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Background The association of several immune-mediated inflammatory diseases (IMIDs) in the same patient is well known. IMID, especially joint and cutaneous diseases, are frequently diagnosed in patients with inflammatory bowel disease (IBD). However, the degree of knowledge that patients with IBD have about the coexistence of other IMIDs is little studied. Our aim was to evaluate the accuracy of self-reporting of IMID by patients with IBD. Methods Prospective, unicentric study that included patients attended in person at the IBD Unit of the Central University Hospital of Asturias (Spain) between August 2020 and December 2021. Patients were invited to participate in the study, and, after signing the informed consent, they answered a questionnaire about the presence or not of 50 IMIDs (self-reported diagnosis). The diagnosis of an IMID was confirmed in the medical records of each patient (reference diagnosis). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (proportion of subjects correctly classified) of self-reporting was calculated. Statistical analyses were performed with R software version 4.0.2. Results A total of 1,621 patients were included. Forty-four percent of patients had ulcerative colitis, 53% had Crohn's disease and 3% had an IBD-unclassified, 50% were men, and the age at diagnosis of IBD was 38±15.2 years. Seven hundred and twelve patients were receiving mesalazine, 67 corticosteroids, 394 immunomodulators and 532 biologics. Six hundred and twenty-seven (39%) patients were diagnosed with at least one IMID, 177 (10.9%) with two, 49 (3%) with three, and 17 (1%) with more than three. Sixteen percent of patients had a joint IMID and 15% a cutaneous IMID. Self-reporting of IMID by IBD patients has a sensitivity, specificity, PPV, NPV and accuracy of 0.75 (95% CI 0.73-0,78), 0.89 (95% CI 0.86-0.91), 0.92 (95% CI 0.89-0.93), 0.69 (95% CI 0.66-0.73) and 0.81 (95% CI 0.79-0.83), respectively. Table 1 shows the results by IMID groups (joint, cutaneous, digestive, endocrinological, ocular, others), and Table 2 shows the results of the most frequent IMIDs. Conclusion Eighty-one percent of patients with IBD are able to correctly identify the coexistence or not of IMIDs. It was observed that in the case of joint IMIDs there is a significant percentage of patients who do not know whether or not they suffer from one of these diseases.

