Acrodermatitis chronica atrophicans medical therapy: Difference between revisions

	Acrodermatitis chronica atrophicans Microchapters
Home
Patient Information
Overview
Historical Perspective
Pathophysiology
Causes
Differentiating Acrodermatitis chronica atrophicans from other Diseases
Epidemiology and Demographics
Risk Factors
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Acrodermatitis chronica atrophicans medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Acrodermatitis chronica atrophicans medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Acrodermatitis chronica atrophicans medical therapy
CDC on Acrodermatitis chronica atrophicans medical therapy
Acrodermatitis chronica atrophicans medical therapy in the news
Blogs on Acrodermatitis chronica atrophicans medical therapy
Directions to Hospitals Treating Type page name here
Risk calculators and risk factors for Acrodermatitis chronica atrophicans medical therapy

VisualWikitext

Latest revision as of 11:29, 17 June 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2] Raviteja Guddeti, M.B.B.S. [3]

Overview

Antibiotic therapy is recommended in patients with acrodermatitis chronica atrophicans. Up to four weeks treatment with antibiotics such as amoxicillin, doxycycline, ceftriaxone, cefotaxime and penicillin G has been recommended for acrodermatitis chronica atrophicans's treatment.

Medical Therapy

Antibiotic therapy is recommended in patients with acrodermatitis chronica atrophicans.^[1]
Up to four weeks treatment with antibiotics such as doxycycline, ceftriaxone and penicillin has been recommended in acute cases. However even with proper treatment, borrelia is able to remain in involved skin tissues. ^[2]^[3]
92% of patients in a study had significant reduction in level of antibody after proper antibiotic therapy.^[4]
In a study 72 hours of appropriate antibiotics concentration, such as penicillin and doxycycline, were not successful in diminishing motile organisms. However in the same study proper concentration of ceftriaxone was able to destroys motile organisms after 72 hours.^[3]
In vitro investigations have been revealed borrelia susceptibility to antibiotics such as erythromycin, ceftriaxone and cefotaxime. Except for erythromycin, borrelia showed susceptibility to ceftriaxone and cefotaxime also in in vivo evaluations. ^[5]
Penicillin G was among antibiotics that weren't effective neither in vivo or in vitro.^[5]
Based on two case reports written in 1988, darkening of skin lesion in 2 children with acrodermatitis chronica atrophicans responded to benzylpenicillin over one week.^[6]
The following table is a summary of standard treatments for acrodermatitis chronica atrophicans:^[7]^[8]^[9]^[10]^[11]^[12]

Antibiotics	Route of Administration	Dose	Interval	Treatment Duration
Amoxicillin	Oral	500 to 1000 mg	Three times a day	14 to 28 days
Doxycycline	Oral	100 mg	Twice a day	14 to 28 days
Doxycycline	Oral	200 mg	Once a day	14 to 28 days
Ceftriaxone	Intravenous	2000 mg	Once a day	14 to 28 days
Cefotaxime	Intravenous	2000 mg	Every 8 hours	14 to 28 days
Penicillin G	Intravenous	3 - 4 MU	Every 4 hours	14 to 28 days

