s meses do t&#233;rmino de tratamento&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> De maneira similar&#44; verificamos 85&#37; de <span class="elsevierStyleItalic">clearance</span> parcial &#40;&#8805; 50&#37;&#41; nos antebra&#231;os tratados com 5&#8208;FU em nosso estudo&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">No que tange ao tratamento de CA em membros superiores&#44; um ensaio cl&#237;nico autocontrolado comparou o uso de creme de 5&#8208;FU 5&#37; 2&#215;&#47;dia em dois ciclos de 15 dias separados por 15 dias de pausa <span class="elsevierStyleItalic">versus</span> quatro sess&#245;es quinzenais de <span class="elsevierStyleItalic">peeling</span> de &#225;cido glic&#243;lico 70&#37; &#43; solu&#231;&#227;o de 5&#8208;FU 5&#37;&#44; apontando redu&#231;&#227;o de 85&#44;7&#37; no n&#250;mero de CA nos membros tratados com 5&#8208;FU creme&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> A menor amostragem do referido estudo&#44; &#225;rea de tratamento incluindo as m&#227;os&#44; bem como a posologia diferente&#44; que pode interferir na ader&#234;ncia ao tratamento&#44; s&#227;o caracter&#237;sticas que podem explicar a discreta diferen&#231;a&#44; a favor&#44; em rela&#231;&#227;o &#224; redu&#231;&#227;o de 75&#37; na contagem de CA encontrada em nosso estudo&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Foi observado <span class="elsevierStyleItalic">clearance</span> completo de 17&#37; nos antebra&#231;os submetidos ao curso de sete dias de creme de COL 0&#44;5&#37;&#44; 2&#215;&#47;dia&#46; A mesma taxa foi constatada em um estudo que utilizou COL 0&#44;5&#37; em antebra&#231;os 2&#215;&#47;dia por 10 dias em 36 antebra&#231;os estudados&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Esses dados sugerem que um curso mais curto&#44; de sete dias&#44; pode apresentar a mesma efic&#225;cia na melhora de CA e CCC&#46; N&#227;o &#233; poss&#237;vel inferir resultados decorrentes de cursos mensais&#44; sequenciais&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Ensaio cl&#237;nico mais recente comparando COL &#40;2&#215;&#47;dia por sete dias&#41; <span class="elsevierStyleItalic">versus</span> mebutato de ingenol ou filtro solar&#44; associados ou n&#227;o a <span class="elsevierStyleItalic">Polypodium leucatomos</span> via oral&#44; evidenciou <span class="elsevierStyleItalic">clearance</span> completo&#44; ap&#243;s 60 dias&#44; de 14&#44;7&#37; para COL&#44; 16&#44;1&#37; para o mebutato de ingenol e 2&#44;8&#37; para filtro solar&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> O presente estudo e os dois ensaios cl&#237;nicos citados apresentam taxa de <span class="elsevierStyleItalic">clearance</span> similar para COL&#44; o que demonstra sua consist&#234;ncia como op&#231;&#227;o de tratamento do CCC&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Constatamos redu&#231;&#227;o de 64&#37; na contagem de CA nos antebra&#231;os tratados com COL comparando D0 com D90&#46; Estudo anterior evidenciou resultado superior da COL nos membros superiores&#44; com redu&#231;&#227;o de 73&#44;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> Essa superioridade pode justificar&#8208;se por&#44; no referido estudo&#44; ter sido realizado um segundo curso de tratamento de 10 dias nos pacientes que apresentaram pouca ou nenhuma resposta inflamat&#243;ria ao primeiro curso&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">O primeiro ensaio cl&#237;nico que testou o uso de COL para tratamento de CA comparou a aplica&#231;&#227;o de gel de COL 2&#215;&#47;dia por 10 dias ao placebo&#44; verificando total resolu&#231;&#227;o das les&#245;es em sete dos 10 pacientes tratados&#44; enquanto no grupo placebo nenhum paciente apresentou resposta&#46; Em contraposi&#231;&#227;o ao nosso estudo&#44; esse ensaio cl&#237;nico n&#227;o era controlado&#44; n&#227;o houve per&#237;odo de <span class="elsevierStyleItalic">washout</span> antes da inclus&#227;o &#40;quantidade n&#227;o informada de participantes havia realizado outros tratamentos para CA pouco antes do estudo&#41;&#44; a concentra&#231;&#227;o utilizada de COL foi de 1&#37; em ve&#237;culo gel&#44; a &#225;rea tratada foi a fronte e a amostragem foi consideravelmente menor&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> diferen&#231;as que podem justificar a discrep&#226;ncia na taxa de <span class="elsevierStyleItalic">clearance</span> completo&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">N&#227;o h&#225; apresenta&#231;&#245;es t&#243;picas industrializadas de COL&#44; mas &#233; poss&#237;vel obter formula&#231;&#245;es de uso t&#243;pico contendo COL por meio de farm&#225;cias de manipula&#231;&#227;o&#46; Em rela&#231;&#227;o &#224; solubilidade&#44; 1<span class="elsevierStyleHsp" style=""></span>g de COL dissolve&#8208;se em 22<span class="elsevierStyleHsp" style=""></span>mL de &#225;gua&#44; 220<span class="elsevierStyleHsp" style=""></span>mL de &#233;ter&#44; 100<span class="elsevierStyleHsp" style=""></span>mL de benzeno&#44; livremente em &#225;lcool ou clorof&#243;rmio e &#233; praticamente insol&#250;vel em &#233;ter de petr&#243;leo ou vaselina&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> Utilizamos como ve&#237;culo neste estudo o creme n&#227;o i&#244;nico&#44; por apresentar bom perfil de solubilidade para COL&#44; propiciando a penetra&#231;&#227;o do f&#225;rmaco&#46; Dois ensaios cl&#237;nicos pr&#233;vios<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16&#44;17</span></a> desse grupo de pesquisa utilizaram a mesma formula&#231;&#227;o&#44; produzida pela mesma farm&#225;cia de manipula&#231;&#227;o &#40;Pharm&#225;cia Spec&#237;fica Ltda&#41;&#44; atingindo taxas de <span class="elsevierStyleItalic">clearance</span> muito similares&#44; o que sugere const&#226;ncia e estabilidade das formula&#231;&#245;es&#46; A COL escurece quando exposta &#224; luz&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> motivo pelo qual optamos por frascos resistentes &#224; luz e <span class="elsevierStyleItalic">airless</span> para armazenamento do creme de COL&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Para o tratamento do fotoenvelhecimento de antebra&#231;os&#44; 5&#8208;FU demonstrou previamente melhorar aspecto visual da pele&#44; al&#233;m de aumentar a