Shari Rone-Adams, DBA, MHSA, PT
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COMMON/DISORDER SYNONYMS
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Contact dermatitis
Seborrheic dermatitis
Atopic dermatitis (AD)
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692.0 Contact dermatitis and other eczema due to detergents
692.1 Contact dermatitis and other eczema due to oils and greases
692.2 Contact dermatitis and other eczema due to solvents
692.3 Contact dermatitis and other eczema due to drugs and medicines in contact with skin
692.4 Contact dermatitis and other eczema due to other chemical products
692.5 Contact dermatitis and other eczema due to food in contact with skin
692.6 Contact dermatitis and other eczema due to plants [except food]
692.7 Contact dermatitis and other eczema due to solar radiation
692.8 Contact dermatitis and other eczema due to other specified agents
692.84 Contact dermatitis and other eczema due to animal (cat) (dog) dander
692.89 Contact dermatitis and other eczema due to other specified agents
692.9 Contact dermatitis and other eczema, unspecified cause
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PREFERRED PRACTICE PATTERN1
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PATIENT PRESENTATION
A 32-year-old female presents with a pink scaly rash on her antecubital fossae, bilaterally. The rash is moderately erythematous and localized. There are excoriated areas indicating scratching due to itching. She reports the rash started on the weekend when she was pulling weeds in the back yard. She did use an over-the-counter hydrocortisone cream that provided some relief from the itching.
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Dermatitis is an inflammation of the skin.
Dermatitis is a common condition that usually is not life threatening or contagious.
It embraces a range of ailments that in most cases are characterized by red, itchy skin.
Common types of dermatitis include
Contact dermatitis: Inflammation that occurs when substances touching the skin cause irritation or an allergic reaction.
AD or eczema: Chronic, relapsing, and inflammatory condition that results in itchy, inflamed, irritated skin.
Seborrheic dermatitis: Common skin disorder occurring in areas rich in sebaceous glands such as the scalp, ears, eyebrows, and chest, causing scaly, itchy red skin, and stubborn dandruff.
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Essentials of Diagnosis
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Diagnosis is generally based on medical history and examination of the skin.
Contact dermatitis: Diagnosis is based on medical history, the appearance of the skin, and a history of exposure to irritants or allergens.
Seborrheic dermatitis: Diagnosis is based on history, appearance of the skin, physical, and skin biopsy.
AD (eczema): Diagnosis is based on history and appearance of the skin.
Skin lesion biopsies or skin cultures may be used to rule out other causes.
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General Considerations
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Individuals in certain outdoor and manufacturing occupations are at higher risk for exposure to allergens and irritants that may cause dermatitis.
Treatment is similar for most types of skin irritation and inflammation.
Individuals often have an inherited tendency to develop other allergic conditions such as asthma and hay fever.
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SIGNS AND SYMPTOMS
Redness or inflammation
Localized swelling
Itching
Skin lesions or rash
Tenderness of the skin in the exposed area
Warmth of the exposed area
Scarring and changes in skin color
Contact dermatitis
Certain flowers, herbs, fruits, and vegetables can cause dermatitis in some people
Itching, which may be severe
Dry, cracked, red patches, which may resemble a burn
Blisters, draining fluid, and crusting in severe reactions
Skin rash limited to an exposed area, for example, directly under a watchband
Pain or tenderness
Seborrheic dermatitis
Greasy, yellowish, or reddish scaling on the scalp and other hairy areas
Often causes dandruff
Called cradle cap in infants, may be aggravated by stress
Inflammation (redness) of the skin
Patchy scaling or thick crusts on the scalp
Yellow or white flakes (dandruff) on the scalp, hair, eyebrows, beard, or mustache
Red, greasy skin covered with flaky white or yellow scales on other areas of the body, including chest, armpits, the area where the thigh meets the abdomen (groin) or the male scrotum
Itching or soreness
AD (commonly called eczema)
Chronic, relapsing, and inflammatory condition that results in itchy, inflamed, irritated skin
Scaly, itchy skin that may swell or blister
Red to brownish-gray colored patches
Itching, which may be severe, especially at night
Small, raised bumps, which may leak fluid and crust over when scratched
Thickened, cracked, or scaly skin
Raw, sensitive skin from scratching
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Functional Implications
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Inability to tolerate stress; cold, dry air; or allergens without rash, itching, and dry skin
Limitation of the use of some modalities
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Possible Contributing Causes
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Skin lesions
Circulation impairment
Edema
The following make symptoms worse:
Allergies to pollen, mold, dust mites, or animals
Colds or the flu
Diet
Contact with rough materials
Dry skin
Exposure to environmental irritants
Exposure to water
Feeling too hot or too cold
Fragrances or dyes added to skin lotions or soaps
Stress
Contact dermatitis: Results from either repeated contact with irritants or contact with allergy-producing substances such as poison ivy, poison oak, flowers, herbs, fruits, and vegetables
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Differential Diagnosis
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Dermatophytid
Fungal infection
Impetigo
Pompholyx
Psoriasis
Scabies
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MEANS OF CONFIRMATION OR DIAGNOSIS
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FINDINGS AND INTERPRETATION
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Corticosteroid creams or ointments3
Calcineurin inhibitors (Tacrolimus and Pimecrolimus)3
Coal tar3
Antihistamines and steroids
Oral or injected corticosteroids3
Immunomodulators
Antibiotics
Tricyclic antidepressants
Wet dressings and soothing anti-itch (antipruritic) or drying lotions may be recommended to reduce other symptoms
Other treatments
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REFERRALS/ADMITTANCE
Allergist/immunologist
Dermatologist
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Skin integrity
Circulation
Pain
Sensation
Gait
Joint ROM
Muscle strength
Functional mobility
Self-care
Home management
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Integumentary integrity tests
Pigmentation
Shape and size of skin involvement
Presence of rash, fungi, blistering, ecchymosis, hair growth, signs of infection
Skin temperature
Tissue mobility, turgor, texture
Circulation tests
Volume and girth measurement for edema and effusion
Pain: Subjective report, visual analog pain (VAS) scale, or verbal report
Gait
Sensation
Joint ROM
Strength
Functional mobility
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Not typically treated by PT, but PT should be able to recognize the condition and check the skin before and after application of modalities
Depending on the extent of condition and secondary impairments, the following may apply
Dressings (e.g., wound coverings)
Topical agents (e.g., ointments, moisturizers, creams, cleansers, sealants)
Athermal modalities (e.g., pulsed ultrasound, pulsed electromagnetic fields)
Hydrotherapy
Phototherapy (e.g., ultraviolet)
Compression therapies (e.g., vasopneumatic compression devices, compression bandaging, compression garments)
Orthotic: Protective and supportive devices
Electrical muscle stimulation
Transcutaneous electrical nerve stimulation (TENS)
Functional training
ADL/IADL training
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Generalized hypersensitivity reaction (anaphylaxis and angioedema) in hypersensitive individuals is potentially fatal and can occur upon exposure to an allergen.