References

↑ Weber K, Preac-Mursic V, Neubert U, Thurmayr R, Herzer P, Wilske B; et al. (1988). "Antibiotic therapy of early European Lyme borreliosis and acrodermatitis chronica atrophicans". Ann N Y Acad Sci. 539: 324–45. doi:10.1111/j.1749-6632.1988.tb31867.x. PMID 3056202.
↑ Aberer, Elisabeth; Breier, F.; Stanek, G.; Schmidt, B. (1996). "Success and failure in the treatment of acrodermatitis chronica atrophicans". Infection. 24 (1): 85–87. doi:10.1007/BF01780666. ISSN 0300-8126.
↑ ^3.0 ^3.1 Kersten, A; Poitschek, C; Rauch, S; Aberer, E (1995). "Effects of penicillin, ceftriaxone, and doxycycline on morphology of Borrelia burgdorferi". Antimicrobial Agents and Chemotherapy. 39 (5): 1127–1133. doi:10.1128/AAC.39.5.1127. ISSN 0066-4804.
↑ . doi:10.2340/0001555574424428. Missing or empty |title= (help)
↑ ^5.0 ^5.1 Mursic, V. P.; Wilske, B.; Schierz, G.; Holmburger, M.; Süß, E. (1987). "In vitro and in vivo susceptibility ofBorrelia burgdorferi". European Journal of Clinical Microbiology. 6 (4): 424–426. doi:10.1007/BF02013102. ISSN 0722-2211.
↑ Nadal, D; Gundelfinger, R; Flueler, U; Boltshauser, E (1988). "Acrodermatitis chronica atrophicans". Archives of Disease in Childhood. 63 (1): 72–74. doi:10.1136/adc.63.1.72. ISSN 0003-9888.
↑ "StatPearls". 2021. PMID 33085436 Check |pmid= value (help).
↑ Flisiak R, Pancewicz S, Polish Society of Epidemiology and Infectious Diseases (2008). "[Diagnostics and treatment of Lyme borreliosis. Recommendations of Polish Society of Epidemiology and Infectious Diseases]". Przegl Epidemiol. 62 (1): 193–9. PMID 18536243.
↑ Pancewicz SA, Garlicki AM, Moniuszko-Malinowska A, Zajkowska J, Kondrusik M, Grygorczuk S; et al. (2015). "Diagnosis and treatment of tick-borne diseases recommendations of the Polish Society of Epidemiology and Infectious Diseases". Przegl Epidemiol. 69 (2): 309–16, 421–8. PMID 26233093.
↑ Moniuszko-Malinowska A, Czupryna P, Dunaj J, Pancewicz S, Garkowski A, Kondrusik M; et al. (2018). "Acrodermatitis chronica atrophicans: various faces of the late form of Lyme borreliosis". Postepy Dermatol Alergol. 35 (5): 490–494. doi:10.5114/ada.2018.77240. PMC 6232541. PMID 30429707.
↑ Asbrink E, Brehmer-Andersson E, Hovmark A (1986). "Acrodermatitis chronica atrophicans--a spirochetosis. Clinical and histopathological picture based on 32 patients; course and relationship to erythema chronicum migrans Afzelius". Am J Dermatopathol. 8 (3): 209–19. doi:10.1097/00000372-198606000-00005. PMID 3728879.
↑ Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1111/j.1365-2133.1994.tb04984.x Check |pmid= value (help).

Template:WH Template:WS

[pmid3056202-1] Weber K, Preac-Mursic V, Neubert U, Thurmayr R, Herzer P, Wilske B; et al. (1988). "Antibiotic therapy of early European Lyme borreliosis and acrodermatitis chronica atrophicans". Ann N Y Acad Sci. 539: 324–45. doi:10.1111/j.1749-6632.1988.tb31867.x. PMID 3056202.

[AbererBreier1996-2] Aberer, Elisabeth; Breier, F.; Stanek, G.; Schmidt, B. (1996). "Success and failure in the treatment of acrodermatitis chronica atrophicans". Infection. 24 (1): 85–87. doi:10.1007/BF01780666. ISSN 0300-8126.

[KerstenPoitschek1995-3] 3.0 ^3.1 Kersten, A; Poitschek, C; Rauch, S; Aberer, E (1995). "Effects of penicillin, ceftriaxone, and doxycycline on morphology of Borrelia burgdorferi". Antimicrobial Agents and Chemotherapy. 39 (5): 1127–1133. doi:10.1128/AAC.39.5.1127. ISSN 0066-4804.

[4] . doi:10.2340/0001555574424428. Missing or empty |title= (help)

[MursicWilske1987-5] 5.0 ^5.1 Mursic, V. P.; Wilske, B.; Schierz, G.; Holmburger, M.; Süß, E. (1987). "In vitro and in vivo susceptibility ofBorrelia burgdorferi". European Journal of Clinical Microbiology. 6 (4): 424–426. doi:10.1007/BF02013102. ISSN 0722-2211.