express&#227;o de pr&#243;&#8208;col&#225;geno I na avalia&#231;&#227;o seis meses ap&#243;s o tratamento&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> Ambos os tratamentos investigados no presente estudo levaram &#224; melhora na EFA&#46; Esse resultado faz refletir se a COL poderia trazer benef&#237;cios tamb&#233;m no tratamento do fotoenvelhecimento&#44; suscitando a import&#226;ncia de estudos com desenho dedicado a elucidar essa quest&#227;o&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A EGCA foi o desfecho em que evidenciamos superioridade significante do 5&#8208;FU em rela&#231;&#227;o &#224; COL &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46; Os crit&#233;rios que definem essa escala s&#227;o di&#226;metro das les&#245;es&#44; grau de hiperceratose e presen&#231;a de exulcera&#231;&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> &#201; importante considerar que&#44; para o paciente&#44; a melhora de hiperceratose e exulcera&#231;&#227;o&#44; ainda que n&#227;o haja resolu&#231;&#227;o completa da les&#227;o&#44; pode trazer mais satisfa&#231;&#227;o e conforto&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Diferen&#231;as relevantes foram encontradas em rela&#231;&#227;o aos efeitos adversos dos tratamentos&#58; COL provocou mais dor&#44; mais edema e mais descama&#231;&#227;o que 5&#8208;FU&#59; em compensa&#231;&#227;o&#44; 5&#8208;FU ocasionou maior forma&#231;&#227;o de crostas&#46; A ocorr&#234;ncia de rea&#231;&#245;es adversas pode ser motivo para o paciente n&#227;o aderir apropriadamente ao tratamento&#59; entretanto&#44; o principal fator que compromete a ader&#234;ncia a tratamentos t&#243;picos para CA e CCC &#233; a dura&#231;&#227;o prolongada de tratamento&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> Assim&#44; ainda que a COL esteja mais associada a alguns dos efeitos adversos&#44; o fato de ter curso mais curto de tratamento comparativamente ao 5&#8208;FU a posiciona como vantajosa op&#231;&#227;o de tratamento de CA e CCC&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Em um estudo que avaliou rea&#231;&#245;es cut&#226;neas em decorr&#234;ncia do uso de 5&#8208;FU 5&#37; 2&#215;&#47;dia por quatro semanas evidenciou&#8208;se que eritema intenso foi a rea&#231;&#227;o mais frequente &#40;46&#44;7&#37;&#41;&#44; seguido por prurido &#40;28&#44;9&#37;&#41;&#44; sensa&#231;&#227;o de queima&#231;&#227;o &#40;21&#44;5&#37;&#41; e descama&#231;&#227;o &#40;18&#44;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Em nosso estudo&#44; houve eritema em 82&#37; e descama&#231;&#227;o em 49&#37; dos antebra&#231;os tratados com 5&#8208;FU&#46; Todavia&#44; na presente pesquisa&#44; o eritema foi classificado como intenso em apenas 2&#37; dos casos&#46; A diferen&#231;a pode ser explicada pelo fato de que o estudo acima mencionado determinou a ocorr&#234;ncia de efeitos adversos por meio do relato telef&#244;nico dos participantes&#44; enquanto em nosso estudo as rea&#231;&#245;es foram aferidas por exame dermatol&#243;gico&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Ademais&#44; o papel adicional dos filtros solares no tratamento do CCC n&#227;o deve ser negligenciado&#59; em estudo com popula&#231;&#227;o semelhante que incluiu 40 indiv&#237;duos &#40;80 antebra&#231;os&#41; com CA nos antebra&#231;os&#44; houve redu&#231;&#227;o de cerca de 30&#37; na contagem de les&#245;es&#44; ap&#243;s 60 dias&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">S&#227;o limita&#231;&#245;es do presente estudo a relativa homogeneidade da popula&#231;&#227;o estudada&#44; por tratar&#8208;se de estudo unic&#234;ntrico&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">&#201; extremamente v&#225;lida a investiga&#231;&#227;o de outros esquemas posol&#243;gicos de COL&#44; a fim de identificar formas de uso mais eficazes e c&#244;modas&#46; &#201; tamb&#233;m pertinente que sejam realizados mais estudos comparativos com COL em outras &#225;reas&#44; como a face e couro cabeludo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclus&#245;es</span><p id="par0220" class="elsevierStylePara elsevierViewall">5&#8208;FU e COL s&#227;o eficazes para tratamento de CCC&#44; com taxas de <span class="elsevierStyleItalic">clearance</span> completo e parcial que n&#227;o tiveram diferen&#231;a estat&#237;stica ap&#243;s 90 dias&#46; 5&#8208;FU foi superior em reduzir a gravidade das CA&#59; COL provocou mais dor&#44; edema e descama&#231;&#227;o que 5&#8208;FU&#44; mas este &#250;ltimo ocasionou mais crostas&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Suporte financeiro</span><p id="par0225" class="elsevierStylePara elsevierViewall">Fundo de Apoio &#224; Dermatologia &#40;FUNADERM&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Contribui&#231;&#227;o dos autores</span><p id="par0230" class="elsevierStylePara elsevierViewall">Amanda Soares Teixeira&#58; Desenho do projeto&#59; coleta dos dados&#59; revis&#227;o da literatura&#59; escrita e aprova&#231;&#227;o do texto&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Ivanka Miranda de Castro Martins&#58; Coleta dos dados&#59; escrita e aprova&#231;&#227;o do texto&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Anna Carolina Miola&#58; Desenho do projeto&#59; revis&#227;o da literatura&#59; escrita e aprova&#231;&#227;o do texto&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">H&#233;lio Amante Miot&#58; Desenho do projeto&#59; an&#225;lise dos dados&#59; revis&#227;o da literatura&#59; escrita e aprova&#231;&#227;o do texto&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflito de interesses</span><p id="par0250" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">5&#8208;fluorouracil &#40;5&#8208;FU&#41; &#233; medicamento de primeira linha para tratar campo de canceriza&#231;&#227;o cut&#226;neo &#40;CCC&#41;&#46; H&#225; poucos ensaios cl&#237;nicos com colchicina &#40;COL&#41; t&#243;pica&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Avaliar a efic&#225;cia do creme de COL 0&#44;5&#37; <span class="elsevierStyleItalic">versus</span> creme de 5&#8208;FU 5&#37; no tratamento do CCC&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todo</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ensaio cl&#237;nico randomizado&#44; aberto&#44; autocontrolado&#46; Quarenta e cinco