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In vivo ultraviolet irradiation of human skin results in profound perturbation of the immune system. Relevance to ultraviolet-induced skin cancer.

Ultraviolet exposure of human skin deletes the function of antigen-presenting Langerhans cells normally resident within the epidermis. Langerhans cells are capable of activating T-lymphocytes by presenting antigens (such as nickel or tumor antigens) to T-lymphocytes. Such activated T-lymphocytes may be involved in the development of contact dermatitis and the immune surveillance of immunogenic skin cancers. Deletion of the function of Langerhans cells does not result in abrogated epidermal antigen presentation since ultraviolet irradiation simultaneously induces the appearance of another epidermal antigen-presenting cell population that is distinct from the Langerhans cell population and seems to induce suppression of the immune response. Suppression of the immune response following ultraviolet irradiation in murine models is critical for growth of immunogenic ultraviolet-induced skin neoplasm. Thus, ultraviolet irradiation of human skin may facilitate the growth of human neoplasms, and the spreading of skin-associated infections due to induction of suppressor T cells.

Animals↗

Sensitive and ethnic skin. A need for special skin-care agents?

Sensitive skin is a complex problem with genetic, individual, environmental, occupational, and ethnic implications. Further work is needed to rank irritants and irritant reactions to classify sensitive skin on the basis of standard models. The development of topical products designed for sensitive and ethnic skin may be advisable to optimize drug activity with minimal side effects. The availability of transdermal systems for drug delivery highlights the problem. Occlusive transdermal patch systems for delivery of clonidine show sensitization rates of 34% in white women, 18% in white men, 14% in black women, and 8% in black men. Besides ethnic differences in transcutaneous penetration, individual and ethnic skin sensitivity may play an important role in determining both patient compliance and therapeutic efficacy of drugs and cosmetics; furthermore, a drug formulation considering skin physiology may prevent unwanted local and general adverse effects.

Dermatitis, Contact↗

Keratin gene expression in mouse skin tumors and in mouse skin treated with 12-O-tetradecanoylphorbol-13-acetate.

Alterations in the pattern of epidermal differentiation and proliferation occur during mouse skin carcinogenesis. We have used cDNA clones corresponding to the major keratin subunits synthesized in differentiating epidermal cells (Mr 67,000 and 59,000) and in proliferating epidermal cells (Mr 60,000, 55,000, and 50,000) to study changes in keratin gene transcript levels in mouse epidermis exposed to tumor promoters. The same probes were used to characterize the keratin expression patterns in benign and malignant skin tumors. A single topical treatment with 12-O-tetradecanoylphorbol-13-acetate caused a rapid initial decrease in the epidermal transcript levels corresponding to the Mr 67,000 and 59,000 keratin subunits. By 48 h the transcript level for the Mr 67,000 keratin subunit was restored to control values, whereas the transcript levels for the Mr 59,000 subunit returned to control at a slower rate. In contrast, the transcript level for the Mr 55,000 subunit was increased substantially 12- 48 h after treatment, the Mr 50,000 subunit transcript increased to a lesser extent, and the Mr 60,000 subunit message was transiently decreased at 12 h but returned to the level of solvent-treated skin by 24 h. Single exposure to the incomplete tumor promoters 4-O-methyl-12-O-tetradecanoylphorbol-13-acetate, the ionophore A23187, and mezerein induced changes in keratin gene transcripts similar to those of 12-O-tetradecanoylphorbol-13-acetate. The antipromoter fluocinolone acetonide, administered with 12-O-tetradecanoylphorbol-13-acetate, partially inhibited the decrease in the Mr 59,000 and 67,000 transcripts and completely inhibited the increase in the Mr 55,000 transcript. In skin papillomas produced by initiation and promotion, keratin gene expression was similar to normal skin, with the exception of a two-fold increase in the transcript levels for the Mr 55,000 keratin subunit. However, in carcinomas, the transcript levels for the Mr 67,000 and 59,000 subunits were only 1-3% of those observed in untreated mouse epidermis. In concert with other data, the rapid and selective loss of transcripts for differentiation-related keratins after exposure to both complete and incomplete tumor promoters is most consistent with an accelerated rate of maturation in differentiating keratinocytes, resulting in the rapid production of transcript-depleted fully mature squames. The enhanced level of Mr 55,000 transcripts suggests a concomitant increase in the number of all cells or a subset of cells in the proliferative compartment.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

[A monoclonal antibody study of carcinoembryonic antigen (CEA) in skin and skin tumors].