[NadalGundelfinger1988-6] Nadal, D; Gundelfinger, R; Flueler, U; Boltshauser, E (1988). "Acrodermatitis chronica atrophicans". Archives of Disease in Childhood. 63 (1): 72–74. doi:10.1136/adc.63.1.72. ISSN 0003-9888.

[pmid33085436-7] "StatPearls". 2021. PMID 33085436 Check |pmid= value (help).

[pmid18536243-8] Flisiak R, Pancewicz S, Polish Society of Epidemiology and Infectious Diseases (2008). "[Diagnostics and treatment of Lyme borreliosis. Recommendations of Polish Society of Epidemiology and Infectious Diseases]". Przegl Epidemiol. 62 (1): 193–9. PMID 18536243.

[pmid26233093-9] Pancewicz SA, Garlicki AM, Moniuszko-Malinowska A, Zajkowska J, Kondrusik M, Grygorczuk S; et al. (2015). "Diagnosis and treatment of tick-borne diseases recommendations of the Polish Society of Epidemiology and Infectious Diseases". Przegl Epidemiol. 69 (2): 309–16, 421–8. PMID 26233093.

[pmid30429707-10] Moniuszko-Malinowska A, Czupryna P, Dunaj J, Pancewicz S, Garkowski A, Kondrusik M; et al. (2018). "Acrodermatitis chronica atrophicans: various faces of the late form of Lyme borreliosis". Postepy Dermatol Alergol. 35 (5): 490–494. doi:10.5114/ada.2018.77240. PMC 6232541. PMID 30429707.

[pmid3728879-11] Asbrink E, Brehmer-Andersson E, Hovmark A (1986). "Acrodermatitis chronica atrophicans--a spirochetosis. Clinical and histopathological picture based on 32 patients; course and relationship to erythema chronicum migrans Afzelius". Am J Dermatopathol. 8 (3): 209–19. doi:10.1097/00000372-198606000-00005. PMID 3728879.

[pmidhttps://doi.org/10.1111/j.1365-2133.1994.tb04984.x-12] Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1111/j.1365-2133.1994.tb04984.x Check |pmid= value (help).