pacientes &#40;90 antebra&#231;os&#41;&#44; com 3 a 10 ceratoses act&#237;nicas &#40;CA&#41; em cada antebra&#231;o&#44; utilizaram creme de COL 0&#44;5&#37; 2&#215;&#47;dia por sete dias em um antebra&#231;o&#44; e creme 5&#8208;FU 5&#37; 2&#215;&#47;dia&#44; por 21 dias&#44; no outro antebra&#231;o&#46; As posologias foram definidas a partir de ensaios cl&#237;nicos pr&#233;vios para cada medicamento&#46; Efeitos adversos foram avaliados ap&#243;s 14 dias e os desfechos&#44; ap&#243;s 90 dias da inclus&#227;o&#46; O desfecho prim&#225;rio foi a elimina&#231;&#227;o completa de CA&#44; e os secund&#225;rios&#58; elimina&#231;&#227;o parcial &#40;&#8805; 50&#37;&#41;&#44; redu&#231;&#227;o na contagem de CA&#44; avalia&#231;&#227;o da escala de fotoenvelhecimento dos antebra&#231;os &#40;EFA&#41;&#44; escala de gravidade das CA &#40;EGCA&#41; e efeitos adversos&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ap&#243;s 90 dias&#44; houve elimina&#231;&#227;o completa das CA em 37&#37; &#40;95&#37; IC 24&#37;&#8208;49&#37;&#41; e elimina&#231;&#227;o parcial em 85&#37; &#40;95&#37; IC 76&#37;&#8208;93&#37;&#41; dos antebra&#231;os tratados com 5&#8208;FU&#44; <span class="elsevierStyleItalic">versus</span> 17&#37; &#40;95&#37; IC 7&#37;&#8208;27&#37;&#41; e 78&#37; &#40;95&#37; IC 66&#37;&#8208;88&#37;&#41; para COL &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;07&#41;&#46; Houve redu&#231;&#227;o percentual de 75&#37; na contagem de CA dos antebra&#231;os tratados com 5&#8208;FU &#40;95&#37; IC 66&#37;&#8208;83&#37;&#41; e de 64&#37; nos tratados com COL &#40;95&#37; IC 55&#37;&#8208;72&#37;&#41;&#46; Quanto &#224; EFA e EGCA&#44; houve melhora em ambos os grupos&#44; sem diferen&#231;a quanto &#224; EFA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;654&#41;&#44; com superioridade do 5&#8208;FU para EGCA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Limita&#231;&#245;es do estudo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estudo monoc&#234;ntrico&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">5&#8208;FU e COL s&#227;o eficazes para tratamento do CCC&#44; sem superioridade entre eles na redu&#231;&#227;o de contagem de CA&#46;</p></span>"
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intenso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ausente&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leve&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8208; &#40;&#8208;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ausente&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leve&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intenso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Bolha</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;125&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ausente&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leve&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8208; &#40;&#8208;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8208; &#40;&#8208;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Eficácia e segurança do creme de colchicina 0,5% versus creme de 5‐fluorouracil 5% no tratamento do campo de cancerização cutâneo: ensaio clínico randomizado
Amanda Soares Teixeiraa,
Autor para correspondência
amandateixeira.dermato@gmail.com

Autor para corespondência.
, Ivanka Miranda de Castro Martinsb, Anna Carolina Miolab, Hélio Amante Miotb
a Departamento de Dermatologia, Instituto Lauro de Souza Lima, Bauru, SP, Brasil
b Departamento de Infectologia, Dermatologia, Radioterapia e Diagnóstico por Imagem, Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, SP, Brasil
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&#233; recomend&#225;vel tratar todo o CCC e&#44; nesse contexto&#44; os tratamentos t&#243;picos s&#227;o as op&#231;&#245;es mais utilizadas&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">5&#8208;FU &#233; an&#225;logo de pirimidina com a&#231;&#227;o antitumoral descrita primariamente em 1957&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> e h&#225; mais de 50 anos &#233; usado para tratamento de les&#245;es cut&#226;neas pr&#233;&#8208;malignas e malignas&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Sua a&#231;&#227;o decorre principalmente da inibi&#231;&#227;o da timidilato sintase e&#44; como interfere no processo de replica&#231;&#227;o celular&#44; c&#233;lulas com alto &#237;ndice mit&#243;tico s&#227;o mais suscet&#237;veis ao seu efeito citot&#243;xico&#44; enquanto c&#233;lulas normais aparentam ser bem menos sens&#237;veis a esses efeitos&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> As rea&#231;&#245;es adversas locais s&#227;o um empecilho &#224; ader&#234;ncia completa ao tratamento&#44; que costuma durar de 14 a 28 dias&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A colchicina &#40;COL&#41; &#233; um dos f&#225;rmacos mais antigos ainda em uso na atualidade&#46; &#201; alcaloide natural extra&#237;do do cormo da planta <span class="elsevierStyleItalic">Colchicum autumnale</span> e outras esp&#233;cies do g&#234;nero <span class="elsevierStyleItalic">Colchicum</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> O uso para tratamento de CA foi descrito em 1968 por Marshall e se fundamenta na a&#231;&#227;o antimit&#243;tica do f&#225;rmaco&#44; uma vez que compromete a composi&#231;&#227;o dos microt&#250;bulos e a divis&#227;o celular&#46; Em 2000&#44; o primeiro ensaio cl&#237;nico que avaliou a efic&#225;cia da COL para tratamento das CA evidenciou <span class="elsevierStyleItalic">clearance</span> total de 70&#37; nas CA do couro cabeludo de pacientes tratados com COL ap&#243;s 60 dias&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A busca por novas op&#231;&#245;es de tratamento&#44; que ofere&#231;am maior toler&#226;ncia&#44; ader&#234;ncia&#44; efic&#225;cia e&#47;ou seguran&#231;a que as existentes&#44; &#233; desej&#225;vel&#46; Apesar de d&#233;cadas terem se passado desde os primeiros relatos de seu uso para tratamento de CA&#44; h&#225; poucos ensaios cl&#237;nicos publicados que permitam estabelecer a efic&#225;cia e a seguran&#231;a da COL para tratamento de CA e CCC&#46; Al&#233;m disso&#44; n&#227;o h&#225; estudo comparando COL a 5&#8208;FU no tratamento para CCC&#46; Este estudo&#44; ent&#227;o&#44; tem