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tr&#234;s grupos foram comparados&#58; pacientes com PV &#40;doravante denominados PV&#41;&#44; pacientes com PF &#40;doravante denominados PF&#41; e controles&#46; Este estudo foi aprovado pelo Comit&#234; de &#201;tica em Pesquisa local do Hospital Universit&#225;rio da Faculdade de Medicina de Ribeir&#227;o Preto da Universidade de S&#227;o Paulo &#40;n&#176; 2248&#47;2010&#41;&#44; e todos os participantes assinaram o termo de consentimento livre e esclarecido&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Grupos de pacientes e controles</span><p id="par0025" class="elsevierStylePara elsevierViewall">Setenta e cinco pacientes com p&#234;nfigo atendidos no Ambulat&#243;rio de Dermatologia do Hospital das Cl&#237;nicas da Faculdade de Medicina de Ribeir&#227;o Preto da Universidade de S&#227;o Paulo &#40;SP&#44; Brasil&#41; foram inclu&#237;dos no estudo&#46; Entre eles&#44; 32 tinham PV &#40;mediana de idade<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50 anos&#44; 75&#37; do sexo feminino&#41; e 43 tinham PF &#40;mediana de idade<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>46 anos&#44; 58&#44;1&#37; do sexo feminino&#41;&#44; respectivamente &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46; O diagn&#243;stico de PV e PF foi estabelecido com base em caracter&#237;sticas cl&#237;nicas&#44; histopatol&#243;gicas e de imunofluoresc&#234;ncia &#40;direta&#44; indireta ou ambas&#41; e determina&#231;&#227;o de autoanticorpos contra Dsg1 e Dsg3 por ELISA &#40;MBL&#44; Jap&#227;o&#41;&#46; Os controles consistiram em 67 parentes e vizinhos saud&#225;veis dos pacientes com p&#234;nfigo &#40;mediana de idade<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>46 anos&#44; 70&#44;1&#37; do sexo feminino&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46; PV&#44; PF e controles residiam na regi&#227;o nordeste do estado de S&#227;o Paulo&#44; localizado no Sudeste do Brasil&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Question&#225;rios</span><p id="par0030" class="elsevierStylePara elsevierViewall">Os question&#225;rios&#44; elaborados pelos autores&#44; foram aplicados a 28 pacientes com PV e 39 com PF e a 48 controles&#46; As respostas a cada item dos question&#225;rios foram incompletas nos tr&#234;s grupos&#46; Assim&#44; 28 pacientes com PV e 40 controles responderam a &#8220;&#193;rea de resid&#234;ncia&#8221;&#59; e 27 pacientes com PV e 48 controles responderam &#224;s quest&#245;es sobre &#8220;Exposi&#231;&#227;o a pesticidas&#8221; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46; Os indiv&#237;duos foram entrevistados por ocasi&#227;o da sua visita ao Ambulat&#243;rio de Dermatologia do Hospital das Cl&#237;nicas da Faculdade de Medicina de Ribeir&#227;o Preto da Universidade de S&#227;o Paulo&#46; Duas informa&#231;&#245;es principais foram analisadas&#58; &#225;rea de resid&#234;ncia &#40;rural ou urbana&#41; por ocasi&#227;o do aparecimento do p&#234;nfigo e exposi&#231;&#227;o a pesticidas relacionada a atividades profissionais ou outras causas&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Coleta de amostras de cabelo</span><p id="par0035" class="elsevierStylePara elsevierViewall">Com o aux&#237;lio de uma tesoura est&#233;ril&#44; foram cortados cerca de 500<span class="elsevierStyleHsp" style=""></span>mg da raiz do cabelo do couro cabeludo na regi&#227;o occipital e armazenados em envelopes de papel individuais em temperatura ambiente at&#233; a an&#225;lise&#46; As amostras foram testadas para pesticidas OP e OC&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos anal&#237;ticos de pesticidas OP e OC e valores aceit&#225;veis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Os agrot&#243;xicos pertencentes &#224;s classes OP e OC foram analisados por cromatografia em fase gasosa acoplada &#224; espectrometria de massa &#40;GC&#47;MS&#41;&#46; O procedimento de extra&#231;&#227;o para an&#225;lise de amostras de cabelo para presen&#231;a de OP e OC foi o mesmo descrito por Tsatsakis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">24</span></a> e adaptado &#224;s condi&#231;&#245;es instrumentais do Laborat&#243;rio de Toxicologia Forense do Departamento de Qu&#237;mica da Faculdade de Filosofia&#44; Ci&#234;ncias e Letras de Ribeir&#227;o Preto da Universidade de S&#227;o Paulo&#46; Os experimentos foram realizados em um cromat&#243;grafo a g&#225;s 7890A acoplado a um espectr&#244;metro de massa 5975C Inert &#40;Agilent Technologies&#44; EUA&#41; equipado com uma coluna cromatogr&#225;fica DB&#8208;5MSUI &#40;30 m<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#44;25<span class="elsevierStyleHsp" style=""></span>mm&#47;d&#46;i&#46;&#44; 0&#44;25<span class="elsevierStyleHsp" style=""></span>&#956;m de espessura de filme&#59; Agilent Technologies&#44; EUA&#41;&#46; Os analitos foram elu&#237;dos com programa&#231;&#227;o linear de temperatura do forno&#44; como descrito a seguir&#58; 60<span class="elsevierStyleHsp" style=""></span>&#176;C por 2&#44;0<span class="elsevierStyleHsp" style=""></span>min&#44; aumento para 315<span class="elsevierStyleHsp" style=""></span>&#176;C a 30<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;min&#44; e 315<span class="elsevierStyleHsp" style=""></span>&#176;C por 2<span class="elsevierStyleHsp" style=""></span>min &#40;tempo total de 12&#44;5<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; As temperaturas da porta de inje&#231;&#227;o e da linha de transfer&#234;ncia foram ajustadas para 280<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; H&#233;lio ultrapuro foi usado como g&#225;s carreador a uma vaz&#227;o de 1&#44;0<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#44; e as amostras foram injetadas no modo <span class="elsevierStyleItalic">splitless</span> &#40;utilizando <span class="elsevierStyleItalic">liner split</span> ultrainerte desativado com l&#227; de vidro para melhorar a cromatografia&#41;&#46; O espectr&#244;metro de massa foi ajustado para o modo SIM&#46; Os dados foram adquiridos e o instrumento foi controlado com o <span class="elsevierStyleItalic">software</span> Agilent Technologies ChemStation&#44; vers&#227;o E02021431&#44; fornecido pelo fabricante&#46; A <a class="elsevierStyleCrossRef" href="#sec0090">tabela suplementar 1</a> fornece os valores de limite de detec&#231;&#227;o &#40;LOD&#41; e limite de quantifica&#231;&#227;o &#40;LOQ&#41; dos pesticidas&#46; Os valores de ingest&#227;o di&#225;ria aceit&#225;vel &#40;IDA&#41; para OP detectados neste estudo s&#227;o os seguintes&#58; clorpirif&#243;s &#40;10 pg&#47;mg&#41;&#44; diazinon &#40;2 pg&#47;mg&#41; e malation &#40;300 pg&#47;mg&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">25</span></a> O uso de diclorv&#243;s&#44; metil&#8208;paration e paration foi banido&#46; O uso dos pesticidas OC aldrin&#44; BHC&#44; DDT e endrin tamb&#233;m foi banido&#44; ent&#227;o nenhum valor de IDA est&#225; dispon&#237;vel para eles&#46; As amostras que testaram positivo&#44; mas abaixo do limite de detec&#231;&#227;o &#40;&#60; LOQ&#41; foram inclu&#237;das no presente estudo&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">An&#225;lise estat&#237;stica</span><p id="par0045" class="elsevierStylePara elsevierViewall">Os testes de Kruskal&#8208;Wallis e Mann&#8208;Whitney foram utilizados para analisar idade e dura&#231;&#227;o da doen&#231;a&#44; respectivamente&#46; O teste de Fischer foi utilizado para analisar as frequ&#234;ncias das vari&#225;veis&#46; Adotou&#8208;se p &#8804; 0&#44;05 e empregou&#8208;se a compara&#231;&#227;o bicaudal&#46; A an&#225;lise estat&#237;stica foi realizada utilizando&#8208;se o <span class="elsevierStyleItalic">software</span> SPSS&#44; 26&#46;0 &#40;IBM&#44; EUA&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Dados demogr&#225;ficos e cl&#237;nicos</span><p id="par0050" class="elsevierStylePara elsevierViewall">Os grupos de 32 PV&#44; 43 PF e 67 controles n&#227;o diferiram quanto &#224; idade ou sexo&#46; Dados sobre a idade de 14 controles n&#227;o estavam dispon&#237;veis&#46; A dura&#231;&#227;o da doen&#231;a foi maior no grupo PF do que no PV &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Dados de entrevistas com base em question&#225;rio</span><p id="par0055" class="elsevierStylePara elsevierViewall">N&#227;o houve diferen&#231;a estat&#237;stica comparando &#225;rea de resid&#234;ncia urbana ou rural entre PV&#44; PF e controles &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2853&#41;&#46; Dois &#40;7&#44;1&#37;&#41; dos 28 PV e 7 &#40;18&#37;&#41; dos 39 PF&#44; mas nenhum dos 48 controles&#44; informaram residir na zona rural&#46; As informa&#231;&#245;es positivas ou negativas sobre a exposi&#231;&#227;o a pesticidas foram semelhantes entre os grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;186&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Quantifica&#231;&#227;o dos n&#237;veis de OP e OC em amostras de cabelo</span><p id="par0060" class="elsevierStylePara elsevierViewall">Pesticidas OP e OC foram quantificados em amostras de cabelo de 32 PV&#44; 43 PF e 67 controles &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46; Vinte e um &#40;14&#44;8&#37;&#41; dos 142 indiv&#237;duos testaram positivo para OP&#44; OC ou ambos&#46; O grupo PF &#40;11 &#91;25&#44;6&#37;&#93;&#41; apresentou mais pacientes contaminados do que o PV &#40;2 &#91;6&#44;3&#37;&#93;&#41;&#44; mas tinha tantos indiv&#237;duos contaminados quanto os controles &#40;8 &#91;11&#44;9&#37;&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;034 e p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0753&#44; respectivamente&#41;&#46; PV e controles tiveram detec&#231;&#227;o de pesticidas semelhante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;4928&#41;&#46; Tr&#234;s &#40;7&#37;&#41; PF testaram positivo para OP e OC&#46; Nenhum dos 32 PV testou positivo para OP&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Quatro OC e seis OP foram detectados em pacientes e controles &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46; Entre os OC&#44; aldrin foi detectado em dois controles &#40;&#60; LOQ e 7&#44;7 pg&#47;mg&#41;&#59; BHC em dois PV e quatro PF &#40;varia&#231;&#227;o &#8804; LOQ a 12&#44;2 pg&#47;mg&#41;&#59; DDT em um PV e dois PF &#40;&#60; LOQ&#41;&#59; e endrin em um controle &#40;9&#44;1 pg&#47;mg&#41;&#46; Entre os OP&#44; o clorpirif&#243;s foi detectado em dois PF e tr&#234;s controles &#40;varia&#231;&#227;o &#8804; LOQ a 12&#44;6 pg&#47;mg&#41;&#59; diazinon em cinco PF e dois controles &#40;varia&#231;&#227;o &#8804; LOQ a 15&#44;6 pg&#47;mg&#41;&#59; diclorv&#243;s em quatro PF e dois controles &#40;varia&#231;&#227;o &#8804; LOQ a 9&#44;1 pg&#47;mg&#41;&#59; malation em dois PF e um controle &#40;varia&#231;&#227;o &#8804; LOQ a 8&#44;3 pg&#47;mg&#41;&#59; metil&#8208;paration em um PF &#40;12&#44;1 pg&#47;mg&#41;&#59; e paration em outro PF &#40;&#60; LOQ&#41;&#46; Alguns PF testaram positivo para tr&#234;s ou quatro OP&#44; com predomin&#226;ncia de diazinon e diclorv&#243;s&#46; Diurom foi detectado em um PF&#46; Sete &#40;70&#37;&#41; dos 10 PF eram do sexo feminino&#44; residiam em &#225;reas rurais no in&#237;cio do p&#234;nfigo e haviam sido expostas a pesticidas durante suas atividades profissionais no campo &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discuss&#227;o</span><p id="par0070" class="elsevierStylePara elsevierViewall">A patog&#234;nese do p&#234;nfigo &#233; atribu&#237;da ao hist&#243;rico gen&#233;tico e a fatores ambientais&#44; incluindo pesticidas&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">4&#8211;6&#44;15&#8211;20&#44;26</span></a> H&#225; poucos relatos de pesticidas desencadeando autoimunidade&#46; Eles foram descritos como causadores de imunotoxicidade&#44; disfun&#231;&#227;o end&#243;crina&#44; dist&#250;rbios neurodegenerativos e c&#226;ncer&#44; entre outras condi&#231;&#245;es&#46; Em rela&#231;&#227;o &#224;s doen&#231;as autoimunes&#44; os pesticidas t&#234;m sido relacionados principalmente ao l&#250;pus eritematoso sist&#234;mico e &#224; artrite reumatoide&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">27&#8211;30</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Que seja do nosso conhecimento&#44; este &#233; o primeiro relato sobre a quantifica&#231;&#227;o de n&#237;veis de pesticidas em pacientes com PV e PF&#44; em compara&#231;&#227;o com controles&#46; Escolheu&#8208;se quantificar os n&#237;veis de pesticidas em amostras de cabelo porque s&#227;o considerados biomarcadores humanos de exposi&#231;&#227;o aos pesticidas&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">31&#8211;33</span></a> O presente estudo confirmou a contamina&#231;&#227;o por OP e&#47;ou OC em amostras de cabelo em PV&#44; PF e controles &#40;6&#44;3&#37;&#44; 25&#44;6&#37; e 11&#44;9&#37;&#44; respectivamente&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0437&#41;&#46; Em compara&#231;&#227;o com PV&#44; PF apresentou maior frequ&#234;ncia de contamina&#231;&#227;o com pesticidas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;034&#41;&#46; Al&#233;m disso&#44; nove &#40;20&#44;9&#37;&#41; de 43 PF&#44; mas nenhum dos 32 PV testou positivo para OP&#46; Alguns PF testaram positivo para tr&#234;s ou quatro OP&#44; com predomin&#226;ncia de diazinon e diclorv&#243;s&#46; OC foi detectado de modo semelhante em PV&#44; PF e controles&#44; embora seu uso tenha sido banido desde 1985&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">34</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">O mecanismo imunol&#243;gico proposto para PV utilizando clorpirif&#243;s&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">23</span></a> que &#233; um dos OP detectados em PF e controles neste estudo&#44; n&#227;o explica a patog&#234;nese do PV nesse pesticida&#44; uma vez que o PV n&#227;o apresentou nenhuma contamina&#231;&#227;o por OP&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Como se explica a preval&#234;ncia aumentada de contamina&#231;&#227;o por pesticidas no PF&#63; Historicamente&#44; no Brasil&#44; o PF estava distribu&#237;do em &#225;reas rurais pr&#243;ximas aos rios&#44; e a exposi&#231;&#227;o a pesticidas foi considerada um poss&#237;vel fator de risco para PF no pa&#237;s&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">20&#44;35</span></a> Entretanto&#44; as entrevistas com base em question&#225;rio n&#227;o revelaram diferen&#231;a estat&#237;stica entre PV&#44; PF e controles em termos de resid&#234;ncia urbana ou rural e exposi&#231;&#227;o a pesticidas&#46; Por outro lado&#44; a maioria do grupo PF com contamina&#231;&#227;o capilar por OC ou OP informou que residia na zona rural no in&#237;cio do p&#234;nfigo e havia sido exposta a pesticidas durante suas atividades profissionais no campo &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46; Al&#233;m disso&#44; a doen&#231;a tem dura&#231;&#227;o maior no PF do que no PV&#44; o que pode ter contribu&#237;do para a bioacumula&#231;&#227;o de pesticidas no PF&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A exposi&#231;&#227;o a pesticidas foi confirmada em doadores de sangue e na popula&#231;&#227;o rural no Brasil&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">36&#8211;38</span></a> Al&#233;m disso&#44; o perfil imunol&#243;gico foi determinado em agricultores brasileiros expostos a pesticidas&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">39&#44;40</span></a> Em nosso estudo&#44; em oito controles que apresentaram contamina&#231;&#227;o com pesticidas &#40;seis OP e dois OC&#59; <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#44; foram pesquisados autoanticorpos contra Dsg1 e Dsg3 utilizando ELISA &#40;MBL&#44; Jap&#227;o&#41;&#44; com resultados negativos em tr&#234;s &#40;C<span class="elsevierStyleInf">1</span>&#44; C<span class="elsevierStyleInf">7</span> e C<span class="elsevierStyleInf">8</span>&#41;&#46; Os perfis de HLA classe II foram determinados nos oito controles &#40;C<span class="elsevierStyleInf">1</span> a C<span class="elsevierStyleInf">8</span>&#59; dados n&#227;o mostrados&#41;&#46; Em dois dos seis controles contaminados com OP observamos&#58; um controle &#40;C1&#41; contaminado com diazinon e malation apresentou ambos os alelos <span class="elsevierStyleItalic">HLA&#8208;DRB1</span>&#42;01&#58;01 e <span class="elsevierStyleItalic">HLA&#8208;DQB1</span>&#42;05&#58;01 de suscetibilidade para PF&#59; e outro &#40;C5&#41; contaminado com diclorv&#243;s e clorpirif&#243;s apresentou o alelo <span class="elsevierStyleItalic">HLA&#8208;DQB1</span>&#42;03&#58;02 de suscetibilidade para PV&#46; Os outros seis controles n&#227;o apresentaram alelos associados com PV e PF &#40;para alelos HLA associados a PV e PF&#44; ver Brochado et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">4</span></a>&#41;&#46; Sabendo que ambas as formas cl&#237;nicas de p&#234;nfigo s&#227;o prevalentes na regi&#227;o nordeste do estado de S&#227;o Paulo<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">35</span></a> testar