BackgroundThe Psoriatic arthritis UnclutteRed screening Evaluation (PURE-4) has been culturally adapted to Spanish language recently following the standardized methodology.1 A group of experts in psoriasis and psoriatic arthritis (PsA) has recently recommended the use of the Spanish version of PURE-4 due to the reduced number of items, its high sensitivity and specificity and the feasibility to implement in the clinical practice.ObjectivesTo validate the Spanish version of the PURE-4 questionnaire.MethodsCross-sectional, observational and multicenter study conducted with primary data collection under conditions of routine clinical practice in Spain. The study included adult patients with diagnosis of psoriasis of any time of evolution and any type of severity, that voluntarily accepted to participate. Primary endpoint: validation of PURE-4 questionnaire in terms of sensitivity, specificity, feasibility, reliability (internal consistency) and construct validity. The study consists in two cross-sectional evaluations: assessment I (a visit performed by a dermatologist, followed by an independent visit to the rheumatologist within the following 4 weeks after to the dermatologist’s visit and scheduled according to routine clinical practice) and assessment II (patients without PsA in assessment I will be evaluated by the rheumatologist one year ±2 months later and the rheumatologist will perform the PsA diagnostic confirmation according to the rheumatologist criteria and will collect clinical characteristics). Since data from assessment II are not yet available, data from assessment I are presented.Results268 evaluable patients included, 57.1% male, with a mean (SD) age of 47.1 (12.6) years, a mean (SD) time from diagnosis of 18.6 (12.9) years and mostly receiving psoriasis treatment (88.8%), biological treatment being the most common (43.3%). Mean (SD) PURE-4 score for all patients was 1.4 (1.3), being 2.3 (1.1) for patients with PsA and 1.3 (1.3) for patients without PsA diagnosis (Table 1). 268 (100.0%) patients answered the full PURE-4 questionnaire. Area under the receiver-operating characteristic (ROC) curve was 0.7185 (95% CI: 0.6391, 0.7978), showing good quality of fit or quality of the questionnaire (Figure 1). Using the Youden index, which determines the optimal cut-off point for the classification of patients, it was identified that a score ≥2 indicated a diagnosis of PsA. PURE-4 questionnaire showed a sensitivity of 77.1% and a specificity of 61.1%.Table 1.Sociodemographic and clinical baseline characteristics (assessment I)CharacteristicsWith PsA diagnosis (n=35)Without PsA diagnosis (n=226)Not assesable (n=7)Total (n=268)Age, mean (SD)50.5 (10.0)46.5 (12.9)49.9 (11.2)47.1 (12.6)Female, n (%)14 (40.0%)97 (42.9%)4 (57.1%)115 (42.9%)Years since diagnosis, mean (SD)19.7 (14.2)18.3 (12.8)22.4 (9.0)18.6 (12.9)Current treatment for psoriasis, n (%)32 (91.4%)199 (88.1%)7 (100.0%)238 (88.8%)Phototherapy, n (%)5 (15.6%)16 (8.0%)0 (0.0%)21 (8.8%)Topic treatment, n (%)20 (62.5%)66 (33.2%)3 (42.9%)89 (37.4%)Conventional systemic no biological treatment, n (%)7 (21.9%)40 (20.1%)2 (28.6%)49 (20.6%)Biological treatment, n (%)8 (25.0%)91 (45.7%)4 (57.1%)103 (43.3%)Phosphodiesterase-4 inhibitors, n (%)0 (0.0%)8 (4.0%)0 (0.0%)8 (3.4%)Others, n (%)0 (0.0%)3 (1.5%)0 (0.0%)3 (1.3%)PASI, mean (SD)8.7 (5.5)7.0 (5.0)4.2 (3.1)7.2 (5.1)Mild (PASI11 (31.4%)95 (42.0%)5 (71.4%)111 (41.4%)Moderate/severe (PASI≥7), n (%)24 (68.6%)131 (58.0%)2 (28.6%)157 (58.6%)APs, psoriatic arthritis; PASI, Psoriasis Area and Severity Index; SD, standard deviation.Figure 1.Area under the ROC curve (assessment I)ConclusionPURE-4 is a valid and compliant questionnaire with clinical practice in dermatology. It could be answered by patients in the waiting room and reviewed by dermatologists during the visit to support decision-making. PURE-4 could also help rheumatologists to early diagnose PsA patients in clinical practice.References[1]Actas Dermosifiliogr. 2020;111(8):655-64.AcknowledgementsThe authors thank IQVIA and Carmen Barrull, Neus Canal and Marco Pinel for providing medical editorial assistance with this presentation.Disclosure of InterestsRubén Queiro Silva Speakers bureau: AbbVie, MSD, Pfizer, Novartis, Lilly, Janssen, UCB y Celgene., Consultant of: AbbVie, MSD, Pfizer, Novartis, Lilly, Janssen, UCB y Celgene., Grant/research support from: Novartis, AbbVie y Janssen., Isabel Belinchón Speakers bureau: Janssen Pharmaceuticals Inc., Almirall, Lilly, AbbVie, Novartis, Celgene, Biogen Amgen, Leo-Pharma, Pfizer-Wyeth, UCB y MSD., Consultant of: Janssen Pharmaceuticals Inc., Almirall, Lilly, AbbVie, Novartis, Celgene, Biogen Amgen, Leo-Pharma, Pfizer-Wyeth, UCB y MSD., Anna Lopez-Ferrer Speakers bureau: Novartis, Janssen, MSD, Lilly, Pfizer,Celgene, Almirall, Leo Pharma, AbbVie y Amgen., Consultant of: Novartis, Janssen, MSD, Lilly, Pfizer,Celgene, Almirall, Leo Pharma, AbbVie y Amgen., Marta Ferran i Farrés Speakers bureau: Janssen, Lilly, Novartis, Pfizer, MSD, AbbVie, Celgene y Almirall., Paid instructor for: Janssen, Lilly, Novartis, Pfizer, MSD, AbbVie, Celgene y Almirall., Consultant of: Janssen, Lilly, Novartis, Pfizer, MSD, AbbVie, Celgene y Almirall., Raquel Rivera Díaz Speakers bureau: AbbVie, Almirall, Celgene Corporation, GSK, Janssen-Cilag, Lilly, LEO Pharma, MSD, Novartis, Pfizer y UCB., Paid instructor for: AbbVie, Almirall, Celgene Corporation, GSK, Janssen-Cilag, Lilly, LEO Pharma, MSD, Novartis, Pfizer y UCB., Consultant of: AbbVie, Almirall, Celgene Corporation, GSK, Janssen-Cilag, Lilly, LEO Pharma, MSD, Novartis, Pfizer y UCB., David Vidal Sarro Speakers bureau: Lilly, Janssen, AbbVie, Novartis, UCB, Celgene, Gebro y Leo., Paid instructor for: Lilly, Janssen, AbbVie, Novartis, UCB, Celgene, Gebro y Leo., Consultant of: Lilly, Janssen, AbbVie, Novartis, UCB, Celgene, Gebro y Leo., lourdes rodriguez freire Speakers bureau: AbbVie, Janssen Pharmaceuticals Inc., MSD, Pfizer-Wyeth, Novartis, Celgene, Almirall SA, Lilly y Leo-Pharma., Consultant of: AbbVie, Janssen Pharmaceuticals Inc., MSD, Pfizer-Wyeth, Novartis, Celgene, Almirall SA, Lilly y Leo-Pharma., Pablo de la Cueva Dobao Speakers bureau: AbbVie, Almirall, Amgen, Boehringer, Biogen, Celgene, Gebro, Janssen Cilag, Leo-Pharma, Lilly, MSD, Novartis, Pfizer- Wyeth, Sandoz, Sanofi y UCB., Paid instructor for: AbbVie, Almirall, Amgen, Boehringer, Biogen, Celgene, Gebro, Janssen Cilag, Leo-Pharma, Lilly, MSD, Novartis, Pfizer- Wyeth, Sandoz, Sanofi y UCB., Consultant of: AbbVie, Almirall, Amgen, Boehringer, Biogen, Celgene, Gebro, Janssen Cilag, Leo-Pharma, Lilly, MSD, Novartis, Pfizer- Wyeth, Sandoz, Sanofi y UCB., Jorge Santos Juanes Speakers bureau: Novartis, Lilly, Janssen, Abbvie, Amgen, y Sanofi., Consultant of: Novartis, Lilly, Janssen, Abbvie, Amgen, y Sanofi., Grant/research support from: Novartis, Lilly, Janssen, Abbvie, Amgen, y Sanofi., Vicenç Rocamora Duran Speakers bureau: Jansen, Lilly, Abbvie, Almirall, Amgen y Novartis., Paid instructor for: Jansen, Lilly, Abbvie, Almirall, Amgen y Novartis., Cristina Sanabra Employee of: Novartis Pharmaceuticals Spain, Guillermo Guinea Uzábal Employee of: Novartis Pharmaceuticals Spain, Víctor Martín Vázquez Employee of: Novartis Pharmaceuticals Spain