Using anti-CEA polyclonal antibody (PoAb), carcinoembryonic antigen (CEA) has been demonstrated immunohistologically in the sweat gland apparatus of normal human skin. Therefore, staining for CAE has been commonly used for the diagnosis of sweat gland tumors and sweat gland differentiation of the skin tumors. However, recently, various kinds of CEA-associated antigens which cross-react with anti-CEA PoAb have been found. It has been pointed out that anti-CEA PoAb is not specific to CEA and gives false positive reactions. In the present study, localization of CEA in normal skin and skin tumors was evaluated immunohistologically using anti-CEA PoAb and three kinds of anti-CEA monoclonal antibodies (MoAbs), which were more specific for CEA. From the studies with PoAb and MoAbs, it appeared that CEA-associated antigens were present in the area which reacted with PoAb and that eccrine glands contained various kinds of CEA-like substances. Pure CEA may not exist in skin tissues.

Antibodies, Monoclonal↗

Allogeneic skin grafting for extensive skin chronic graft-versus-host disease.

A 35-year-old female with chronic myelogenous leukemia in chronic phase underwent allogeneic bone marrow transplantation from her genotypically-matched brother in 1990. The extensive chronic graft-versus-host skin disease supervened with skin ulcers on both lower legs in 1992. Conservative therapy was unsuccessful for these lesions. Therefore, not only autologous skin grafting but also allogeneic skin grafting from the marrow donor was successfully performed. She has been maintaining her daily activities (Karnofsky performance status 90%) with little limitation for 17 months after the final skin grafting.

Adult↗

Loss of retinoic acid receptors in mouse skin and skin tumors is associated with activation of the ras(Ha) oncogene and high risk for premalignant progression.

Retinoic acid receptor transcripts (RARalpha and RARgamma) are decreased in benign mouse epidermal tumors relative to normal skin and are almost absent in carcinomas. In this report, the expression of RARalpha and RARgamma proteins was analyzed by immunoblotting in benign skin tumors induced by two different promotion protocols designed to yield tumors at low or high risk for malignant conversion. RARalpha was slightly reduced in papillomas promoted with 12-O-tetradecanoylphorbol-13-acetate (low risk) and markedly decreased or absent in papillomas promoted by mezerein (high risk). However, mezerein also caused substantial reduction of RARalpha in nontumorous skin. RARgamma was not detected in tumors from either protocol and was greatly reduced in skin treated by either promoter. Both RARalpha and RARgamma proteins were decreased in keratinocytes overexpressing an oncogenic v-ras(Ha) gene, and RARalpha was underexpressed in a benign keratinocyte cell line carrying a mutated c-ras(Ha) gene. Introduction of a recombinant RARalpha expression vector into benign keratinocyte tumor cells reduced the S-phase population and inhibited [3H]thymidine incorporation in response to retinoic acid. Furthermore, transactivation of B-RARE-tk-LUC by retinoic acid was markedly decreased in keratinocytes transduced with the v-ras(Ha) oncogene (v-ras(Ha)-keratinocytes). Blocking protein kinase C function in v-ras(Ha)-keratinocytes with bryostatin restored RARalpha protein to near normal levels, reflecting the involvement of protein kinase C in RARalpha regulation. Both RARalpha and RARgamma are down-regulated in cultured keratinocytes by 12-O-tetradecanoylphorbol-13-acetate, further implicating PKC in the regulation of retinoid receptors. Our data suggest that modulation of RARs could contribute to the neoplastic phenotype in mouse skin carcinogenesis and may be involved in the differential promoting activity of mezerein and 12-O-tetradecanoylphorbol-13-acetate, particularly for selecting tumors at high risk for malignant conversion.

Animals↗

Lower extremity reconstruction after necrotising fasciitis and necrotic skin lesions using a porcine-derived skin substitute.