anticorpos contra Dsg e determinar os alelos HLA em uma ampla popula&#231;&#227;o exposta a pesticidas forneceria informa&#231;&#245;es importantes sobre a rela&#231;&#227;o pesticidas&#8208;p&#234;nfigo&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Os resultados do presente estudo corroboram um relato recente de Chang e Tsai&#44;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">41</span></a> em revis&#227;o sistem&#225;tica e metan&#225;lise&#46; Eles inclu&#237;ram cinco estudos de caso&#8208;controle<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">15&#8211;17&#44;19&#44;20</span></a> com base em entrevistas sobre a rela&#231;&#227;o entre exposi&#231;&#227;o a pesticidas e PV e PF&#46; Os autoress conclu&#237;ram haver associa&#231;&#227;o entre exposi&#231;&#227;o a pesticidas e p&#234;nfigo&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">41</span></a> Em nosso estudo&#44; demonstramos a contamina&#231;&#227;o do cabelo por OC e&#47;ou OP nos tr&#234;s grupos estudados&#59; o grupo PF foi o que apresentou a maior contamina&#231;&#227;o por pesticidas&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclus&#227;o</span><p id="par0100" class="elsevierStylePara elsevierViewall">O presente estudo confirmou a contamina&#231;&#227;o do cabelo com pesticidas OC e&#47;ou OP em PF&#44; PV e controles&#46; Os pacientes com PV n&#227;o testaram positivo para pesticidas OP&#46; Alguns pacientes com PF testaram positivo para tr&#234;s ou quatro OP&#44; com predomin&#226;ncia de diazinon e diclorv&#243;s&#46; Embora PV e PF tenham fornecido informa&#231;&#245;es semelhantes sobre resid&#234;ncia em &#225;reas rurais no in&#237;cio do p&#234;nfigo e estarem expostos a pesticidas&#44; a detec&#231;&#227;o desses foi mais frequente em amostras de cabelo de PF em compara&#231;&#227;o com PV&#46; A rela&#231;&#227;o entre a patog&#234;nese de PF e pesticidas ainda precisa ser elucidada&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Suporte financeiro</span><p id="par0105" class="elsevierStylePara elsevierViewall">Este estudo foi parcialmente financiado pela Funda&#231;&#227;o de Amparo &#224; Pesquisa do Estado de S&#227;o Paulo &#40;FAPESP&#44; n&#176; 2010&#47;51729&#8208;2&#41;&#46; O primeiro autor recebeu bolsa de mestrado da Coordena&#231;&#227;o de Aperfei&#231;oamento de Pessoal de N&#237;vel Superior &#40;CAPES&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Contribui&#231;&#227;o dos autores</span><p id="par0110" class="elsevierStylePara elsevierViewall">Bruno de Martins&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Leonardo La Serra&#58; An&#225;lise estat&#237;stica&#59; aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#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; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Rafael Lanaro&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Ana Maria Roselino&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflito de interesses</span><p id="par0130" 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">Pesticidas&#44; principalmente os organofosforados &#40;OP&#41;&#44; t&#234;m sido relacionados ao aumento do risco de p&#234;nfigo vulgar &#40;PV&#41; e p&#234;nfigo foli&#225;ceo &#40;PF&#41;&#44; por&#233;m seus n&#237;veis n&#227;o foram determinados em pacientes com p&#234;nfigo&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Avaliar a exposi&#231;&#227;o e a quantifica&#231;&#227;o dos pesticidas&#44; comparando PV&#44; PF e grupos controle no Sudeste do Brasil&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Informa&#231;&#245;es sobre resid&#234;ncia urbana ou rural e exposi&#231;&#227;o a pesticidas no in&#237;cio do p&#234;nfigo foram avaliadas por meio de entrevista por question&#225;rio&#46; Amostras de cabelos do couro cabeludo de casos de PV&#44; PF e controles foram testadas para pesticidas OP e organoclorados &#40;OC&#41; por cromatografia em fase gasosa acoplada &#224; espectrometria de massa&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A minoria dos casos de PV &#40;2 &#91;7&#44;1&#37;&#93; de 28&#41; e PF &#40;7 &#91;18&#37;&#93; de 39&#41;&#44; mas nenhum dos 48 controles&#44; informou viver em &#225;reas rurais no in&#237;cio do p&#234;nfigo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2853&#41;&#46; PV &#40;33&#44;3&#37;&#41;&#44; PF &#40;38&#44;5&#37;&#41; e controles &#40;20&#37;&#41; relataram exposi&#231;&#227;o a pesticidas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;186&#41;&#46; Vinte e um &#40;14&#44;8&#37;&#41; de 142 indiv&#237;duos testaram positivo para OP e&#47;ou OC&#58; PV &#40;2 &#91;6&#44;3&#37;&#93; de 32&#41; e PF &#40;11 &#91;25&#44;6&#37;&#93; de 43&#41; apresentaram contamina&#231;&#227;o por pesticidas semelhante aos controles &#40;8 &#91;11&#44;9&#37;&#93; de 67&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;4928&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0753&#44; respectivamente&#41;&#44; mas PF apresentou maior contamina&#231;&#227;o do que PV &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;034&#41;&#46; PV n&#227;o mostrou nenhuma positividade para OP&#46; Tr&#234;s &#40;7&#37;&#41; casos de PF testaram positivo para OP e OC&#46; Alguns PF testaram positivo para tr&#234;s ou quatro OP&#44; com predomin&#226;ncia de diazinon e diclorv&#243;s&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Limita&#231;&#227;o do estudo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Falta de dados para alguns controles&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Embora a frequ&#234;ncia de pacientes com PV e PF expostos a pesticidas tenha sido semelhante&#44; os pesticidas foram mais frequentemente detectados em amostras de cabelo de PF em compara&#231;&#227;o com PV&#46; A rela&#231;&#227;o entre causa e efeito precisa ser determinada&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 &#40;41&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;29&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;2218</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">Feminino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 &#40;75&#44;0&#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 &#40;58&#44;1&#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 &#40;70&#44;1&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">31</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"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">43</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">NA&nbsp;\t\t\t\t\t\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></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Dura&#231;&#227;o da doen&#231;a &#40;anos&#41; mediana &#40;p25&#8211;p75&#41;</span></td><td class="td" title="\n
                  \t\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 &#40;2&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;5&#8211;14&#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="" 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"><span class="elsevierStyleItalic">0&#44;005</span>&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Entrevista por question&#225;rio</span><a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a></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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">28 &#40;&#37;&#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"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">39 &#40;&#37;&#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"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">48 &#40;&#37;&#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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleSup">a&#44;b</span>0&#44;2853</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"><span class="elsevierStyleBold">&#193;rea de resid&#234;ncia</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">Rural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;7&#44;1&#41;<span class="elsevierStyleSup">a</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">7 &#40;18&#44;0&#41;<span class="elsevierStyleSup">b</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">0 &#40;0&#41;&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">Urbana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;92&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;82&#44;0&#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">48 &#40;100&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">27 &#40;&#37;&#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"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">39 &#40;&#37;&#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"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">40 &#40;&#37;&#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  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;1860</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"><span class="elsevierStyleBold">Exposi&#231;&#227;o a pesticidas</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">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 &#40;33&#44;3&#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">15 &#40;38&#44;5&#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">8 &#40;20&#44;0&#41;&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">N&#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">18 &#40;66&#44;7&#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">24 &#40;61&#44;5&#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">32 &#40;80&#44;0&#41;&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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Detec&#231;&#227;o de pesticidas no cabelo</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">32 &#40;&#37;&#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"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">43 &#40;&#37;&#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"><span class="elsevierStyleBold">n<span class="elsevierStyleHsp" style=""></span>&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">67 &#40;&#37;&#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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Organofosforados</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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 &#40;0&#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 &#40;20&#44;9&#41;<span class="elsevierStyleSup">b</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">6 &#40;9&#44;0&#41;<span class="elsevierStyleSup">c</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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleSup">b&#44;c</span>0&#44;0914</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">N&#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">32 &#40;100&#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">34 &#40;79&#44;1&#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">61 &#40;91&#44;0&#41;&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Organoclorados</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;6&#44;3&#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">5 &#40;11&#44;6&#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
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                  \t\t\t\t">2 &#40;3&#44;0&#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  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">0&#44;1707</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">N&#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
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                  \t\t\t\t">30 &#40;93&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;88&#44;4&#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">65 &#40;97&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Total</td><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sim</td><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">2 &#40;6&#44;3&#41;<span class="elsevierStyleSup">a</span></td><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">11 &#40;25&#44;6&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#167;</span></a><span class="elsevierStyleSup">b</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleSup">abc</span><span class="elsevierStyleItalic">0&#44;043</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleSup">ab</span><span class="elsevierStyleItalic">0&#44;034</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">N&#227;o</td><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;93&#44;7&#41;</td><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">32 &#40;74&#44;4&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">59 &#40;88&#44;1&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleSup">bc</span>0&#44;0753&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleSup">ac</span>0&#44;4928&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Tr&#234;s pacientes com PF apresentaram detec&#231;&#227;o de pesticidas organofosforados e organoclorados&#46;</p>"
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          "pt" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Dados demogr&#225;ficos e cl&#237;nicos&#44; &#225;rea de resid&#234;ncia e exposi&#231;&#227;o a pesticidas no in&#237;cio da doen&#231;a&#44; registrados em question&#225;rios&#44; e detec&#231;&#227;o de pesticidas organofosforados e organoclorados em amostras de cabelo de pacientes com p&#234;nfigo vulgar &#40;PV&#41; e p&#234;nfigo foli&#225;ceo &#40;PF&#41; e controles</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">BHC&#44; hexaclorobenzeno&#59; DDT&#44; dicloro&#8208;difenil&#8208;tricloroetano&#59; LOQ&#44; limite de quantifica&#231;&#227;o&#59; ND&#44; n&#227;o dispon&#237;vel&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Sexo&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" scope="col">In&#237;cio da doen&#231;a at&#233; a coleta de amostras de cabelo &#40;anos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Idade&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" scope="col">Profiss&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Question&#225;rios&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&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  " colspan="11" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Classes de pesticidas &#40;pg&#47;mL&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></th></tr><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">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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="" valign="\n
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                  \t\t\t\t" scope="col">&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">Zona de resid&#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">Pesticidas&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  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Organoclorados</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="6" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Organofosforados</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">Outro&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><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="" 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="" 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="" 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="" 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="" 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">Exposi&#231;&#227;o&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">Aldrin&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">BHC&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">DDT&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">Endrin&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">Clorpirif&#243;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">Diazinon&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">Diclorv&#243;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">Malation&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">Metil paration&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">Paration&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="" 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></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">PV<span class="elsevierStyleInf">1</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">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\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&nbsp;\t\t\t\t\t\t\n
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Vol. 98. Núm. 5.
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Vol. 98. Núm. 5.
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Quantificação de pesticidas em amostras de cabelo de pacientes com pênfigo foliáceo e pênfigo vulgar no Sudeste do Brasil
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Leonardo La Serraa, Adriana Martinelli Salathiela, Rafael Lanarob,c, Bruno de Martinisd, Ana Maria Roselinoa,
Autor para correspondência
amfrosel@fmrp.usp.br