Graphical abstract, Background and objectives Spain is in a situation of indefinite lockdown due to the ongoing coronavirus disease 2019 (COVID-19) pandemic. One of the consequences of this lockdown is delays in medical and surgical procedures for common diseases. The aim of this study was to model the impact on survival of tumor growth caused by such delays in patients with squamous cell carcinoma (SCC) and melanoma. Material and methods Multicenter, retrospective, observational cohort study. We constructed an exponential growth model for both SCC and melanoma to estimate tumor growth between patient-reported onset and surgical excision at different time points. Results Data from 200 patients with SCC of the head and neck and 1000 patients with cutaneous melanoma were included. An exponential growth curve was calculated for each tumor type and we estimated tumor size after 1, 2, and 3 months of potential surgical delay. The proportion of patients with T3 SCC (diameter > 4 cm or thickness > 6 mm) increased from 41.5% (83 patients) in the initial study group to an estimated 58.5%, 70.5%, and 72% after 1, 2, and 3 months of delay. Disease-specific survival at 2, 5, and 10 years in patients whose surgery was delayed by 3 months decreased by 6.2%, 8.2%, and 5.2%, respectively. The proportion of patients with ultrathick melanoma (> 6 mm) increased from 6.9% in the initial study group to 21.9%, 30.2%, and 30.2% at 1, 2, and 3 months. Five- and 10-year disease-specific survival both decreased by 14.4% in patients treated after a potential delay of 3 months. Conclusions In the absence of adequate diagnosis and treatment of SCC and melanoma in the current lockdown situation in Spain, we can expect to see to a considerable increase in large and thick SCCs and melanomas. Efforts must be taken to encourage self-examination and facilitate access to dermatologists in order to prevent further delays.