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

@@ Line 1: / Line 1: @@
 __NOTOC__
-{{CMG}}; {{AE}} {{RT}}
+{{CMG}}; {{AE}} {{Anahita}} {{RT}}
 {{ACA}}
 ==Overview==
-===Pharmacotherapy===
+[[Antibiotic]] [[therapy]] is recommended in [[patients]] with [[acrodermatitis chronica atrophicans]]. Up to four weeks [[treatment]] with [[antibiotics]] such as [[amoxicillin]], [[doxycycline]], [[ceftriaxone]], [[cefotaxime]] and [[Penicillin|penicillin G]] has been recommended for [[acrodermatitis chronica atrophicans]]'s [[treatment]].
-* Treatment consists of antibiotics including [[doxycycline]] and [[penicillin]] for up to four weeks in the acute case.
+==Medical Therapy==
+*[[Antibiotic]] [[therapy]] is recommended in [[patients]] with [[acrodermatitis chronica atrophicans]].<ref name="pmid3056202">{{cite journal| author=Weber K, Preac-Mursic V, Neubert U, Thurmayr R, Herzer P, Wilske B | display-authors=etal| title=Antibiotic therapy of early European Lyme borreliosis and acrodermatitis chronica atrophicans. | journal=Ann N Y Acad Sci | year= 1988 | volume= 539 | issue=  | pages= 324-45 | pmid=3056202 | doi=10.1111/j.1749-6632.1988.tb31867.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3056202  }} </ref>
+*Up to four weeks [[treatment]] with [[antibiotics]] such as [[doxycycline]], [[ceftriaxone]] and [[penicillin]] has been recommended in acute cases. However even with proper [[treatment]], [[borrelia]] is able to remain in involved [[skin]] tissues. <ref name="AbererBreier1996">{{cite journal|last1=Aberer|first1=Elisabeth|last2=Breier|first2=F.|last3=Stanek|first3=G.|last4=Schmidt|first4=B.|title=Success and failure in the treatment of acrodermatitis chronica atrophicans|journal=Infection|volume=24|issue=1|year=1996|pages=85–87|issn=0300-8126|doi=10.1007/BF01780666}}</ref><ref name="KerstenPoitschek1995">{{cite journal|last1=Kersten|first1=A|last2=Poitschek|first2=C|last3=Rauch|first3=S|last4=Aberer|first4=E|title=Effects of penicillin, ceftriaxone, and doxycycline on morphology of Borrelia burgdorferi|journal=Antimicrobial Agents and Chemotherapy|volume=39|issue=5|year=1995|pages=1127–1133|issn=0066-4804|doi=10.1128/AAC.39.5.1127}}</ref>
+*92% of [[patients]] in a study had significant reduction in level of [[antibody]] after proper [[antibiotic]] [[therapy]].<ref>{{cite journal|doi=10.2340/0001555574424428}}</ref>
+*In a study 72 hours of appropriate [[antibiotics]] concentration, such as [[penicillin]] and [[doxycycline]], were not successful in diminishing motile [[organisms]]. However in the same study proper concentration of [[ceftriaxone]] was able to destroys motile [[organisms]] after 72 hours.<ref name="KerstenPoitschek1995">{{cite journal|last1=Kersten|first1=A|last2=Poitschek|first2=C|last3=Rauch|first3=S|last4=Aberer|first4=E|title=Effects of penicillin, ceftriaxone, and doxycycline on morphology of Borrelia burgdorferi|journal=Antimicrobial Agents and Chemotherapy|volume=39|issue=5|year=1995|pages=1127–1133|issn=0066-4804|doi=10.1128/AAC.39.5.1127}}</ref>
+*[[In vitro]] investigations have been revealed [[borrelia]] susceptibility to [[antibiotics]] such as [[erythromycin]], [[ceftriaxone]] and [[Cefotaxime sodium|cefotaxime]]. Except for [[erythromycin]], [[borrelia]] showed susceptibility to [[ceftriaxone]] and [[Cefotaxime sodium|cefotaxime]] also in [[in vivo]] evaluations. <ref name="MursicWilske1987">{{cite journal|last1=Mursic|first1=V. P.|last2=Wilske|first2=B.|last3=Schierz|first3=G.|last4=Holmburger|first4=M.|last5=Süß|first5=E.|title=In vitro and in vivo susceptibility ofBorrelia burgdorferi|journal=European Journal of Clinical Microbiology|volume=6|issue=4|year=1987|pages=424–426|issn=0722-2211|doi=10.1007/BF02013102}}</ref>
+*[[Penicillin G potassium|Penicillin G]] was among [[antibiotics]] that weren't effective neither [[in vivo]] or [[in vitro]].<ref name="MursicWilske1987">{{cite journal|last1=Mursic|first1=V. P.|last2=Wilske|first2=B.|last3=Schierz|first3=G.|last4=Holmburger|first4=M.|last5=Süß|first5=E.|title=In vitro and in vivo susceptibility ofBorrelia burgdorferi|journal=European Journal of Clinical Microbiology|volume=6|issue=4|year=1987|pages=424–426|issn=0722-2211|doi=10.1007/BF02013102}}</ref>
+*Based on two case reports written in 1988, darkening of [[skin]] lesion in 2 [[child|children]] with [[acrodermatitis chronica atrophicans]] responded to [[Penicillin|benzylpenicillin]] over one week.<ref name="NadalGundelfinger1988">{{cite journal|last1=Nadal|first1=D|last2=Gundelfinger|first2=R|last3=Flueler|first3=U|last4=Boltshauser|first4=E|title=Acrodermatitis chronica atrophicans.|journal=Archives of Disease in Childhood|volume=63|issue=1|year=1988|pages=72–74|issn=0003-9888|doi=10.1136/adc.63.1.72}}</ref>