Autor para correspondência.
a Departamento de Clínica Médica, Divisão de Dermatologia, Hospital Universitário, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil
b Centro de Controle de Intoxicações, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brasil
c Faculdade de Ciências Farmacêuticas, Universidade Estadual de Campinas, Campinas, SP, Brasil
d Departamento de Química, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Tabelas (2)
Tabela 1. Dados demográficos e clínicos, área de residência e exposição a pesticidas no início da doença, registrados em questionários, e detecção de pesticidas organofosforados e organoclorados em amostras de cabelo de pacientes com pênfigo vulgar (PV) e pênfigo foliáceo (PF) e controles
Tabela 2. Dados demográficos, questionários e classes de pesticidas detectados em amostras de cabelo dos grupos pênfigo vulgar (PV; n=32), pênfigo foliáceo (PF; n=43) e controle (C; n=67)
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Resumo
Fundamentos

Pesticidas, principalmente os organofosforados (OP), têm sido relacionados ao aumento do risco de pênfigo vulgar (PV) e pênfigo foliáceo (PF), porém seus níveis não foram determinados em pacientes com pênfigo.

Objetivo

Avaliar a exposição e a quantificação dos pesticidas, comparando PV, PF e grupos controle no Sudeste do Brasil.

Métodos

Informações sobre residência urbana ou rural e exposição a pesticidas no início do pênfigo foram avaliadas por meio de entrevista por questionário. Amostras de cabelos do couro cabeludo de casos de PV, PF e controles foram testadas para pesticidas OP e organoclorados (OC) por cromatografia em fase gasosa acoplada à espectrometria de massa.

Resultados

A minoria dos casos de PV (2 [7,1%] de 28) e PF (7 [18%] de 39), mas nenhum dos 48 controles, informou viver em áreas rurais no início do pênfigo (p=0,2853). PV (33,3%), PF (38,5%) e controles (20%) relataram exposição a pesticidas (p=0,186). Vinte e um (14,8%) de 142 indivíduos testaram positivo para OP e/ou OC: PV (2 [6,3%] de 32) e PF (11 [25,6%] de 43) apresentaram contaminação por pesticidas semelhante aos controles (8 [11,9%] de 67; p=0,4928; p=0,0753, respectivamente), mas PF apresentou maior contaminação do que PV (p=0,034). PV não mostrou nenhuma positividade para OP. Três (7%) casos de PF testaram positivo para OP e OC. Alguns PF testaram positivo para três ou quatro OP, com predominância de diazinon e diclorvós.

Limitação do estudo

Falta de dados para alguns controles.

Conclusão

Embora a frequência de pacientes com PV e PF expostos a pesticidas tenha sido semelhante, os pesticidas foram mais frequentemente detectados em amostras de cabelo de PF em comparação com PV. A relação entre causa e efeito precisa ser determinada.