Seven consecutive clinical cases of necrotising fasciitis or necrotic skin lesions (42-78 years old; average 65.0 years of age, three females and four males) due to group A Streptococcus, group B Streptococcus, methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa in the lower extremities, who demonstrated rapid systemic symptoms, were investigated for the usefulness of a bilayer artificial dermis, derived from porcine tendons, over 4 +/- 2.4 years (1-7 years). All surgical debridement was confirmed as sufficiently deep and wide for clinically infected lesions and artificial dermis was applied to all wounds. The average interval to secondary split-thickness skin grafting was about 17.5 days (17.5 +/- 2.44 days, 21 days max., 14 days min.) and the average thickness was 0.009 +/- 0.0022 in. (range: 0.006 - 0.012 in.). No clinical problems were noted during the application of the artificial dermis and the subsequent skin grafting. Since, the donated skin graft was thin, the morbidity was minimised. The use of artificial dermis after extensive surgical debridement in necrotising fasciitis was easy and effective. Local or systemic infection was negligible.

Adult↗

Electrical measurement of the water content of the stratum corneum in vivo and in vitro under various conditions: comparison between skin surface hygrometer and corneometer in evaluation of the skin surface hydration state.

Two commercially available electrical instruments which evaluate the hydration state of the skin surface were compared in in vitro and in vivo experiments. The skin surface hygrometer (Skicon-200) employs high-frequency conductance, whereas the corneometer (CM 420, CM 820) uses electrical capacitance to determine the level of hydration. In a simulation model of in vivo stratum corneum (SC), the high frequency conductance device showed a much closer correlation with the hydration state of the surface SC (r = 0.99) than the capacitance device (r = 0.79), suggesting that the former can accurately assess the hydration dynamics of SC, particularly that due to the accumulation of easily releasable secondary bound water and free water. Both devices were insensitive to changes of hydration taking place in deeper viable skin tissues, e.g. the accumulated tissue fluids in suction blisters. Although the capacitance device correlated poorly with the hydration dynamics in normal SC, its sensitivity to changes occurring in extremely dry skin, such as scaly psoriatic lesions, suggests its measurements characteristics at an extremely low state of hydration, consisting of mostly bound water, such as noted in pathologic SC.

Adolescent↗

Basal cell skin carcinoma and other nonmelanoma skin cancers in Finland from 1956 through 1995.

OBJECTIVE: To study trends of nonmelanoma skin cancer in Finland. DESIGN: Descriptive analysis of incidence and mortality rates for basal cell skin carcinoma (BCC) and other non-melanoma skin cancers (NMSCs) from 1966 and 1956, respectively, through 1995 in relation to sex, age, anatomical distribution, place of residence, and occupation. SETTING: Data were obtained from the nationwide Finnish Cancer Registry, to which reporting of skin cancer is compulsory. PATIENTS: Inhabitants of Finland (5.1 million in 1998). MAIN OUTCOME MEASURES: Age- and sex-specific incidence and mortality rates and overall rates adjusted for age to the world standard population; occupation-specific standardized incidence ratios, with the total Finnish population as reference. RESULTS: The age-adjusted incidence rate in 1991 through 1995 for BCC was 49 per 100,000 person-years in men and 45 in women. For NMSC it was 8.7 in men and 5.3 in women. Both cancer types showed an increasing trend in incidence rates. The proportion of tumors in the face, scalp, and neck was 59% for BCC and 67% for NMSC. The incidence rate of NMSC increased from north to south, while there was no great urban-rural or occupational variation in the occurrence of NMSC. The incidence rate for BCC was higher in urban than in rural regions. Farmers, forestry workers, and fishermen showed low incidence of BCC, whereas occupations with a high level of education or compulsory health checkups and medical care occupations appeared to have an increased incidence of BCC. The mortality rate for BCC in 1991 through 1995 was 0.08 per 100,000 person-years in men and 0.05 in women, and for NMSC, it was 0.38 in men and 0.23 in women. The mortality trend was decreasing for both cancer types. CONCLUSIONS: The incidence of NMSC is fairly low in Finland, accounting for 3.5% of all new cancer cases. Conversely, BCC is the most common cancer type. The incidence trend is increasing for both skin cancer types, but mortality remains low.

Aged↗

Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis.

