Advertisement

Immediate Skin Contact Reactions Induced by Proteins

  • Kayria Muttardi
  • Emek Kocatürk
Chapter
Part of the Updates in Clinical Dermatology book series (UCD)

Abstract

Proteins may cause two main types of immediate skin reactions, namely, contact urticaria and protein contact dermatitis. Contact urticaria presents with a wheal and flare reaction that occurs within 30 min of direct contact of the protein and resolves completely within hours. Protein contact dermatitis manifests as an eczematous rash that appears rapidly after contact with the protein. Other symptoms such as angioedema, rhinoconjunctivitis, asthma, gut symptoms, oral allergy syndrome, and even anaphylaxis may occur. Among the proteins that cause immediate reactions, latex is the most commonly encountered, which explains why the number one affected occupation is healthcare workers, followed by hairdressers and veterinarians. Other proteins that may be capable of inducing these types of reactions are grouped into four types: (1) fruits, vegetables, spices, plants and woods, (2) animal proteins, (3) grains, and (4) enzymes. Food handlers, those working in agriculture, farming, floriculture, and bakery, as well as hunters and biologists, are other occupations involved. The gold standard for diagnosis is skin prick testing, and management is aimed at avoiding the responsible allergen.

Keywords

Contact urticaria Protein contact dermatitis Latex allergy Immediate skin reactions Contact urticaria syndrome Management Diagnosis 