+*The following table is a summary of standard [[treatments]] for [[acrodermatitis chronica atrophicans]]:<ref name="pmid33085436">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=33085436 | doi= | pmc= | url= }} </ref><ref name="pmid18536243">{{cite journal| author=Flisiak R, Pancewicz S, Polish Society of Epidemiology and Infectious Diseases| title=[Diagnostics and treatment of Lyme borreliosis. Recommendations of Polish Society of Epidemiology and Infectious Diseases]. | journal=Przegl Epidemiol | year= 2008 | volume= 62 | issue= 1 | pages= 193-9 | pmid=18536243 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18536243  }} </ref><ref name="pmid26233093">{{cite journal| author=Pancewicz SA, Garlicki AM, Moniuszko-Malinowska A, Zajkowska J, Kondrusik M, Grygorczuk S | display-authors=etal| title=Diagnosis and treatment of tick-borne diseases recommendations of the Polish Society of Epidemiology and Infectious Diseases. | journal=Przegl Epidemiol | year= 2015 | volume= 69 | issue= 2 | pages= 309-16, 421-8 | pmid=26233093 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26233093  }} </ref><ref name="pmid30429707">{{cite journal| author=Moniuszko-Malinowska A, Czupryna P, Dunaj J, Pancewicz S, Garkowski A, Kondrusik M | display-authors=etal| title=Acrodermatitis chronica atrophicans: various faces of the late form of Lyme borreliosis. | journal=Postepy Dermatol Alergol | year= 2018 | volume= 35 | issue= 5 | pages= 490-494 | pmid=30429707 | doi=10.5114/ada.2018.77240 | pmc=6232541 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30429707  }} </ref><ref name="pmid3728879">{{cite journal| author=Asbrink E, Brehmer-Andersson E, Hovmark A| title=Acrodermatitis chronica atrophicans--a spirochetosis. Clinical and histopathological picture based on 32 patients; course and relationship to erythema chronicum migrans Afzelius. | journal=Am J Dermatopathol | year= 1986 | volume= 8 | issue= 3 | pages= 209-19 | pmid=3728879 | doi=10.1097/00000372-198606000-00005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3728879  }} </ref><ref name="pmidhttps://doi.org/10.1111/j.1365-2133.1994.tb04984.x">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=https://doi.org/10.1111/j.1365-2133.1994.tb04984.x | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref>
+<br>
+{| style="border: 2px solid #4479BA; align="left"
+! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|[[Antibiotics]]}}
+! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|[[Route of administration|Route of Administration]]}}
+! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|[[Dose]]}}
+! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Interval}}
+! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|[[Treatment]] Duration}}
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Amoxicillin]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[mouth|Oral]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 500 to 1000 mg
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Three times a day
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 14 to 28 days
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Doxycycline]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[mouth|Oral]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 100 mg
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Twice a day
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 14 to 28 days
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Doxycycline]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[mouth|Oral]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  200 mg
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Once a day
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 14 to 28 days
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Ceftriaxone]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Intravenous therapy|Intravenous]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2000 mg
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Once a day
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 14 to 28 days
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cefotaxime]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Intravenous therapy|Intravenous]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2000 mg
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Every 8 hours
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 14 to 28 days
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Penicillin|Penicillin G]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Intravenous therapy|Intravenous]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 3 - 4 MU
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Every 4 hours
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 14 to 28 days
+|}
 ==References==
@@ Line 12: / Line 65: @@
 [[Category:Disease]]
 [[Category:Dermatology]]
-[[Category:Symptoms]]
 [[Category:Insect-borne diseases]]
 [[Category:Lyme disease]]
 [[Category:Zoonoses]]
 [[Category:Spirochaetes]]
-[[Category:Infectious disease|*]]
+[[Category:Needs review]]
+{{WH}}
+{{WS}}

Acrodermatitis chronica atrophicans medical therapy: Difference between revisions

Latest revision as of 11:29, 17 June 2021

Overview

Medical Therapy

References

Navigation menu