Palavras‐chave:
Diazinon, diclorvós
Hidrocarbonetos clorados
Organofosfatos
Pênfigo
Praguicidas
Texto Completo
Introdução

O pênfigo engloba um grupo de doenças bolhosas autoimunes resultantes da produção de autoanticorpos contra as desmogleínas (Dsg). Autoanticorpos IgG contra Dsg1 afetam a pele no pênfigo foliáceo (PF), e autoanticorpos IgG contra Dsg3 e Dsg1 afetam as mucosas e a pele no pênfigo vulgar (PV).1 O PF é endêmico no Brasil, onde é conhecido como “fogo selvagem”. Mais recentemente, o diagnóstico de PV superou o de PF em algumas regiões brasileiras.2,3 Embora os alelos HLA classe I e II diferenciem as formas clínicas de PF e de PV, sua etiopatogenia não é totalmente compreendida.4–6

Fatores exógenos têm sido associados à patogênese do pênfigo, incluindo medicamentos e elementos nutricionais ricos em tiol, metais pesados, infecção pelo vírus herpes e picada de inseto.7–14 Além disso, em estudos de caso‐controle com base em entrevistas, a exposição a pesticidas, principalmente aos organofosforados (OP), tem sido relacionada ao PV na Ásia, Europa e América do Norte,15–19 e também ao “fogo selvagem” no Brasil.20 PV foi descrito após dermatite de contato com dicloro‐difenil‐tricloroetano e diazinon.21,22 Utilizando pele humana normal como substrato e amostras de soro de PV, o clorpirifós induziu pênfigo em um experimento in vitro.23

Não há relato de abordagem mais abrangente em relação à quantificação de níveis de pesticidas em uma população brasileira mais ampla de pênfigo para melhor compreensão da sua conexão ambiental com o pênfigo. Este estudo teve como objetivo avaliar a exposição a pesticidas por meio de (i) entrevista com base em questionário e (ii) medidas quantificação dos níveis de pesticidas OP e organoclorados (OC) em amostras de cabelo do couro cabeludo de pacientes com PV e PF e controles residentes na região nordeste do estado de São Paulo, uma área do Sudeste brasileiro onde ambas as formas clínicas de pênfigo são prevalentes.3

Materiais e métodos

Neste estudo transversal de caso‐controle, três grupos foram comparados: pacientes com PV (doravante denominados PV), pacientes com PF (doravante denominados PF) e controles. Este estudo foi aprovado pelo Comitê de Ética em Pesquisa local do Hospital Universitário da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (n° 2248/2010), e todos os participantes assinaram o termo de consentimento livre e esclarecido.

Grupos de pacientes e controles

Setenta e cinco pacientes com pênfigo atendidos no Ambulatório de Dermatologia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (SP, Brasil) foram incluídos no estudo. Entre eles, 32 tinham PV (mediana de idade=50 anos, 75% do sexo feminino) e 43 tinham PF (mediana de idade=46 anos, 58,1% do sexo feminino), respectivamente (tabela 1). O diagnóstico de PV e PF foi estabelecido com base em características clínicas, histopatológicas e de imunofluorescência (direta, indireta ou ambas) e determinação de autoanticorpos contra Dsg1 e Dsg3 por ELISA (MBL, Japão). Os controles consistiram em 67 parentes e vizinhos saudáveis dos pacientes com pênfigo (mediana de idade=46 anos, 70,1% do sexo feminino; tabela 1). PV, PF e controles residiam na região nordeste do estado de São Paulo, localizado no Sudeste do Brasil.

Tabela 1.

Dados demográficos e clínicos, área de residência e exposição a pesticidas no início da doença, registrados em questionários, e detecção de pesticidas organofosforados e organoclorados em amostras de cabelo de pacientes com pênfigo vulgar (PV) e pênfigo foliáceo (PF) e controles

PV  PF  Controls  p-value
n=32  n=43  n=53 
Idade (anos) mediana (p25–p75)50 (36–62)  46 (31–58)  46 (38–59)  0,6513 
n=32 (%)  n=43 (%)  n=67 (%)   
Sexo  Masculino  8 (25,0)  18 (41,9)  20 (29,9)  0,2218
  Feminino  24 (75,0)  25 (58,1)  47 (70,1) 
n=31  n=43  NA   
Duração da doença (anos) mediana (p25–p75)4 (2–6)  7 (5–14)    0,005 
Entrevista por questionário*       
n=28 (%)  n=39 (%)  n=48 (%)  a,b0,2853
Área de residência  Rural  2 (7,1)a  7 (18,0)b  0 (0) 
  Urbana  26 (92,9)  32 (82,0)  48 (100) 
n=27 (%)  n=39 (%)  n=40 (%)  0,1860
Exposição a pesticidas  Sim  9 (33,3)  15 (38,5)  8 (20,0) 
  Não  18 (66,7)  24 (61,5)  32 (80,0) 
Detecção de pesticidas no cabelon=32 (%)  n=43 (%)  n=67 (%)   
OrganofosforadosSim  0 (0)  9 (20,9)b  6 (9,0)c  b,c0,0914
Não  32 (100)  34 (79,1)  61 (91,0) 
OrganocloradosSim  2 (6,3)  5 (11,6)  2 (3,0)  0,1707
Não  30 (93,7)  38 (88,4)  65 (97,0) 
TotalSim2 (6,3)a11 (25,6)§b8 (11,9)cabc0,043 
ab0,034 
Não30 (93,7)32 (74,4)59 (88,1)bc0,0753 
ac0,4928 

NA, não aplicável.

*

Indivíduos dos grupos PV e controle responderam ao questionário de forma desproporcional.

§

Três pacientes com PF apresentaram detecção de pesticidas organofosforados e organoclorados.

Questionários

Os questionários, elaborados pelos autores, foram aplicados a 28 pacientes com PV e 39 com PF e a 48 controles. As respostas a cada item dos questionários foram incompletas nos três grupos. Assim, 28 pacientes com PV e 40 controles responderam a “Área de residência”; e 27 pacientes com PV e 48 controles responderam às questões sobre “Exposição a pesticidas” (tabela 1). Os indivíduos foram entrevistados por ocasião da sua visita ao Ambulatório de Dermatologia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. Duas informações principais foram analisadas: área de residência (rural ou urbana) por ocasião do aparecimento do pênfigo e exposição a pesticidas relacionada a atividades profissionais ou outras causas.

Coleta de amostras de cabelo

Com o auxílio de uma tesoura estéril, foram cortados cerca de 500mg da raiz do cabelo do couro cabeludo na região occipital e armazenados em envelopes de papel individuais em temperatura ambiente até a análise. As amostras foram testadas para pesticidas OP e OC.