References

  1. 1.
    Gimenez-Arnau A, Maibach HI. Contact urticaria syndrome. Florida: Taylor & Francis Group, LLC; 2015.Google Scholar
  2. 2.
    Warner RM, Taylor S, Yung-Hian L. Agents causing contact urticaria. Clin Dermatol. 1997;15:623–35.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Hjorth N, Roed-Petersen J. Occupational protein contact dermatitis in food handlers. Contact Dermatitis. 1976;2:28–42.CrossRefPubMedGoogle Scholar
  4. 4.
    Elpern DJ. The syndrome of immediate reactivities (contact urticaria syndrome). A historical study from a dermatology practice. I. Age, sex, race and putative substances. Hawaii Med J. 1985;44:426–39.PubMedGoogle Scholar
  5. 5.
    Nilsson E. Contact sensitivity and urticaria in “wet” work. Contact Dermatitis. 1985;13:321–8.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Kanerva L, Jolanki R, Toikkanen J, Estlander T. Statistics on occupational contact urticaria. In: Smita A, Lahti A, Maibach HI, editors. Contact urticaria syndrome. Boca Raton: CRC Press; 1997. p. 57–69.Google Scholar
  7. 7.
    Williams JD, Lee AY, Matheson MC, Frowen KE, Noonan AM, Nixon RL. Occupational contact urticaria: Australian data. Br J Dermatol. 2008;159:125–31.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Johansen JD, Lepoittevin JP, Thyssen JP. Quick guide to contact dermatitis. Berlin Heidelberg: Springer; 2016.CrossRefGoogle Scholar
  9. 9.
    Amsler E, Bayrou O, Pecquet C, Francès C. Five cases of contact dermatitis to a trendy pet. Dermatology. 2012;224(4):292–4.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Janssens V, Morren M, Dooms-Goossens A, Degreef H. Protein contact dermatitis: myth or reality? Br J Dermatol. 1995;132:1–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Tosti A, Guerra L, Morelli R, Bardazzi F, Fanti PA. Role of foods in the pathogenesis of chronic paronychia. J Am Acad Dermatol. 1992;27:706–10.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kanerva L. Occupational protein contact dermatitis and paronychia from natural rubber latex. J Eur Acad Dermatol Venereol. 2000;14:504–6.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Laing ME, Barry J, Buckley AM, Murphy GM. Immediate and delayed hypersensitivity reactions to food and latex in a chef. Contact Dermatitis. 2006;55:193–4.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Doutre M-S. Occupational contact urticaria and protein contact dermatitis. Eur J Dermatol. 2005;15:419–24.PubMedGoogle Scholar
  15. 15.
    Amaro C, Goossens A. Immunological occupational contact urticaria and contact dermatitis from proteins: a review. Contact Dermatitis. 2008;58:67–75.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Morren M, Janssens V, Dooms-Goossens A, et al. A – Amylase, a flour additive: an important cause of protein contact dermatitis in bakers. J Am Acad Dermatol. 1993;29:723–8.Google Scholar
  17. 17.
    Hernández-Bel P, de la Cuadra J, García R, Alegre V. Protein contact dermatitis: review of 27 cases. Actas Dermosifiliogr. 2011;102(5):336–43.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Von Krogh C, Maibach HI. The contact urticaria syndrome. An update review. J Am Acad Dermatol. 1981;5:328–42.CrossRefGoogle Scholar
  19. 19.
    Liss GM, Sussman GL. Latex sensitization: occupational versus general population prevalence rates. Am J Ind Med. 1999;35:196–200.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Liss GM, Sussman GL, Deal K, et al. Latex allergy: epidemiological study of 1351 hospital workers. Occup Environ Med. 1997;54:335–42.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Valsecchi R, Leghissa P, Zerbinati N. Contact urticaria from latex in hairdressers. Eur J Inflamm. 2003;1:143–4.Google Scholar
  22. 22.
    Valsecchi R, Leghissa P, Cortinovis R. Occupational contact dermatitis and contact urticaria in veterinarians. Contact Dermatitis. 2003;49:167–8.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Eiwegger T, Dehlinke E, Schwindt J, et al. Early exposure to latex products mediates latex sensitization in spina bifida but not in other diseases with comparable latex exposure rates. Clin Exp Allergy. 2006;36:1242–6.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Ylitalo L. Natural rubber latex allergy in children, PhD Thesis, Acta Universitatis Tamperensis 719, University of Tampere, Tampere, Finland, 2000.Google Scholar
  25. 25.
    Taylor JS, Erkek E. Latex allergy: diagnosis and management. Dermatol Ther. 2004;17:289–301.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Fezcko PJ, Simms SM, Bakirci N. Fatal hypersensitivity during a barium enema. Am J Roentgenol. 1989;153:276–7.Google Scholar
  27. 27.
    Niggemann B, Kulig M, Bergmann R, et al. Development of latex allergy in children up to 5 years of age – a retrospective analysis of risk factors. Pediatr Allergy Immunol. 1999;9:36–9.CrossRefGoogle Scholar