por objetivo avaliar a efic&#225;cia do creme de COL 0&#44;5&#37; <span class="elsevierStyleItalic">versus</span> creme de 5&#8208;FU 5&#37; no tratamento do CCC em pacientes imunocompetentes com m&#250;ltiplas CA nos antebra&#231;os&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ensaio cl&#237;nico randomizado&#44; aberto&#44; autocontrolado&#44; comparando creme de COL 0&#44;5&#37; <span class="elsevierStyleItalic">versus</span> creme de 5&#8208;FU 5&#37;&#44; realizado no Ambulat&#243;rio de Dermatologia do Instituto Lauro de Souza Lima &#40;ILSL&#41; em Bauru&#47;SP&#46; O estudo foi aprovado pelo comit&#234; de &#233;tica institucional &#40;n&#176; 3&#46;751&#46;592&#41;&#44; registrado no Registro Brasileiro de Ensaios Cl&#237;nicos &#40;<a href="https://ensaiosclinicos.gov.br/rg/RBR-487ctp">https&#58;&#47;&#47;ensaiosclinicos&#46;gov&#46;br&#47;rg&#47;RBR&#8208;487ctp</a>&#41; e financiado pelo Fundo de Apoio &#224; Dermatologia &#40;FUNADERM&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ap&#243;s concord&#226;ncia e assinatura do termo de consentimento&#44; foram inclu&#237;dos 45 pacientes imunocompetentes&#44; de ambos os sexos&#44; com mais de 18 anos e com diagn&#243;stico cl&#237;nico de tr&#234;s a dez CA em cada antebra&#231;o&#44; que n&#227;o tivessem realizado quaisquer tratamentos para CA ou CCC nos &#250;ltimos seis meses&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Os crit&#233;rios de exclus&#227;o definidos foram&#58; dermatoses extensas afetando um dos antebra&#231;os&#44; hipersensibilidade ou alergia sabida a alguma das subst&#226;ncias estudadas&#44; imunossupress&#227;o por medicamentos e&#47;ou doen&#231;as&#44; gesta&#231;&#227;o&#44; amamenta&#231;&#227;o e uso de retinoides&#44; anti&#8208;inflamat&#243;rios ou qualquer outro tratamento t&#243;pico na regi&#227;o avaliada&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os participantes foram randomizados para definir em qual antebra&#231;o receberiam 5&#8208;FU ou COL&#44; em aloca&#231;&#227;o de 1&#58;1&#44; gerada por simula&#231;&#227;o computacional &#40;randomiza&#231;&#227;o em bloco&#41;&#46; A randomiza&#231;&#227;o foi executada por pesquisador n&#227;o envolvido na avalia&#231;&#227;o dos pacientes&#44; com aloca&#231;&#227;o sequencial&#44; e a inclus&#227;o e avalia&#231;&#227;o dos pacientes foi realizada por outro pesquisador&#46; Cada indiv&#237;duo foi submetido aos dois tratamentos&#44; um em cada antebra&#231;o&#46; 5&#8208;FU foi aplicado 2&#215;&#47;dia por 21 dias&#44; e COL 2&#215;&#47;dia por sete dias&#46; Os pacientes tamb&#233;m receberam filtro solar para uso regular em ambos os antebra&#231;os durante todo o per&#237;odo do estudo&#46; A aplica&#231;&#227;o das medica&#231;&#245;es e do filtro solar foi realizada pelos pr&#243;prios pacientes&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Na inclus&#227;o&#44; cada participante recebeu um pacote correspondente ao seu grupo de randomiza&#231;&#227;o&#44; contendo&#58; 1&#41; tr&#234;s tubos de 15<span class="elsevierStyleHsp" style=""></span>g de creme de 5&#8208;FU 5&#37; &#40;Efurix&#174;&#44; Valeant&#41;&#59; 2&#41; um frasco resistente &#224; luz <span class="elsevierStyleItalic">airless</span> de 20<span class="elsevierStyleHsp" style=""></span>g &#40;libera&#231;&#227;o de 1<span class="elsevierStyleHsp" style=""></span>g por <span class="elsevierStyleItalic">pump</span>&#41; de creme de COL 0&#44;5&#37; &#40;produto manipulado&#44; Pharm&#225;cia Spec&#237;fica Ltda&#46;&#41;&#59; 3&#41; dois tubos de 200<span class="elsevierStyleHsp" style=""></span>mL de filtro solar &#40;Protetor Solar Corporal Neutrogena&#174; Sun Fresh FPS30&#41;&#59; 4&#41; folha com orienta&#231;&#245;es de uso&#44; telefone para contato e com ilustra&#231;&#227;o demonstrando &#225;rea e lado em que cada medica&#231;&#227;o deveria ser utilizada&#44; al&#233;m do modo de uso de acordo com grupo de randomiza&#231;&#227;o&#46; Todas as embalagens das medica&#231;&#245;es foram etiquetadas em &#8220;direito&#8221; ou &#8220;esquerdo&#8221; &#40;com ilustra&#231;&#227;o do antebra&#231;o correspondente&#41; e com a forma de uso de cada f&#225;rmaco&#44; obedecendo &#224; randomiza&#231;&#227;o dos antebra&#231;os&#44; para diminuir o risco de confus&#227;o entre os tratamentos&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Para cada paciente&#44; o estudo teve 90 dias de dura&#231;&#227;o&#44; com tr&#234;s avalia&#231;&#245;es&#58; 1&#41; D0 &#8208; inclus&#227;o&#44; contagem de CA em cada antebra&#231;o&#44; escala de fotoenvelhecimento de antebra&#231;os &#40;EFA&#41; e escala de gravidade das CA &#40;EGCA&#41;&#59; 2&#41; D14 &#8208; avalia&#231;&#227;o de tolerabilidade e efeitos adversos&#59; 3&#41; D90 &#8208; contagem de CA&#44; EFA e EGCA &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Para a avalia&#231;&#227;o e tratamento&#44; foi definida a face dorsal de cada antebra&#231;o&#44; como a &#225;rea delimitada por linha imagin&#225;ria que liga os processos estiloides da ulna e do r&#225;dio&#44; a borda medial do antebra&#231;o&#44; borda lateral do antebra&#231;o e uma linha que une o epic&#244;ndilo lateral &#224; fossa antecubital &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Ap&#243;s marca&#231;&#227;o das CA com caneta&#44; foi realizada contagem e confirma&#231;&#227;o da contagem para cada antebra&#231;o&#44; pelo mesmo avaliador &#40;A&#46;S&#46;T&#46;&#41; em ambas as avalia&#231;&#245;es&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A EFA &#233; uma escala validada&#44; que mensura o grau de envelhecimento dos antebra&#231;os por meio do n&#250;mero de CA superficiais e hipertr&#243;ficas&#44; quantidade e gravidade de rugas&#44; lentigos solares&#44; p&#250;rpuras vis&#237;veis&#44; cicatrizes atr&#243;ficas estelares&#44; elastose e perda de elasticidade&#46; Cada crit&#233;rio tem um peso e&#44; ao final da avalia&#231;&#227;o&#44; os valores s&#227;o somados resultando em n&#250;mero que varia de 0 a 192&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">A EGCA permite avaliar resposta a modalidades terap&#234;uticas para CCC de maneira qualitativa&#44; e &#233; complementar &#224; contagem de CA&#46; Di&#226;metro em mil&#237;metros&#44; grau de hiperceratose e exulcera&#231;&#227;o de cada CA s&#227;o