OBJECTIVE: To assess the risk of developing a basal cell carcinoma (BCC), and/or a squamous cell carcinoma (SCC), and/or Bowen disease (SCC in situ) after a nonmelanoma skin cancer (NMSC) of a specific type. DATA SOURCES: Four electronic databases were searched from January 1, 1966, to October 21, 1999. STUDY SELECTION: We included all studies published in English, identified by standard search strategies, that provided original data quantifying the risk of an NMSC among persons with a previous NMSC. DATA EXTRACTION: For each study and separate histological type of index skin tumor and subsequent skin tumor (SCC, BCC, NMSC, or Bowen disease), we determined the 3-year cumulative risk and the incidence rate of second tumors per 100 000 person-years. In cases where more than 1 study was assessing the risk of one specific tumor type after another, we undertook a formal meta-analysis. We compared the incidence of a subsequent SCC after an index SCC and of a subsequent BCC after an index BCC with the incidence of the first occurrence of such tumors in the comparable general population. DATA SYNTHESIS: We identified and reviewed 17 studies that included data for 26 tumor combinations. Overall, the 3-year cumulative risk of a subsequent SCC after an index SCC is 18%, at least a 10-fold increase in incidence compared with the incidence of first tumors in a comparable general population. For BCCs, the 3-year cumulative risk is 44%, also at least a 10-fold increase in incidence compared with the rate in a comparable general population. The risk of developing a BCC in patients with a prior SCC is about equal to that risk among persons with a prior BCC, but the risk of developing an SCC in patients with a prior BCC is low (6%). CONCLUSIONS: Although these studies vary in their study type, location, and biases, their results are consistent. The risk of developing a subsequent skin cancer of a specific type depends on the type of prior NMSC and number of prior skin tumors of that type. Based on these findings, follow-up strategies for patients with BCC and SCC are suggested.

Bowen's Disease↗

Comparison of skin biopsy triage decisions in 49 patients with pigmented lesions and skin neoplasms: store-and-forward teledermatology vs face-to-face dermatology.

OBJECTIVE: To determine the relative efficacy of store-and-forward teledermatology vs face-to-face dermatology consultations in triage decisions about the need for a biopsy of neoplastic skin changes. DESIGN: Prospective study of consecutive patients judged by an internist to require dermatologic consultation for a skin growth. SETTING: Private primary care and dermatology practices and an academic dermatology practice. PATIENTS: Patients requiring dermatology consultation for evaluation of skin growths. Patients were seen by a single primary care physician between July 10, 1998, and August 4, 2000. INTERVENTION: Digital photographs of skin growths were obtained by the primary care physician and evaluated by a teledermatologist. The patient was then seen face-to-face by a dermatologist. A biopsy was performed if either dermatologist favored biopsy. MAIN OUTCOME MEASURES: Decisions to perform a biopsy. Agreement between the dermatologists was assessed. RESULTS: Of the 49 patients with evaluable photographs, the face-to-face dermatologist and teledermatologist recommended a biopsy for the same 26 patients, yielding a sensitivity of the teledermatologist of 1.00 (95% confidence interval [CI], 0.87-1.00) and a specificity of 1.00 (95% CI, 0.85-1.00). The agreement between the dermatologists (kappa) was 1.00 (95% CI, 0.72-1.00). CONCLUSION: Store-and-forward teledermatology may provide an accurate and cost-effective method of determining whether skin growths in patients presenting to primary care physicians should undergo biopsy.

Biopsy↗

Skin ulceration potential of paclitaxel in a mouse skin model in vivo.