  28. 28.
    Ylitalo L, Turjanmaa K, Palosuo T, et al. Natural rubber latex allergy in children who had not undergone surgery and children who had undergone multiple operations. J Allergy Clin Immunol. 1997;100:606–12.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Bensefa-Colas L, Telle-Lamberton M, Faye S, Bourrain JL, Crépy MN, Lasfargues G, Choudat D, RNV3P members, Momas I. Occupational contact urticaria: lessons from the French National Network for Occupational Disease Vigilance and Prevention (RNV3P). Br J Dermatol. 2015;173(6):1453–61.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Ibler KS, Jemec GB, Garvey LH, Agner T. Prevalence of delayed-type and immediate-type hypersensitivity in healthcare workers with hand eczema. Contact Dermatitis. 2016;75(4):223–9.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Mellström GA, Boman AS. Gloves: types, materials, and manufacturing. In: Mellström GA, Wahlberg JE, Maibach HL, editors. Protective gloves for occupational use. Boca Raton: CRC Press; 1994.Google Scholar
  32. 32.
    European Commission. Health and Consumer Protection Directorate General (internet).Opinion on Natural Rubber Latex Allergy 27th June 2000. Available from: http://ec.europa.eu/health/ph_risk/committees/scmp/documents/out31_en.pdf. Accessed on 8 Aug 2017.
  33. 33.
    Yeang HY. Natural rubber allergens: new developments. Curr Opin Clin Immunol. 2004;4:99–10.CrossRefGoogle Scholar
  34. 34.
    American Latex Allergy Association (internet). Latex allergens registered by WHO-IUIS. Available from http://latexallergyresources.org/sites/default/files/article-attachments/sec9_latexAllergens.pdf. Accessed 11 Aug 2017.
  35. 35.
    Asthma and Allergy Foundation of America (internet). Latex allergy. http://www.aafa.org/page/latex-allergy.aspx. Accessed 11 Aug 2017.
  36. 36.
    Shah D, Chowdhury MMU. Rubber allergy. Clin Dermatol. 2011;29:278–86.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Barbaud A, Poreaux C, Penven E, Waton J. Occupational protein contact dermatitis. Eur J Dermatol. 2015;25(6):527–34.PubMedGoogle Scholar
  38. 38.
    Kanerva L, Alanko K, Jolanki R, Kanervo K, Susitaival P, Estlander T. The dental face mask – the most common cause of work-related face dermatitis in dental nurses. Contact Dermatitis. 2001;44:261–2.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Dias-Perales A, Sanchez-Monge R, Blanco C, et al. What is the role of the hevein-like domain of fruit class I chitinases in their allergenic capacity? Clin Exp Allergy. 2002;32:448–54.CrossRefGoogle Scholar
  40. 40.
    Blanco C. Latex-fruit syndrome. Curr Allergy Asthma Rep. 2003;3:47–53.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Soares J, Dias A, Peixoto S, Pereira A, Quaresma M. Particularities in a child with cashew nut allergy. Glob Pediatr Health. 2014;1:2333794X14552898 (Epub).Google Scholar
  42. 42.
    Poley GE, Slater JE, HS N. Latex allergy from the current reviews of allergy and immunology. J Allergy Clin Immunol. 2000;105(N6, 1):1054–62.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Hamilton RG, Biagini RE, Krieg EF. Diagnostic performance of food and drug administration–cleared serologic assays for natural rubber latex-specific IgE antibody: the multi-center latex skin testing study task force. J Allergy Clin Immunol. 1999;103:925–30.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Hamilton RG, Adkinson NF Jr. Natural rubber latex skin testing reagents: safety and diagnostic accuracy of non-ammoniated, ammoniated and latex glove extracts. J Allergy Clin Immunol. 1996;98:872–83.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Jezierski M. Creating a latex-safe environment: Riddle Memorial Hospital’s response to protect patients and employees. J Emerg Nurs. 1997;23:191–8.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Crippa M, Belleri L, Mistrello G, et al. Prevention of latex allergy among healthcare workers and in general population: latex protein content in devices commonly used in hospitals and general practice. Int Arch Occup Environ Health. 2006;79:550–7.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Heilman DK, Jones RT, Swanson MC, Yunginger JW. A prospective, controlled study showing that rubber gloves are the major contributor to latex aeroallergen levels in the operating room. J Allergy Clin Immunol. 1996;98:325–30.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Nettis E, Delle Donne P, Di Leo E, et al. Latex immunotherapy: state of the art. Ann Allergy Asthma Immunol. 2012;109:160.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Moscato G, Pala G, Sastre J. Specific immunotherapy and biological treatments for occupational allergy. Curr Opin Allergy Clin Immunol. 2014;14(6):576–81.