Scalp lesions are common in psoriasis and difficult to treat. Scientific evidence on the topic is scant and fragmentary, especially with respect to long-term treatment. This consensus statement is based on a critical assessment of the results of a MEDLINE search for clinical trials of the efficacy and safety of therapies used to treat scalp psoriasis. The recommendations were developed by an expert panel using the Delphi process to reach a consensus and then ratified by the members of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology. The recommended induction therapy for scalp psoriasis is either a topical corticosteroid or a topical treatment combining calcipotriol and betamethasone. The choice of an appropriate vehicle is crucial in improving effectiveness and patient adherence to treatment. The only formulations that have been studied in the long-term treatment of scalp psoriasis are a combination of calcipotriol and betamethasone in gel and calcipotriol alone in solution.

Resumen Los anti-factor de necrosis tumoral (TNF) presentan un amplio espectro de lesiones cutaneas, entre las que se encuentra paradojicamente la psoriasis. Una mujer de 42 anos, con una historia de artritis reumatoidea desde los 19 anos, fue remitida al servicio de Dermatologia por presentar una psoriasis pustulosa en ambas plantas de los pies durante un tratamiento con etanercept. Ante la presencia de este cuadro se instauro tratamiento corticoideo topico oclusivo, con mejoria clinica a las 4 semanas y desaparicion total de las lesiones a las 6 semanas. Los anti-TNF son farmacos que actuan en enfermedades mediadas por celulas T. La aparicion de erupciones psoriasiformes es mas frecuente de lo comunicado en la literatura, ya que aparecen en todas las indicaciones y con todos los anti-TNF, con mayor frecuencia con adalimumab. Se producen tres tipos de reacciones, siendo la pustulosa la mas comun; predomina en mujeres y puede aparecer cronologicamente en cualquier momento durante el tratamiento. Respecto al tratamiento es aconsejable continuar con los anti-TNF.

Scalp lesions are common in psoriasis and difficult to treat. Scientific evidence on the topic is scant and fragmentary, especially with respect to long-term treatment. This consensus statement is based on a critical assessment of the results of a MEDLINE search for clinical trials of the efficacy and safety of therapies used to treat scalp psoriasis. The recommendations were developed by an expert panel using the Delphi process to reach a consensus and then ratified by the members of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology. The recommended induction therapy for scalp psoriasis is either a topical corticosteroid or a topical treatment combining calcipotriol and betamethasone. The choice of an appropriate vehicle is crucial in improving effectiveness and patient adherence to treatment. The only formulations that have been studied in the long-term treatment of scalp psoriasis are a combination of calcipotriol and betamethasone in gel and calcipotriol alone in solution.

Resumen El hamartoma o nevus oligemicus es una entidad infrecuente, de etiopatogenia poco aclarada, en la que se produce una vasoconstriccion selectiva del plexo vascular profundo dermico con relacion al superficial. Estas alteraciones funcionales dan lugar a lesiones fijas, adquiridas y asintomaticas a modo de maculas lividas, eritematosas, tipicamente frias al tacto si se compara con la piel sana adyacente. Comunicamos los casos de 6 varones jovenes con lesiones en el abdomen y en los flancos, compatibles clinicamente con nevus oligemicus . La medicion de la temperatura superficial de la lesion, constatando un descenso de hasta 2,5 °C respecto de la piel sana adyacente, permitio realizar el diagnostico definitivo. Se describen los estudios complementarios realizados, los diagnosticos diferenciales, los posibles agentes etiologicos responsables y se comentan los casos referidos en la literatura hasta el momento. Consideramos que el nevus oligemicus es una entidad infradiagnosticada y mucho mas frecuente de lo referido en la literatura.

Hamartoma or nevus oligemicus is an uncommon lesion that is characterized by selective vasoconstriction of the deep dermal vascular plexus with respect to the superficial one and whose cause has not been clearly established. This selective vasoconstriction gives rise to fixed, acquired, and asymptomatic lesions in the form of livid, erythematous macules that are typically cold to touch compared with surrounding skin. We report the cases of 6 young men with lesions clinically compatible with nevus oligemicus on the abdomen and flanks. Measurement of the surface temperature of the lesion revealed a decrease of up to 2.5°C with respect to healthy surrounding skin and allowed a definitive diagnosis to be made. We describe the additional studies undertaken, the differential diagnosis, and the possible etiologic agents, and discuss the cases reported in the literature to date. In our opinion, nevus oligemicus is an underdiagnosed lesion that is much more common than has been reported in the literature.