BACKGROUND: THe antimitotic agent paclitaxel is highly active in the therapy of several tumor types, including ovarian and breast cancer. The commercial formulation (Taxol) is supplied in a vehicle containing alcohol and the surfactant Cremophor EL (polyethoxylated castor oil). Whereas Phase I studies did not describe extravasation necrosis, more recent case reports have suggested that paclitaxel can cause soft tissue necrosis if inadvertently extravasated. The efficacy of various antidotal maneuvers, if any, was not known. METHODS: Dehaired, BALB/c mice were given intradermal (ID) injections of paclitaxel 0.3 mg, 0.6 mg, or 1.2 mg, or Cremophor EL, 0.1 mL, into the dorsal skin. The sites were observed thrice weekly for evidence of ulceration. Perpendicular widths of skin ulcers were measured by caliper and multiplied to yield a lesion area in cm2. The lesion area multiplied by time in days was integrated by computer to yield cumulative ulceration areas in (cm2 x days). Potential pharmacologic adjuvants were injected ID after paclitaxel. These included saline (0.05 mL), albumin (0.05 mL), hyaluronidase (15 Units), and hydrocortisone (2.5 mg). Topical adjuvants included dimethylsulfoxide solution, (0.1 mL), cooling to 8-10 degrees C or heating to 43-44 degrees C for 30 minutes after ID paclitaxel. RESULTS: Dose-dependent skin ulcers that lasted 12-17 days were created with the 3 ID paclitaxel doses. The two higher paclitaxel dose levels, 0.6 mg and 1.2 mg, were selected for antidote studies. Hyaluronidase and saline were effective ID antidotes for lesions induced by the 0.6-mg paclitaxel dose, but not for the higher paclitaxel dose of 1.2 mg (P<0.05 by analysis of variance). None of the topical adjuvants or other ID adjuvants significantly reduced paclitaxel-induced skin ulcers in the mice. CONCLUSIONS: Paclitaxel has experimental vesicant potential in the ID mouse skin model. Clinical extravasations of paclitaxel may be treated by subcutaneous injections of hyaluronidase diluted in saline.

Animals↗

A role for CD4+ T cells in the pathogenesis of skin fibrosis in tight skin mice.

The tight skin (Tsk/+) mouse represents a murine model of heritable fibrosis with some similarities to the skin fibrosis seen in human scleroderma. Tsk/+ animals display alterations in connective tissue in some internal organs. Skin fibrosis can be adoptively transferred to normal recipients with Tsk/+ bone marrow or spleen cells and older Tsk/+ animals develop autoantibodies against topoisomerase suggesting that some of the pathogenesis in the Tsk/+ mouse may be mediated by autoimmunity. To determine the role of T cell subsets in the pathogenesis of fibrotic disease, Tsk/+ mice were bred with CD4- and CD8-deficient (CD4-/- and CD8-/-) mice. Tsk/+ CD4-/- mice showed a marked reduction in skin fibrosis as well as decreased cellularity and only mild collagen disorganization as compared to Tsk/+ CD4+ CD8+ control mice yet did not differ from Tsk controls in the level of serum anti-topoisomerase activity. In contrast, Tsk/+ CD8-/- mice exhibited the same histology in the skin as Tsk/+ controls yet had significantly reduced levels of serum anti-topoisomerase activity. Lung pathology, i.e. emphysema, was unaffected by both the CD4 or CD8 mutations. These data show that only some of the pathological effects of the Tsk mutation are T cell dependent and that different T cell subsets affect different parameters in this multi-organ model of fibrotic disease.

Animals↗

Food intake and risk of squamous cell carcinoma of the skin in a community: the Nambour skin cancer cohort study.

There is some evidence that dietary factors may modify the risk of squamous cell carcinoma (SCC) of the skin, but the association between food intake and SCC has not been evaluated prospectively. We examined the association between food intake and SCC incidence among 1,056 randomly selected adults living in an Australian sub-tropical community. Measurement-error corrected estimates of intake in 15 food groups were defined from a validated food frequency questionnaire in 1992. Associations with SCC risk were assessed using Poisson and negative binomial regression to the persons affected and tumour counts, respectively, based on incident, histologically confirmed tumours occurring between 1992 and 2002. After multivariable adjustment, none of the food groups was significantly associated with SCC risk. Stratified analysis in participants with a past history of skin cancer showed a decreased risk of SCC tumours for high intakes of green leafy vegetables (RR = 0.45, 95% CI = 0.22-0.91; p for trend = 0.02) and an increased risk for high intake of unmodified dairy products (RR = 2.53, 95% CI: 1.15-5.54; p for trend = 0.03). Food intake was not associated with SCC risk in persons who had no past history of skin cancer. These findings suggest that consumption of green leafy vegetables may help prevent development of subsequent SCCs of the skin among people with previous skin cancer and that consumption of unmodified dairy products, such as whole milk, cheese and yoghurt, may increase SCC risk in susceptible persons.

Adult↗

Non-ablative skin tightening with radiofrequency in Asian skin.