par&#226;metros considerados&#44; e o valor final da EGCA &#233; dado pela somat&#243;ria da pontua&#231;&#227;o de todas as CA na &#225;rea avaliada&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">O desfecho prim&#225;rio avaliado foi a taxa de <span class="elsevierStyleItalic">clearance</span> completo de CA em cada antebra&#231;o&#46; Os desfechos secund&#225;rios foram <span class="elsevierStyleItalic">clearance</span> parcial &#40;redu&#231;&#227;o &#8805; 50&#37; da contagem de CA&#41;&#44; redu&#231;&#227;o na contagem de CA&#44; melhora da EFA&#44; redu&#231;&#227;o da EGCA e avalia&#231;&#227;o dos efeitos adversos&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A compara&#231;&#227;o dos efeitos adversos provocados por terapias t&#243;picas com posologias distintas em um mesmo paciente pode ser complexa&#44; uma vez que o &#225;pice das rea&#231;&#245;es locais ocorre em momentos diferentes&#46; O creme de COL teve seu uso avaliado&#44; na maioria dos estudos&#44; no esquema de 2&#215;&#47;dia por 10 dias&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16&#8211;18</span></a> Ensaios cl&#237;nicos pr&#233;vios com COL t&#243;pica realizados pelo nosso grupo de pesquisa revelaram que os &#250;ltimos dias de tratamento levaram a rea&#231;&#245;es locais mais acentuadas&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16&#44;17</span></a> No presente estudo&#44; adotamos curso mais curto&#44; de sete dias&#44; de modo a avaliar se a redu&#231;&#227;o do per&#237;odo de tratamento demonstraria a mesma efic&#225;cia&#44; mas com menos efeitos adversos&#46; De outro modo&#44; a posologia usual do creme de 5&#8208;FU 5&#37; para o tratamento de CA &#233; de 2&#215;&#47;dia por duas a quatro semanas&#44; e os efeitos adversos s&#227;o mais intensos quanto mais prolongado o esquema terap&#234;utico&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Diante do exposto&#44; foi estabelecido curso de tratamento de sete dias para COL&#44; de 21 dias para 5&#8208;FU e a avalia&#231;&#227;o de efeitos adversos foi realizada ap&#243;s 14 dias do in&#237;cio dos tratamentos&#44; momento considerado oportuno para n&#227;o supervalorizar a ocorr&#234;ncia de rea&#231;&#245;es locais por nenhuma das terapias&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A amostra foi dimensionada a fim de detectar 30&#37; ou mais de diferen&#231;a na taxa de <span class="elsevierStyleItalic">clearance</span> completo de CA &#40;D90&#41; entre os grupos &#40;p&#46; ex&#46;&#44; 16&#37; <span class="elsevierStyleItalic">vs&#46;</span> 46&#37;&#41;&#46; Adotou&#8208;se o poder de 0&#44;85&#59; alfa de 0&#44;05 e estimativa de <span class="elsevierStyleItalic">dropout</span> de at&#233; 20&#37;&#44; resultando 45 pacientes &#40;90 antebra&#231;os&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Todos os pacientes inclu&#237;dos no estudo e randomizados fizeram parte da popula&#231;&#227;o ITT &#40;<span class="elsevierStyleItalic">intention to treat</span>&#41;&#46; <span class="elsevierStyleItalic">Clearance</span> de CA&#44; a EFA e a EGCA dos antebra&#231;os foram comparados por tempo e grupos &#40;ao longo do tempo&#41; usando o modelo linear generalizado de efeitos mistos&#44; estrutura de covari&#226;ncia robusta&#44; covari&#226;ncia matriz autorregressiva tipo 1&#44; compara&#231;&#227;o <span class="elsevierStyleItalic">post&#8208;hoc</span> de &#352;id&#225;k&#44; e ajuste de probabilidade gama ou binomial negativa&#44; quando indicado&#46; Os casos faltantes tiveram seus valores imputados pelo modelo misto&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">O tamanho do efeito foi calculado como a diferen&#231;a nas m&#233;dias de cada vari&#225;vel em D0 e D90&#44; e o intervalo de confian&#231;a usando a t&#233;cnica de <span class="elsevierStyleItalic">bootstrap</span> com 1&#46;000 reamostras&#46; Os dados foram analisados no IBM SPSS 25<span class="elsevierStyleHsp" style=""></span>v&#46; A signific&#226;ncia foi definida como p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="par0105" class="elsevierStylePara elsevierViewall">De maio de 2021 a abril de 2022 foram inclu&#237;dos 45 pacientes eleg&#237;veis&#44; submetidos a tratamento com creme de 5&#8208;FU 5&#37; em um antebra&#231;o e creme de COL 0&#44;5&#37; no antebra&#231;o contralateral &#40;total de 90 antebra&#231;os&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Os principais dados cl&#237;nicos e demogr&#225;ficos dos 45 participantes na inclus&#227;o &#40;D0&#41; est&#227;o expostos na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46; Houve predomin&#226;ncia de mulheres &#40;62&#37;&#41;&#59; a idade m&#233;dia dos participantes foi de 67&#44;3 anos&#59; fototipo II foi o mais comum &#40;69&#37;&#41;&#59; e a maioria dos pacientes tinha antecedente pessoal de c&#226;ncer de pele &#40;60&#37;&#41; e intensa exposi&#231;&#227;o solar pr&#233;via &#40;64&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">No que concerne aos desfechos cl&#237;nicos&#44; 15 antebra&#231;os tratados com 5&#8208;FU apresentaram <span class="elsevierStyleItalic">clearance</span> completo das CA em D90 &#40;37&#37;&#59; 95&#37; IC 24&#37;&#8208;49&#37;&#41;&#44; enquanto entre os tratados com COL&#44; sete alcan&#231;aram esse desfecho &#40;17&#37;&#59; 95&#37; IC 7&#37;&#8208;27&#37;&#41;&#44; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;077&#41;&#46; J&#225; o <span class="elsevierStyleItalic">clearance</span> parcial &#40;redu&#231;&#227;o &#8805; 50&#37; no n&#250;mero de CA&#41; foi obtido por 35 dos antebra&#231;os 5&#8208;FU &#40;85&#37;&#59; 95&#37; IC 76&#37;&#8211;93&#37;&#41; e por 32 dos COL &#40;78&#37;&#59; 95&#37; IC 66&#37;&#8211;88&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;508&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Em D90&#44; houve redu&#231;&#227;o percentual de 75&#37; na contagem de CA para os antebra&#231;os submetidos ao tratamento com 5&#8208;FU &#40;95&#37; IC 66&#37;&#8211;83&#37;&#41; e de 64&#37; nos tratados com COL &#40;95&#37; IC 55&#37;&#8211;72&#37;&#41;&#44; havendo melhora ao longo do tempo para ambos os tratamentos &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; por&#233;m&#44; sem diferen&#231;a entre eles &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;069&#41;&#46; Nenhum