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Leynadier F, Doudou O, Gaouar H, et al. Effect of omalizumab in health care workers with occupational latex allergy. J Allergy Clin Immunol. 2004;113:360–1.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Wakelin SH. Contact urticaria. Clin Exp Dermatol. 2001;26:132–6.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Foti C, Carino M, Cassano N, et al. Occupational contact urticaria from paprika. Contact Dermatitis. 1997;37:135.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Quirce S, Tabar AI, Olaguibel JM, Cuevas M. Occupational contact urticaria syndrome caused by globe artichoke (Cynara scolymus). J Allergy Clin Immunol. 1996;97:710–1.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Aalto-Korte K, Susitaival P, Kaminska R, Makinen-Kiljunen S. Occupational protein contact dermatitis from shiitake mushroom and demonstration of shiitake-specific immunoglobulin E. Contact Dermatitis. 2005;53:211–3.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Lukacs J, Schliemann S, Elsner P. Occupational contact urticaria caused by food- a systematic clinical review. Contact Dermatitis. 2016;75:195–204.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Brancaccio RR, Alvarez MS. Contact allergy to food. Dermatol Ther. 2004;17:302–13.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Webber CM, England RW. Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge. Ann Allergy Asthma Immunol. 2010;104:101–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Breiteneder H, Ebner C. Molecular and biochemical classification of plant-derived food allergens. J Allergy Clin Immunol. 2000;106:27–36.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Paulsen E, Andersen KE. Lettuce contact allergy. Contact Dermatitis. 2015;74:67–75.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Paulsen E, Skov PS, Andersen KE. Immediate skin and mucosal symptoms from pot plants and vegetables in gardeners and greenhouse workers. Contact Dermatitis. 1998;39:166–70.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Kanerva L, Estlander T, Petman L, Mäkinen-Kiljunen S. Occupational allergic contact urticaria to yucca (Yucca aloifolia), weeping fig (Ficus benjamina), and spathe flower (Spathiphyllum wallisii). Allergy. 2001;56:1008–11.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Quirce S, García-Figueroa B, Olaguíbel JM, Muro MD, Tabar AI. Occupational asthma and contact urticaria from dried flowers of Limonium tataricum. Allergy. 1993;48(4):285–90.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Alvarez-Cuesta C, Gala Ortiz G, Rodrı’guez Dı’az E, et al. Occupational asthma and IgE-mediated contact dermatitis from sapele wood. Contact Dermatitis. 2004;51:88–98.CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Lahti A. Non-immunologic contact urticaria. Acta Derm Venereol Suppl (Stockh). 1980;Suppl 91:1–49.Google Scholar
  65. 65.
    Susitaival P. Animals and animal products as a cause of contact urticaria and protein contact dermatitis. In: Gimenez-Arnau A, Maibach HI, editors. Contact urticaria syndrome. Florida: Taylor & Francis Group, LLC; 2015. p. 141–50.Google Scholar
  66. 66.
    Finnish Institute of Occupational Diseases. Register of occupational diseases. Information of the register available at https://osha.europa.eu/en/topics/osm/reports/finnish_system_009.stm. Accessed 24 Aug 2017.
  67. 67.
    Virtanen T, Zeiler T, Mäntyjärvi R. Important animal allergens are lipocalin proteins: why are they allergenic? Int Arch Allergy Immunol. 1999;120:247–58.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Virtanen T, Kinnunen T, Rytkönen-Nissinen M. Mammalian lipocalin allergens – insight into their enigmatic allergenity. Clin Exp Allergy. 2011;42:494–504.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Susitaival P, Kirk J, Schenker M. Self-reported hand dermatitis in California Veterinarians. Am J Contact Dermat. 2001;12:103–8.PubMedGoogle Scholar
  70. 70.
    Aoyama K, Ueda A, Manda F, et al. Allergy to laboratory animals: an epidemiological study. Br J Ind Med. 1992;49(1):41–7.PubMedPubMedCentralGoogle Scholar
  71. 71.
    Bhabha FK, Nixon R. Occupational exposure to laboratory animals causing a severe exacerbation of atopic eczema. Autralas J Dermatol. 2012;53(2):155–6.CrossRefGoogle Scholar
  72. 72.
    Lopata A, Fenemore B, Jeebhay M, Gäde G, Potter P. Occupational allergy in laboratory workers caused by the African migratory grasshopper Locusta migratoria. Allergy. 2005;60:200–5.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Herzinger T, Scharrer E, Placzek M, Przybilla B. Contact urticaria to giraffe hair. Int Arch Allergy Immunol. 2005;138:324–7.CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    Vester L, Thyssen JP, Menné T, Johansen JD. Occupational food-related hand dermatoses seen over a 10-year period. Contact Dermatitis. 2012;66:264–70.CrossRefPubMedGoogle Scholar