Resumen —Una paciente de 63 anos afecta de leucemia aguda mieloblastica, tras 5 dias de infeccion de las vias respiratorias altas, presento una placa necrotica en ala nasal derecha; posteriormente, una lesion satelite en la pierna derecha y empeoramiento del estado general. Se aislo Mucor spp. En el cultivo de una de las dos biopsias efectuadas. En ambas habia trombos formados por hifas no septadas. A pesar de un tratamiento precoz con anfotericina B intravenosa y desbridamiento quirurgico la paciente fallecio. La mucormicosis es una infeccion por hongos saprofitos de la clase de los zigomicetos que afecta a pacientes inmunodeprimidos. Las manifestaciones cutaneas en la mucormicosis diseminada son raras; sus formas de presentacion varian: nodulos con centros equimoticos, placas eritematosas con centro purpurico y lesiones similares al ectima gangrenoso. Dada su ubicuidad, para su diagnostico se necesitan criterios microbiologicos e histopatologicos estrictos. El tratamiento mas eficaz es el empleo de anfotericina B intravenosa a dosis altas y el desbridamiento quirurgico, a pesar de lo cual la mortalidad es elevada.

Several studies stated that patient with psoriasis carried an increased risk of psoriasis but some studies did not demonstrate this association. The aim of this study was to evaluate the prevalence of hypertension in psoriasis based on a sample of Spanish population. This was a hospital-based case-control study involving 661 psoriatic patients (cases) and 661 control matched by gender and age. Meta-analysis of the previous studies was made. The prevalence of hypertension was significantly higher in psoriasis patients than controls (30.3%, 21.3%, respectively, P 0.001). In a multivariate analysis, hypertension was associated with psoriasis after controlling for age, gender, diabetes, obesity and smoking (OR = 1.44, 95% confidence interval: 1.07-1.94). The results of this study support the association between psoriasis and hypertension.

The nails are affected in a substantial number of patients with psoriasis. Nevertheless, few epidemiological studies have reported the characteristics of patients with nail psoriasis. Here we describe the epidemiology of nail psoriasis and the main characteristics of affected patients.We undertook a prospective case-control study at Hospital Universitario Marqués de Valdecilla and Hospital Universitario Central de Asturias in Spain between January 2007 and December 2009.Of a total of 661 patients included, 47.4% were diagnosed with nail psoriasis, which was 13.5% more prevalent in men. The group of patients with nail disease had more severe psoriasis (12.82 vs 8.22 points on the psoriasis area and severity index) and a longer disease duration (20.30 vs 13.94years), and included a larger percentage of patients with psoriatic arthritis (29.7% vs 11.5%), a positive family history of the disease (53.7% vs 42.8%), and a body mass index greater than 30 (31.6% vs 23.9%). A larger percentage of the patients with nail disease had early-onset psoriasis (74.1% vs 65.5%) and fewer were carriers of the human lymphocyte antigen Cw*0602 allele (33% vs 50.3%).Nail disease is frequent in psoriasis and is associated with greater severity of psoriasis and a larger number of comorbidities.

Anti-TNFs have a wide spectrum of skin lesions, psoriasis being found among them paradoxically. A 42-year old woman with a history of rheumatoid arthritis since 19 years of age was referred to the Dermatology service due to pustular psoriasis on both soles during treatment with etanercept. Due to her incapacity to walk and the pain reported by the patient, etanercept was replaced with adalimumab with clinical improvement and total disappearance of the lesions at six weeks of switching the anti-TNF. Tumor necrosis factor inhibitors are drugs that act in T cell mediated diseases. The appearance of psoriasiform rashes is more frequent than reported in the literature. They appear in all the indications and with all the anti-TNFs. Adalimumab is the most frequent. Three types of reactions are produced, the pustular one being the most frequent. It predominates in women and may appear chronologically at any time during the treatment. Regarding the treatment, it is recommendable to continue with the anti-TNFs.

Resumen: Presentamos un caso de mastocitoma solitario en la muñeca izquierda de un recién nacido de dos días de vida, surgiendo bajo el lugar de colocación de la pulsera de identificación. El signo de Darier fue provocado en la zona rascando la lesión. La examinación histopatológica del espécimen obtenido por punción biopsia objetivó un denso infiltrado mastocitario en la dermis, lo que se confirmó con las tinciones de Giemsa y azul de toluidina. Creemos que este caso supone un raro proceso reactivo. : We report the case of solitary mastocytoma, which appeared under the identification bracelet on the left wrist of a 2-day-old newborn infant. Stroking the lesion elicited Darier's sign. Histopathologic examination of a punch biopsy specimen revealed a dense mast cell infiltrate of the dermis, which was confirmed by Giemsa and toluidine blue stains. We believe that this case represents an unusual reactive process.