participante apresentou piora da contagem de CA&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">A diferen&#231;a intergrupos da melhora da EFA tamb&#233;m n&#227;o foi relevante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;654&#41;&#59; por outro lado&#44; ambos os tratamentos levaram &#224; redu&#231;&#227;o significante da EGCA&#44; e nesse quesito houve superioridade do 5&#8208;FU &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#59; <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">A respeito dos efeitos adversos&#44; este estudo demonstrou que COL provocou mais dor que 5&#8208;FU&#44; al&#233;m de causar mais edema e desencadear descama&#231;&#227;o mais intensa&#46; Em contrapartida&#44; 5&#8208;FU levou &#224; maior forma&#231;&#227;o de crostas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46; Contudo&#44; apenas um participante &#40;2&#44;2&#37;&#41; referiu n&#227;o estar disposto a realizar novamente os tratamentos caso fosse necess&#225;rio&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">N&#227;o houve surgimento de neoplasias malignas nas regi&#245;es tratadas durante o seguimento de 90 dias&#46; No per&#237;odo do estudo&#44; houve quatro <span class="elsevierStyleItalic">dropouts</span>&#44; de modo que 41 participantes &#40;82 antebra&#231;os&#41; passaram por todas as tr&#234;s avalia&#231;&#245;es &#40;D0&#44; D14 e D90&#41;&#46; Os <span class="elsevierStyleItalic">dropouts</span> n&#227;o ocorreram em virtude dos efeitos adversos da interven&#231;&#227;o&#44; mas por n&#227;o comparecimento dos pacientes no dia agendado para a avalia&#231;&#227;o e impossibilidade de reagendamento &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Os participantes faltantes foram contactados e n&#227;o compareceram por motivos ligados &#224; pandemia de COVID&#8208;19&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discuss&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">O presente estudo n&#227;o demonstrou diferen&#231;a quanto &#224; efic&#225;cia no tratamento de CA entre 5&#8208;FU 5&#37; e COL 0&#44;5&#37; nas posologias e tempo de uso testados&#46; Uma vez que 5&#8208;FU &#233; tratamento consagrado e fortemente recomendado para tratamento de CA e CCC&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> esse dado refor&#231;a COL tamb&#233;m como op&#231;&#227;o terap&#234;utica&#44; de custo acess&#237;vel e posologia que facilita a ader&#234;ncia&#44; em que pesem efeitos adversos mais intensos&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Entre os antebra&#231;os tratados com 5&#8208;FU&#44; 37&#37; apresentaram <span class="elsevierStyleItalic">clearance</span> completo das CA&#44; resultado muito semelhante ao encontrado em um ensaio cl&#237;nico randomizado duplo&#8208;cego&#44; com 932 pacientes&#44; em que foi avaliada a efic&#225;cia de creme de 5&#8208;FU 5&#37; seis meses ap&#243;s um curso de tratamento de 2&#215;&#47;dia por quatro semanas na face e orelhas &#40;<span class="elsevierStyleItalic">clearance</span> completo 5&#8208;FU 38&#37; <span class="elsevierStyleItalic">versus</span> placebo 17&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Outro ensaio cl&#237;nico randomizado&#44; envolvendo 602 pacientes&#44; que comparou 5&#8208;FU 5&#37; a outras tr&#234;s op&#231;&#245;es de tratamento para CA na cabe&#231;a&#44; evidenciou <span class="elsevierStyleItalic">clearance</span> &#8805; 75&#37; em 90&#44;6&#37; dos pacientes ap&#243;s tr&#234;s meses do t&#233;rmino de tratamento&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> De maneira similar&#44; verificamos 85&#37; de <span class="elsevierStyleItalic">clearance</span> parcial &#40;&#8805; 50&#37;&#41; nos antebra&#231;os tratados com 5&#8208;FU em nosso estudo&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">No que tange ao tratamento de CA em membros superiores&#44; um ensaio cl&#237;nico autocontrolado comparou o uso de creme de 5&#8208;FU 5&#37; 2&#215;&#47;dia em dois ciclos de 15 dias separados por 15 dias de pausa <span class="elsevierStyleItalic">versus</span> quatro sess&#245;es quinzenais de <span class="elsevierStyleItalic">peeling</span> de &#225;cido glic&#243;lico 70&#37; &#43; solu&#231;&#227;o de 5&#8208;FU 5&#37;&#44; apontando redu&#231;&#227;o de 85&#44;7&#37; no n&#250;mero de CA nos membros tratados com 5&#8208;FU creme&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> A menor amostragem do referido estudo&#44; &#225;rea de tratamento incluindo as m&#227;os&#44; bem como a posologia diferente&#44; que pode interferir na ader&#234;ncia ao tratamento&#44; s&#227;o caracter&#237;sticas que podem explicar a discreta diferen&#231;a&#44; a favor&#44; em rela&#231;&#227;o &#224; redu&#231;&#227;o de 75&#37; na contagem de CA encontrada em nosso estudo&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Foi observado <span class="elsevierStyleItalic">clearance</span> completo de 17&#37; nos antebra&#231;os submetidos ao curso de sete dias de creme de COL 0&#44;5&#37;&#44; 2&#215;&#47;dia&#46; A mesma taxa foi constatada em um estudo que utilizou COL 0&#44;5&#37; em antebra&#231;os 2&#215;&#47;dia por 10 dias em 36 antebra&#231;os estudados&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Esses dados sugerem que um curso mais curto&#44; de sete dias&#44; pode apresentar a mesma efic&#225;cia na melhora de CA e CCC&#46; N&#227;o &#233; poss&#237;vel inferir resultados decorrentes de cursos mensais&#44; sequenciais&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Ensaio cl&#237;nico mais recente comparando COL &#40;2&#215;&#47;dia por sete dias&#41; <span class="elsevierStyleItalic">versus</span> mebutato de ingenol ou filtro solar&#44; associados ou n&#227;o a <span class="elsevierStyleItalic">Polypodium leucatomos</span> via oral&#44; evidenciou <span class="elsevierStyleItalic">clearance</span> completo&#44; ap&#243;s 60 dias&#44; de 14&#44;7&#37; para COL&#44; 16&#44;1&#37; para o mebutato de ingenol e 2&#44;8&#37; para filtro solar&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> O presente estudo e os dois ensaios cl&#237;nicos citados apresentam taxa de <span class="elsevierStyleItalic">clearance</span> similar para COL&#44; o que demonstra sua consist&#234;ncia como op&#231;&#227;o de tratamento do