  75. 75.
    Onesimo R, Giorgio V, Pili S, et al. Isolated contact urticaria caused by immunoglobulin E-mediated fish allergy. Isr Med Assoc J. 2012;14(1):11–3.PubMedGoogle Scholar
  76. 76.
    Jovanovic M, Oliwiecki S, Beck MH. Occupational contact urticaria from beef associated with hand eczema. Contact Dermatitis. 1992;27(3):188–9.CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Houba R, Heederik D, Doekes G. Wheat sensitization and work-related symptoms in the baking industry are preventable. An epidemiologic study. Am J Respir Crit Care Med. 1998;158(5 Pt 1):1499–503.CrossRefPubMedPubMedCentralGoogle Scholar
  78. 78.
    Matsuo H, Uemura M, Yorozuya M, Adachi A, Morita E. Identification of IgE-reactive proteins in patients with wheat protein contact dermatitis. Contact Dermatitis. 2010;63(1):23–30.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Coenraads PJ. Sensitization potential of hydrolysed wheat proteins. Contact Dermatitis. 2016;74(6):321–2.CrossRefPubMedPubMedCentralGoogle Scholar
  80. 80.
    Pootongkam S, Nedorost S. Oat and wheat as contact allergens in personal care products. Dermatitis. 2013;24(6):291–5.CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Fukutomi Y, Taniguchi M, Nakamura H, Akiyama K. Epidemiological link between wheat allergy and exposure to hydrolyzed wheat protein in facial soap. Allergy. 2014;69(10):1405–11.CrossRefPubMedPubMedCentralGoogle Scholar
  82. 82.
    Di Lernia V, Albertini G, Bisighini G. Immunologic contact urticaria syndrome from raw rice. Contact Dermatitis. 1992;27:196.CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Stanciu M, Sassville D. Contact urticaria, dermatitis and respiratory allergy caused by enzymes. In: Gimenez-Arnau A, Maibach HI, editors. Contact urticaria syndrome. Florida: Taylor & Francis Group, LLC; 2015. p. 169–88.Google Scholar
  84. 84.
    Moreno-Ancillo A, Domínguez-Noche C, Gil-Adrados AC, Cosmes PM. Bread eating induced oral angioedema due to alpha-amylase allergy. J Investig Allergol Clin Immunol. 2004;14:346–7.PubMedGoogle Scholar
  85. 85.
    Pichler WJ, Campi P. Allergy to lysozyme/egg white-containing vaginal suppositories. Ann Allergy. 1992;69(6):521–5.PubMedGoogle Scholar
  86. 86.
    Chaplin MF, Bucke C. Enzyme technology. Cambridge: Cambridge University Press; 1990. p. 280.Google Scholar
  87. 87.
    Kanerva L, Tarvainen K. Allergic contact dermatitis and contact urticaria from cellulolytic enzymes. Am J Contact Dermatitis. 1990;1:244–5.CrossRefGoogle Scholar
  88. 88.
    Tarvainen K, Kanerva L, Tupasela O, Grenquist-Nordén B, Jolanki R, et al. Allergy from cellulase and xylanase enzymes. Clin Exp Allergy. 1991;21:609–15.CrossRefPubMedPubMedCentralGoogle Scholar
  89. 89.
    Verhulst L, Goossens A. Cosmetic components causing contact urticaria: a review and update. Contact Dermatitis. 2016;75(6):333–44.Google Scholar
  90. 90.
    Pumphrey RS, Duddridge M, Norton J. Fatal latex allergy. J Allergy Clin Immunol. 2001;107:558.CrossRefPubMedPubMedCentralGoogle Scholar
  91. 91.
    Kobayashi T, Ito T, Kawakami H, Fuzishiro K, Hirano H, Okubo Y, Tsuboi R. Eighteen cases of wheat allergy and wheat-dependent exercise-induced urticaria/anaphylaxis sensitized by hydrolyzed wheat protein in soap. Int J Dermatol. 2015;54(8):e302–5.CrossRefPubMedPubMedCentralGoogle Scholar
  92. 92.
    Inomata N, Nagashima M, Hakuta A, Aihara M. Food allergy preceded by contact urticaria due to the same food: involvement of epicutaneous sensitization in food allergy. Allergol Int. 2015;64(1):73–8.CrossRefPubMedGoogle Scholar
  93. 93.
    Nakamura M, Yagami A, Hara K, Sano-Nagai A, Kobayashi T, Matsunaga K. Evaluation of the cross-reactivity of antigens in Glupearl 19S and other hydrolysed wheat proteins in cosmetics. Contact Dermatitis. 2016;74:346–52.CrossRefPubMedPubMedCentralGoogle Scholar
  94. 94.
    Verhulst L, Kerre S, Goossens A. The unsuspected power of mare's milk. Contact Dermatitis. 2016;74:376–7.CrossRefPubMedPubMedCentralGoogle Scholar
  95. 95.
    Katayama M, Inomata N, Inagawa N, et al. A case of contact urticaria syndrome stage 3 after honey ingestion, induced by epicutaneous sensitization during skin care with honey. Contact Dermatitis. 2016;74:189–91.CrossRefPubMedPubMedCentralGoogle Scholar
  96. 96.
    Assier A, Wolkenstein P, Chosidow O. First case of contact dermatitis caused by hydroxypropyl tetrahydropyrantriol used in an anti-ageing cream. Contact Dermatitis. 2017;1:60–1.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of DermatologyWest Hertfordshire NHS TrustHertfordshireUK
  2. 2.Department of DermatologyOkmeydanı Training and Research HospitalİstanbulTurkey

Personalised recommendations