Schonlein-Henoch purpura is a small vessel disease that affects mainly skin and kidney, although several gastrointestinal symptoms may occur including abdominal pain, intussusception, perforation or bleeding. Massive lower gastrointestinal haemorrhage is rare and even more as the main symptom of the disease. We present a case of a 2-year-old boy with Schonlein-Henoch purpura who developed a massive lower gastrointestinal bleeding requiring blood transfusion. In this patient both Schonlein-Henoch purpura and gastrointestinal haemorrhage were successfully treated with intravenous methylprednisolone, avoiding surgical intervention. Physicians need to have a high index of suspicion when evaluating these patients, even more when dermatologic signs are scarce. Glucocorticosteroid therapy may be effective when treating severe gastrointestinal symptoms.

Hamartoma or nevus oligemicus is an uncommon lesion that is characterized by selective vasoconstriction of the deep dermal vascular plexus with respect to the superficial one and whose cause has not been clearly established. This selective vasoconstriction gives rise to fixed, acquired, and asymptomatic lesions in the form of livid, erythematous macules that are typically cold to touch compared with surrounding skin. We report the cases of 6 young men with lesions clinically compatible with nevus oligemicus on the abdomen and flanks. Measurement of the surface temperature of the lesion revealed a decrease of up to 2.5 degrees C with respect to healthy surrounding skin and allowed a definitive diagnosis to be made. We describe the additional studies undertaken, the differential diagnosis, and the possible etiologic agents, and discuss the cases reported in the literature to date. In our opinion, nevus oligemicus is an underdiagnosed lesion that is much more common than has been reported in the literature.

We report the case of solitary mastocytoma, which appeared under the identification bracelet on the left wrist of a 2-day-old newborn infant. Stroking the lesion elicited Darier's sign. Histopathologic examination of a punch biopsy specimen revealed a dense mast cell infiltrate of the dermis, which was confirmed by Giemsa and toluidine blue stains. We believe that this case represents and unusual reactive process.

En los estudios complementarios destacaba: unos linfocitos CD4 17 celulas/mm3, carga viral 2.600 copias/ml y antigenemia de citomegalovirus negativa. La tomografia axial computarizada de cuello mostraba pequenas adenopatias laterocervicales bilaterales, sin observarse masas en los espacios parafaringeos. Un esofagograma realizado tras un intento fallido de endoscopia demostro la presencia de una ulcera en el tercio distal del esofago (fig. 2).

The patient was a 41-year-old man who was admitted for a 3-week history of fever, dysphagia, odynophagia, and painful ulcers in the oropharynx. The patient reported that 3 years earlier he suffered a similar condition that was less severe and resolved spontaneously. He had been diagnosed with human immunodeficiency virus (HIV) infection, category B3, and hepatitis C infection, and was on treatment with cotrimoxazole.

La utilizacion de agentes biologicos constituye un tratamiento eficaz y seguro en determinadas enfermedades, fundamentalmente dermatologicas y reumatologicas. En particular, el adalimumab (Humira), anticuerpo monoclonal humano recombinante inhibidor del factor de necrosis tumoral(TNF) se viene indicando en el tratamiento de la artritis reumatoide, la espondilitis anquilopoyetica y la artritis psoriasica. Las reacciones cutaneas a este anticuerpo son poco frecuentes, alrededor del 1 % segun estudios clinicos1,2, e incluyen, entre otras, exantema alergico, reaccion anafilactica, exantema fijo medicamentoso, reaccion medicamentosa inespecifica y urticaria. Esta ultima es muy infrecuente, con una unica referencia en el ano 2006, en una mujer de 41 anos con psoriasis en placas de largo tiempo de evolucion que presento lesiones compatibles con urticaria aguda en el cuello y en las extremidades superiores, de inicio en las horas siCartas al director

in the service list not to be eligible for referral. Despite the limited scope of the study in terms of data collection and with no prior study that could be used as a reference, the results suggest that consensus and subsequent distribution of the service list in the referral area would have some impact on referrals of trivial, extremely widespread lesions that account for almost 1 of 3 consultations. The factors that lead to a high prevalence of consultations for trivial lesions in the public health care system and their medium-term and long-term consequences on dermatologists’ activity are unquestionably complex and deserve lengthy and careful discussion. However, this situation not only requires funding, as MacayaPascual et al 1 pointed, but could largely