CCC&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Constatamos redu&#231;&#227;o de 64&#37; na contagem de CA nos antebra&#231;os tratados com COL comparando D0 com D90&#46; Estudo anterior evidenciou resultado superior da COL nos membros superiores&#44; com redu&#231;&#227;o de 73&#44;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> Essa superioridade pode justificar&#8208;se por&#44; no referido estudo&#44; ter sido realizado um segundo curso de tratamento de 10 dias nos pacientes que apresentaram pouca ou nenhuma resposta inflamat&#243;ria ao primeiro curso&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">O primeiro ensaio cl&#237;nico que testou o uso de COL para tratamento de CA comparou a aplica&#231;&#227;o de gel de COL 2&#215;&#47;dia por 10 dias ao placebo&#44; verificando total resolu&#231;&#227;o das les&#245;es em sete dos 10 pacientes tratados&#44; enquanto no grupo placebo nenhum paciente apresentou resposta&#46; Em contraposi&#231;&#227;o ao nosso estudo&#44; esse ensaio cl&#237;nico n&#227;o era controlado&#44; n&#227;o houve per&#237;odo de <span class="elsevierStyleItalic">washout</span> antes da inclus&#227;o &#40;quantidade n&#227;o informada de participantes havia realizado outros tratamentos para CA pouco antes do estudo&#41;&#44; a concentra&#231;&#227;o utilizada de COL foi de 1&#37; em ve&#237;culo gel&#44; a &#225;rea tratada foi a fronte e a amostragem foi consideravelmente menor&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> diferen&#231;as que podem justificar a discrep&#226;ncia na taxa de <span class="elsevierStyleItalic">clearance</span> completo&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">N&#227;o h&#225; apresenta&#231;&#245;es t&#243;picas industrializadas de COL&#44; mas &#233; poss&#237;vel obter formula&#231;&#245;es de uso t&#243;pico contendo COL por meio de farm&#225;cias de manipula&#231;&#227;o&#46; Em rela&#231;&#227;o &#224; solubilidade&#44; 1<span class="elsevierStyleHsp" style=""></span>g de COL dissolve&#8208;se em 22<span class="elsevierStyleHsp" style=""></span>mL de &#225;gua&#44; 220<span class="elsevierStyleHsp" style=""></span>mL de &#233;ter&#44; 100<span class="elsevierStyleHsp" style=""></span>mL de benzeno&#44; livremente em &#225;lcool ou clorof&#243;rmio e &#233; praticamente insol&#250;vel em &#233;ter de petr&#243;leo ou vaselina&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> Utilizamos como ve&#237;culo neste estudo o creme n&#227;o i&#244;nico&#44; por apresentar bom perfil de solubilidade para COL&#44; propiciando a penetra&#231;&#227;o do f&#225;rmaco&#46; Dois ensaios cl&#237;nicos pr&#233;vios<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16&#44;17</span></a> desse grupo de pesquisa utilizaram a mesma formula&#231;&#227;o&#44; produzida pela mesma farm&#225;cia de manipula&#231;&#227;o &#40;Pharm&#225;cia Spec&#237;fica Ltda&#41;&#44; atingindo taxas de <span class="elsevierStyleItalic">clearance</span> muito similares&#44; o que sugere const&#226;ncia e estabilidade das formula&#231;&#245;es&#46; A COL escurece quando exposta &#224; luz&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> motivo pelo qual optamos por frascos resistentes &#224; luz e <span class="elsevierStyleItalic">airless</span> para armazenamento do creme de COL&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Para o tratamento do fotoenvelhecimento de antebra&#231;os&#44; 5&#8208;FU demonstrou previamente melhorar aspecto visual da pele&#44; al&#233;m de aumentar a express&#227;o de pr&#243;&#8208;col&#225;geno I na avalia&#231;&#227;o seis meses ap&#243;s o tratamento&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> Ambos os tratamentos investigados no presente estudo levaram &#224; melhora na EFA&#46; Esse resultado faz refletir se a COL poderia trazer benef&#237;cios tamb&#233;m no tratamento do fotoenvelhecimento&#44; suscitando a import&#226;ncia de estudos com desenho dedicado a elucidar essa quest&#227;o&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A EGCA foi o desfecho em que evidenciamos superioridade significante do 5&#8208;FU em rela&#231;&#227;o &#224; COL &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46; Os crit&#233;rios que definem essa escala s&#227;o di&#226;metro das les&#245;es&#44; grau de hiperceratose e presen&#231;a de exulcera&#231;&#227;o&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> &#201; importante considerar que&#44; para o paciente&#44; a melhora de hiperceratose e exulcera&#231;&#227;o&#44; ainda que n&#227;o haja resolu&#231;&#227;o completa da les&#227;o&#44; pode trazer mais satisfa&#231;&#227;o e conforto&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Diferen&#231;as relevantes foram encontradas em rela&#231;&#227;o aos efeitos adversos dos tratamentos&#58; COL provocou mais dor&#44; mais edema e mais descama&#231;&#227;o que 5&#8208;FU&#59; em compensa&#231;&#227;o&#44; 5&#8208;FU ocasionou maior forma&#231;&#227;o de crostas&#46; A ocorr&#234;ncia de rea&#231;&#245;es adversas pode ser motivo para o paciente n&#227;o aderir apropriadamente ao tratamento&#59; entretanto&#44; o principal fator que compromete a ader&#234;ncia a tratamentos t&#243;picos para CA e CCC &#233; a dura&#231;&#227;o prolongada de tratamento&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> Assim&#44; ainda que a COL esteja mais associada a alguns dos efeitos adversos&#44; o fato de ter curso mais curto de tratamento comparativamente ao 5&#8208;FU a posiciona como vantajosa op&#231;&#227;o de tratamento de CA e CCC&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Em um estudo que avaliou rea&#231;&#245;es cut&#226;neas em decorr&#234;ncia do uso de 5&#8208;FU 5&#37; 2&#215;&#47;dia por quatro semanas evidenciou&#8208;se que eritema intenso foi a rea&#231;&#227;o mais frequente &#40;46&#44;7&#37;&#41;&#44; seguido por prurido &#40;28&#44;9&#37;&#41;&#44; sensa&#231;&#227;o de queima&#231;&#227;o &#40;21&#44;5&#37;&#41; e descama&#231;&#227;o &#40;18&#44;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Em nosso estudo&#44; houve eritema em 82&#37; e descama&#231;&#227;o em 49&#37; dos antebra&#231;os tratados com 5&#8208;FU&#46; Todavia&#44; na presente pesquisa&#44; o eritema foi classificado como intenso em apenas 2&#37; dos casos&#46; A diferen&#231;a pode ser explicada pelo fato de que o