Métodos analíticos de pesticidas OP e OC e valores aceitáveis

Os agrotóxicos pertencentes às classes OP e OC foram analisados por cromatografia em fase gasosa acoplada à espectrometria de massa (GC/MS). O procedimento de extração para análise de amostras de cabelo para presença de OP e OC foi o mesmo descrito por Tsatsakis et al.24 e adaptado às condições instrumentais do Laboratório de Toxicologia Forense do Departamento de Química da Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto da Universidade de São Paulo. Os experimentos foram realizados em um cromatógrafo a gás 7890A acoplado a um espectrômetro de massa 5975C Inert (Agilent Technologies, EUA) equipado com uma coluna cromatográfica DB‐5MSUI (30 m×0,25mm/d.i., 0,25μm de espessura de filme; Agilent Technologies, EUA). Os analitos foram eluídos com programação linear de temperatura do forno, como descrito a seguir: 60°C por 2,0min, aumento para 315°C a 30°C/min, e 315°C por 2min (tempo total de 12,5min). As temperaturas da porta de injeção e da linha de transferência foram ajustadas para 280°C. Hélio ultrapuro foi usado como gás carreador a uma vazão de 1,0mL/min, e as amostras foram injetadas no modo splitless (utilizando liner split ultrainerte desativado com lã de vidro para melhorar a cromatografia). O espectrômetro de massa foi ajustado para o modo SIM. Os dados foram adquiridos e o instrumento foi controlado com o software Agilent Technologies ChemStation, versão E02021431, fornecido pelo fabricante. A tabela suplementar 1 fornece os valores de limite de detecção (LOD) e limite de quantificação (LOQ) dos pesticidas. Os valores de ingestão diária aceitável (IDA) para OP detectados neste estudo são os seguintes: clorpirifós (10 pg/mg), diazinon (2 pg/mg) e malation (300 pg/mg).25 O uso de diclorvós, metil‐paration e paration foi banido. O uso dos pesticidas OC aldrin, BHC, DDT e endrin também foi banido, então nenhum valor de IDA está disponível para eles. As amostras que testaram positivo, mas abaixo do limite de detecção (< LOQ) foram incluídas no presente estudo.

Análise estatística

Os testes de Kruskal‐Wallis e Mann‐Whitney foram utilizados para analisar idade e duração da doença, respectivamente. O teste de Fischer foi utilizado para analisar as frequências das variáveis. Adotou‐se p ≤ 0,05 e empregou‐se a comparação bicaudal. A análise estatística foi realizada utilizando‐se o software SPSS, 26.0 (IBM, EUA).

ResultadosDados demográficos e clínicos

Os grupos de 32 PV, 43 PF e 67 controles não diferiram quanto à idade ou sexo. Dados sobre a idade de 14 controles não estavam disponíveis. A duração da doença foi maior no grupo PF do que no PV (p=0,005; tabela 1).

Dados de entrevistas com base em questionário

Não houve diferença estatística comparando área de residência urbana ou rural entre PV, PF e controles (p=0,2853). Dois (7,1%) dos 28 PV e 7 (18%) dos 39 PF, mas nenhum dos 48 controles, informaram residir na zona rural. As informações positivas ou negativas sobre a exposição a pesticidas foram semelhantes entre os grupos (p=0,186; tabela 1).

Quantificação dos níveis de OP e OC em amostras de cabelo

Pesticidas OP e OC foram quantificados em amostras de cabelo de 32 PV, 43 PF e 67 controles (tabela 1). Vinte e um (14,8%) dos 142 indivíduos testaram positivo para OP, OC ou ambos. O grupo PF (11 [25,6%]) apresentou mais pacientes contaminados do que o PV (2 [6,3%]), mas tinha tantos indivíduos contaminados quanto os controles (8 [11,9%]; p=0,034 e p=0,0753, respectivamente). PV e controles tiveram detecção de pesticidas semelhante (p=0,4928). Três (7%) PF testaram positivo para OP e OC. Nenhum dos 32 PV testou positivo para OP.

Quatro OC e seis OP foram detectados em pacientes e controles (tabela 2). Entre os OC, aldrin foi detectado em dois controles (< LOQ e 7,7 pg/mg); BHC em dois PV e quatro PF (variação ≤ LOQ a 12,2 pg/mg); DDT em um PV e dois PF (< LOQ); e endrin em um controle (9,1 pg/mg). Entre os OP, o clorpirifós foi detectado em dois PF e três controles (variação ≤ LOQ a 12,6 pg/mg); diazinon em cinco PF e dois controles (variação ≤ LOQ a 15,6 pg/mg); diclorvós em quatro PF e dois controles (variação ≤ LOQ a 9,1 pg/mg); malation em dois PF e um controle (variação ≤ LOQ a 8,3 pg/mg); metil‐paration em um PF (12,1 pg/mg); e paration em outro PF (< LOQ). Alguns PF testaram positivo para três ou quatro OP, com predominância de diazinon e diclorvós. Diurom foi detectado em um PF. Sete (70%) dos 10 PF eram do sexo feminino, residiam em áreas rurais no início do pênfigo e haviam sido expostas a pesticidas durante suas atividades profissionais no campo (tabela 2).

Tabela 2.

Dados demográficos, questionários e classes de pesticidas detectados em amostras de cabelo dos grupos pênfigo vulgar (PV; n=32), pênfigo foliáceo (PF; n=43) e controle (C; n=67)

  Sexo  Início da doença até a coleta de amostras de cabelo (anos)  Idade  Profissão  Questionários    Classes de pesticidas (pg/mL)a
          Zona de residência  Pesticidas  OrganocloradosOrganofosforadosOutro 
            Exposição  Aldrin  BHC  DDT  Endrin  Clorpirifós  Diazinon  Diclorvós  Malation  Metil paration  Paration   
PV1  53  Empregada doméstica  Urbana  NA    9,2                   
PV2  72  Apicultor  Rural  Sim    <LOQ  <LOQ                 
PF1  13  58  Agricultor  Urbana  Sim          <LOQ      8,3       
PF2  32  Agricultor  Rural  Sim          12,6  <LOQ  6,4         
PF3  72  Empregada doméstica  Rural  Não              5,8         
PF4  19  49  Agricultor  Urbana  Sim    12,2        2,1           
PF5  32  73  Agricultor  Rural  Sim      <LOQ        <LOQ        Diurom 
PF6  18  52  Agricultor  Rural  Sim    <LOQ  <LOQ      7,6           
PF7  51  Empregada doméstica  Rural  Sim    8,3                   
PF8  39  Agricultor  Urbana  Sim            15,6           
PF9  39  Agricultor  Urbana  Sim            3,5  9,1    12,1  <LOQ   
PF10  59  Empregada doméstica  Rural  Sim                <LOQ       
PF11  49  58  ND  Rural  Não    7,4                   
C1  ND  58  Tapeceiro  Urbana  Não            8,4    5,5       
C2  ND  ND  ND  ND  ND  7,7      9,1               
C3  ND  ND  Empregada doméstica  ND  ND  <LOQ                     
C4  ND  47  ND  ND  ND          8,2             
C5  ND  ND  ND  ND  ND          <LOQ    7,2         
C6  ND  ND  ND  ND  ND            6,3           
C7  ND  54  Costureira  Urbana  Sim          <LOQ             
C8  ND  53  Empregada doméstica  Urbana  Não              <LOQ         

BHC, hexaclorobenzeno; DDT, dicloro‐difenil‐tricloroetano; LOQ, limite de quantificação; ND, não disponível.

a

Dimetoato, terbufós, disulfoton, heptacloro, fenitrotiona, fentiona, metidationa, endosulfan, etiona, hexazinona e cetoendrina não foram detectados.