BACKGROUND AND OBJECTIVES: The recent successful application of radiofrequency (RF) in non-ablative skin tightening for skin laxity has attracted attention worldwide. The efficacy and clinical effect of RF were assessed in Asian skin, with additional study on the duration of the effect and any complications. STUDY DESIGN/MATERIALS AND METHODS: Eighty-five Japanese females were enrolled in the study for treatment of nasolabial folds, marionette lines, and sagging jowls with 6-month follow-up. RESULTS: RF treatment was effective for nasolabial folds, marionette lines, and jowls. Objective physician evaluation found relatively good improvement at 3 months post-treatment, and even better improvement at the 6-month evaluation. CONCLUSIONS: RF treatment was very satisfactory for skin tightening in Asian facial skin. When compared with published literature from the United States, the results suggested that there might be race-related differences in the treatment parameters.

Adult↗

Induction of skin fibrosis and autoantibodies by infusion of immunocompetent cells from tight skin mice into C57BL/6 Pa/Pa mice.

Tight skin (TSK/+) mice develop a cutaneous hyperplasia associated with the occurrence of autoantibodies characteristic for scleroderma. In order to study the role of autoimmunity in the production of skin fibrosis, we conducted adoptive transfer experiments in which bone marrow cells of TSK/pa mice were infused into pa/pa mice littermates. (C57BL/6 pa/pa mice are used to produce heterozygous TSK/pa mice). Our results showed that after a prodromal period of several months, the transfer of bone marrow cells led to skin fibrosis, the presence of autoantibodies, and increased transcription of (alpha 1) collagen I and TGF beta genes. Infusion of enriched B or T cells alone did not cause skin fibrosis but of B cells alone increased autoantibody production. By contrast, transfer of T and B lymphocytes led to earlier mild fibrosis, cellular infiltration and autoantibody production as well as increased transcription of the (alpha 1) collagen gene. Our results strongly demonstrate, for the first time, that immunocompetent cells can play a role in the activation of collagen synthesis leading to skin fibrosis.

Animals↗

Biochemical responses of skin to allergenic and non-allergenic nitrohalobenzenes. Evidence that an NADPH-dependent reductase in skin may act as a prohapten-activating enzyme.

Using a selection of 'classic' haptens (dinitrohalobenzenes and picryl chloride) and related non-sensitizing analogous, we examined changes in levels of glutathione (GSH) and glutathione disulphide (GSSG) in mouse skin 12 h after their epicutaneous application. We observed that elevation of GSSG levels and/or depletion of GSH levels correlated well with contact allergenic potential. Non-sensitizing analogous failed to perturb GSH/GSSG status. In vitro assays using mouse skin and rat liver microsomal preparations indicated that only the allergenic nitrohalobenzenes initiated NADPH-dependent oxygen utilization, with the activity falling off in the order picryl chloride >> DNIB > DNBB > DNCB > DNFB. In addition, an examination of the colour of mouse skin homogenates ex vivo after application of the dinitrohalobenzenes showed significant yellowing (consistent with aromatic nucleophilic substitution) only with DNFB. Our results indicate that, while an aromatic nucleophilic substitution reaction with skin protein can possibly account for the allergenicity of DNFB, it does not seem to occur with DNCB, DNBB or DNIB. These may instead behave mainly as prohaptens which are activated enzymically by NADPH-dependent reductase(s) within the skin, with the concomitant generation of superoxide and hydrogen peroxide, to form potentially protein-reactive free radical and other metabolites. Picryl chloride appears capable of both conjugating directly with proteins by aromatic nucleophilic substitution and undergoing NADPH-dependent metabolism to other potentially protein-reactive metabolites.

Animals↗

Effect of occlusion on resident flora, skin-moisture and skin-pH.

The effects of a 3-day test of an occlusion dressing of the forearm on the resident flora of the skin, relative skin-moisture and skin-pH were studied in 26 male and female volunteers. The geometrical mean values of coagulase-negative Staphylococci and Corynebacterium species increased five and four logs and decreased 1 day post occlusion only two logs. Relative skin-moisture increased from 20% to 75% under occlusion and decreased to 5% 24h after removal. Skin-pH increased from 4.9 to 7.1 and decreased to pH 5.2. Investigations of the resident flora should be made, if the influence of external, not antimicrobial active agents, is to be examined, because changes in the substrate can cause secondary changes in the resident flora.

Adult↗