estudo acima mencionado determinou a ocorr&#234;ncia de efeitos adversos por meio do relato telef&#244;nico dos participantes&#44; enquanto em nosso estudo as rea&#231;&#245;es foram aferidas por exame dermatol&#243;gico&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Ademais&#44; o papel adicional dos filtros solares no tratamento do CCC n&#227;o deve ser negligenciado&#59; em estudo com popula&#231;&#227;o semelhante que incluiu 40 indiv&#237;duos &#40;80 antebra&#231;os&#41; com CA nos antebra&#231;os&#44; houve redu&#231;&#227;o de cerca de 30&#37; na contagem de les&#245;es&#44; ap&#243;s 60 dias&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">S&#227;o limita&#231;&#245;es do presente estudo a relativa homogeneidade da popula&#231;&#227;o estudada&#44; por tratar&#8208;se de estudo unic&#234;ntrico&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">&#201; extremamente v&#225;lida a investiga&#231;&#227;o de outros esquemas posol&#243;gicos de COL&#44; a fim de identificar formas de uso mais eficazes e c&#244;modas&#46; &#201; tamb&#233;m pertinente que sejam realizados mais estudos comparativos com COL em outras &#225;reas&#44; como a face e couro cabeludo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclus&#245;es</span><p id="par0220" class="elsevierStylePara elsevierViewall">5&#8208;FU e COL s&#227;o eficazes para tratamento de CCC&#44; com taxas de <span class="elsevierStyleItalic">clearance</span> completo e parcial que n&#227;o tiveram diferen&#231;a estat&#237;stica ap&#243;s 90 dias&#46; 5&#8208;FU foi superior em reduzir a gravidade das CA&#59; COL provocou mais dor&#44; edema e descama&#231;&#227;o que 5&#8208;FU&#44; mas este &#250;ltimo ocasionou mais crostas&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Suporte financeiro</span><p id="par0225" class="elsevierStylePara elsevierViewall">Fundo de Apoio &#224; Dermatologia &#40;FUNADERM&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Contribui&#231;&#227;o dos autores</span><p id="par0230" class="elsevierStylePara elsevierViewall">Amanda Soares Teixeira&#58; Desenho do projeto&#59; coleta dos dados&#59; revis&#227;o da literatura&#59; escrita e aprova&#231;&#227;o do texto&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Ivanka Miranda de Castro Martins&#58; Coleta dos dados&#59; escrita e aprova&#231;&#227;o do texto&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Anna Carolina Miola&#58; Desenho do projeto&#59; revis&#227;o da literatura&#59; escrita e aprova&#231;&#227;o do texto&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">H&#233;lio Amante Miot&#58; Desenho do projeto&#59; an&#225;lise dos dados&#59; revis&#227;o da literatura&#59; escrita e aprova&#231;&#227;o do texto&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflito de interesses</span><p id="par0250" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">5&#8208;fluorouracil &#40;5&#8208;FU&#41; &#233; medicamento de primeira linha para tratar campo de canceriza&#231;&#227;o cut&#226;neo &#40;CCC&#41;&#46; H&#225; poucos ensaios cl&#237;nicos com colchicina &#40;COL&#41; t&#243;pica&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Avaliar a efic&#225;cia do creme de COL 0&#44;5&#37; <span class="elsevierStyleItalic">versus</span> creme de 5&#8208;FU 5&#37; no tratamento do CCC&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todo</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ensaio cl&#237;nico randomizado&#44; aberto&#44; autocontrolado&#46; Quarenta e cinco pacientes &#40;90 antebra&#231;os&#41;&#44; com 3 a 10 ceratoses act&#237;nicas &#40;CA&#41; em cada antebra&#231;o&#44; utilizaram creme de COL 0&#44;5&#37; 2&#215;&#47;dia por sete dias em um antebra&#231;o&#44; e creme 5&#8208;FU 5&#37; 2&#215;&#47;dia&#44; por 21 dias&#44; no outro antebra&#231;o&#46; As posologias foram definidas a partir de ensaios cl&#237;nicos pr&#233;vios para cada medicamento&#46; Efeitos adversos foram avaliados ap&#243;s 14 dias e os desfechos&#44; ap&#243;s 90 dias da inclus&#227;o&#46; O desfecho prim&#225;rio foi a elimina&#231;&#227;o completa de CA&#44; e os secund&#225;rios&#58; elimina&#231;&#227;o parcial &#40;&#8805; 50&#37;&#41;&#44; redu&#231;&#227;o na contagem de CA&#44; avalia&#231;&#227;o da escala de fotoenvelhecimento dos antebra&#231;os &#40;EFA&#41;&#44; escala de gravidade das CA &#40;EGCA&#41; e efeitos adversos&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ap&#243;s 90 dias&#44; houve elimina&#231;&#227;o completa das CA em 37&#37; &#40;95&#37; IC 24&#37;&#8208;49&#37;&#41; e elimina&#231;&#227;o parcial em 85&#37; &#40;95&#37; IC 76&#37;&#8208;93&#37;&#41; dos antebra&#231;os tratados com 5&#8208;FU&#44; <span class="elsevierStyleItalic">versus</span> 17&#37; &#40;95&#37; IC 7&#37;&#8208;27&#37;&#41; e 78&#37; &#40;95&#37; IC 66&#37;&#8208;88&#37;&#41; para COL &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;07&#41;&#46; Houve redu&#231;&#227;o percentual de 75&#37; na contagem de CA dos antebra&#231;os tratados com 5&#8208;FU &#40;95&#37; IC 66&#37;&#8208;83&#37;&#41; e de 64&#37; nos tratados com COL &#40;95&#37; IC 55&#37;&#8208;72&#37;&#41;&#46; Quanto &#224; EFA e EGCA&#44; houve melhora em ambos os grupos&#44; sem diferen&#231;a quanto &#224; EFA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;654&#41;&#44; com superioridade do 5&#8208;FU para EGCA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Limita&#231;&#245;es do estudo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estudo monoc&#234;ntrico&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">5&#8208;FU e COL s&#227;o eficazes para tratamento do CCC&#44; sem superioridade entre eles na redu&#231;&#227;o de contagem de CA&#46;</p></span>"
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                  """
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intenso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ausente&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8208; &#40;&#8208;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ausente&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leve&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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Informação do artigo
ISSN: 26662752
Idioma original: Português
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