Discussão

A patogênese do pênfigo é atribuída ao histórico genético e a fatores ambientais, incluindo pesticidas.4–6,15–20,26 Há poucos relatos de pesticidas desencadeando autoimunidade. Eles foram descritos como causadores de imunotoxicidade, disfunção endócrina, distúrbios neurodegenerativos e câncer, entre outras condições. Em relação às doenças autoimunes, os pesticidas têm sido relacionados principalmente ao lúpus eritematoso sistêmico e à artrite reumatoide.27–30

Que seja do nosso conhecimento, este é o primeiro relato sobre a quantificação de níveis de pesticidas em pacientes com PV e PF, em comparação com controles. Escolheu‐se quantificar os níveis de pesticidas em amostras de cabelo porque são considerados biomarcadores humanos de exposição aos pesticidas.31–33 O presente estudo confirmou a contaminação por OP e/ou OC em amostras de cabelo em PV, PF e controles (6,3%, 25,6% e 11,9%, respectivamente; p=0,0437). Em comparação com PV, PF apresentou maior frequência de contaminação com pesticidas (p=0,034). Além disso, nove (20,9%) de 43 PF, mas nenhum dos 32 PV testou positivo para OP. Alguns PF testaram positivo para três ou quatro OP, com predominância de diazinon e diclorvós. OC foi detectado de modo semelhante em PV, PF e controles, embora seu uso tenha sido banido desde 1985.34

O mecanismo imunológico proposto para PV utilizando clorpirifós,23 que é um dos OP detectados em PF e controles neste estudo, não explica a patogênese do PV nesse pesticida, uma vez que o PV não apresentou nenhuma contaminação por OP.

Como se explica a prevalência aumentada de contaminação por pesticidas no PF? Historicamente, no Brasil, o PF estava distribuído em áreas rurais próximas aos rios, e a exposição a pesticidas foi considerada um possível fator de risco para PF no país.20,35 Entretanto, as entrevistas com base em questionário não revelaram diferença estatística entre PV, PF e controles em termos de residência urbana ou rural e exposição a pesticidas. Por outro lado, a maioria do grupo PF com contaminação capilar por OC ou OP informou que residia na zona rural no início do pênfigo e havia sido exposta a pesticidas durante suas atividades profissionais no campo (tabela 2). Além disso, a doença tem duração maior no PF do que no PV, o que pode ter contribuído para a bioacumulação de pesticidas no PF.

A exposição a pesticidas foi confirmada em doadores de sangue e na população rural no Brasil.36–38 Além disso, o perfil imunológico foi determinado em agricultores brasileiros expostos a pesticidas.39,40 Em nosso estudo, em oito controles que apresentaram contaminação com pesticidas (seis OP e dois OC; tabela 2), foram pesquisados autoanticorpos contra Dsg1 e Dsg3 utilizando ELISA (MBL, Japão), com resultados negativos em três (C1, C7 e C8). Os perfis de HLA classe II foram determinados nos oito controles (C1 a C8; dados não mostrados). Em dois dos seis controles contaminados com OP observamos: um controle (C1) contaminado com diazinon e malation apresentou ambos os alelos HLA‐DRB1*01:01 e HLA‐DQB1*05:01 de suscetibilidade para PF; e outro (C5) contaminado com diclorvós e clorpirifós apresentou o alelo HLA‐DQB1*03:02 de suscetibilidade para PV. Os outros seis controles não apresentaram alelos associados com PV e PF (para alelos HLA associados a PV e PF, ver Brochado et al.4). Sabendo que ambas as formas clínicas de pênfigo são prevalentes na região nordeste do estado de São Paulo35 testar anticorpos contra Dsg e determinar os alelos HLA em uma ampla população exposta a pesticidas forneceria informações importantes sobre a relação pesticidas‐pênfigo.

Os resultados do presente estudo corroboram um relato recente de Chang e Tsai,41 em revisão sistemática e metanálise. Eles incluíram cinco estudos de caso‐controle15–17,19,20 com base em entrevistas sobre a relação entre exposição a pesticidas e PV e PF. Os autoress concluíram haver associação entre exposição a pesticidas e pênfigo.41 Em nosso estudo, demonstramos a contaminação do cabelo por OC e/ou OP nos três grupos estudados; o grupo PF foi o que apresentou a maior contaminação por pesticidas.

Conclusão

O presente estudo confirmou a contaminação do cabelo com pesticidas OC e/ou OP em PF, PV e controles. Os pacientes com PV não testaram positivo para pesticidas OP. Alguns pacientes com PF testaram positivo para três ou quatro OP, com predominância de diazinon e diclorvós. Embora PV e PF tenham fornecido informações semelhantes sobre residência em áreas rurais no início do pênfigo e estarem expostos a pesticidas, a detecção desses foi mais frequente em amostras de cabelo de PF em comparação com PV. A relação entre a patogênese de PF e pesticidas ainda precisa ser elucidada.

Suporte financeiro

Este estudo foi parcialmente financiado pela Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, n° 2010/51729‐2). O primeiro autor recebeu bolsa de mestrado da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

Contribuição dos autores

Bruno de Martins: Aprovação da versão final do manuscrito; obtenção, análise e interpretação dos dados; revisão crítica do manuscrito.

Leonardo La Serra: Análise estatística; aprovação da versão final do manuscrito; elaboração e redação do manuscrito; obtenção, análise e interpretação dos dados; revisão crítica da literatura; revisão crítica do manuscrito.

Rafael Lanaro: Aprovação da versão final do manuscrito; obtenção, análise e interpretação dos dados; revisão crítica do manuscrito.

Ana Maria Roselino: Aprovação da versão final do manuscrito; concepção e planejamento do estudo; obtenção, análise e interpretação dos dados; participação efetiva na orientação da pesquisa; participação intelectual em conduta propedêutica e/ou terapêutica de casos estudados; revisão crítica do manuscrito.

Conflito de interesses

Nenhum.

Agradecimentos

Agradecemos a Aline Lobo de Oliveira, MSc, e Daniela Francisca Nascimento, PhD, pela ajuda na coleta de amostras de cabelo. Agradecemos ao grupo técnico laboratorial pediátrico e ao corpo clínico dos ambulatórios de dermatoses autoimunes do Hospital Universitário da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil.

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Como citar este artigo: La Serra L, Salathiel AM, Lanaro R, Martinis B, Roselino AM. Measurement of pesticides in hair samples from pemphigus foliaceous and pemphigus vulgaris patients in Southeastern Brazil. An Bras Dermatol. 2023;98:644–50.

Trabalho realizado na Divisão de Dermatologia, Hospital Universitário da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil.

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