Contact dermatitis usually clears up without complications within 2 or 3 weeks but may return if the substance or material that caused it cannot be identified or avoided.
Seborrheic dermatitis and AD are chronic conditions that are likely to recur after treatment.
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3. +
Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR. Treatment. In:Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR CURRENT Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/content/6589527. Accessed June 1, 2013.
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ADDITIONAL REFERENCES
+
Cork
MJ, Danby
SG, Vasilopoulos
Y
et al. Epidermal barrier dysfunction in atopic dermatitis. J Invest Dermatol. 2009;129(8):1892–1908. doi:10.1038/jid.2009.133.
[PubMed: 19494826]
CrossRef +
Nicol
NH, Boguniewicz
M. Successful strategies in atopic dermatitis management. Dermatol Nurs. 2008;(Suppl):3–18.
Shari Rone-Adams, DBA, MHSA, PT
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CONDITION/DISORDER SYNONYMS
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Atopic dermatitis (AD)
Atopic eczema
Infantile eczema
Nummular eczema
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692.0 Contact dermatitis and other eczema due to detergents
692.1 Contact dermatitis and other eczema due to oils and greases
692.2 Contact dermatitis and other eczema due to solvents
692.3 Contact dermatitis and other eczema due to drugs and medicines in contact with skin
692.4 Contact dermatitis and other eczema due to other chemical products
692.5 Contact dermatitis and other eczema due to food in contact with skin
692.6 Contact dermatitis and other eczema due to plants [except food]
692.7 Contact dermatitis and other eczema due to solar radiation
692.8 Contact dermatitis and other eczema due to other specified agents
692.84 Contact dermatitis and other eczema due to animal (cat) (dog) dander
692.89 Contact dermatitis and other eczema due to other specified agents
692.9 Contact dermatitis and other eczema, unspecified cause
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PREFERRED PRACTICE PATTERN1
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PATIENT PRESENTATION
A 15-year-old female presents with a dry, rough, red rash on her arms, legs, and trunk. The rash is itchy and inflamed. The itchiness is intense and she often scratches till it bleeds. During times of stress, the rash spreads to her face and neck. The rash has gotten worse over time. As a baby, she had small patches on her arm which have now spread to her legs and trunk. The patient states that when it is testing time at school the skin condition becomes worse.
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Eczema is a common group of skin conditions
Form of dermatitis
A chronic, relapsing, and inflammatory skin condition
Results in itchy, inflamed, irritated skin
Often has an inherited tendency to develop other allergic conditions such as asthma and hay fever
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Essentials of Diagnosis
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There are no laboratory tests used to diagnose eczema
Clinical features of the disease are used for diagnosis, including the itchiness and the biology and spread (appearance) of the lesions
Ruling out other skin diseases like contact dermatitis and seborrheic dermatitis is used to confirm the diagnosis
Skin lesion biopsies or skin cultures may be used to rule out other causes
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General Considerations
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SIGNS AND SYMPTOMS
Itching, which may be severe, especially at night
Small, raised bumps, which may leak fluid and crust over when scratched
Rash, most common on face, back of knees, wrists, hands, and feet
Thickened, cracked, or scaly skin
Change in skin pigmentation making affected area lighter or darker
Red to brownish-gray colored patches
Areas with loss of hair and skin color changes
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Functional Implications
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Inability to tolerate stress; cold, dry air; allergens without rash, itching, and dry skin
Limitation of the use of some modalities
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Possible Contributing Causes
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Differential Diagnosis
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Chronic dermatoses
Measles
Pityriasis rosea
Psoriasis
Scarlet fever
Squamous cell carcinoma
Tinea corporis
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MEANS OF CONFIRMATION OR DIAGNOSIS
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Scraping of the lesion and examination under the microscope
Skin biopsy (when eczema does not respond to treatment)
Skin patch tests
Immunological testing
Elevated total hemoglobin (IgE)
There are no laboratory tests used to diagnose eczema
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FINDINGS AND INTERPRETATION
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Corticosteroid creams or ointments3
Calcineurin inhibitors (Tacrolimus and Pimecrolimus)3
Coal tar3
Antihistamines and steroids
Oral or injected corticosteroids3
Immunomodulators
Antibiotics
Tricyclic antidepressants
Other treatments
Phototherapy
Wrap therapy
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REFERRALS/ADMITTANCE
Allergist/immunologist
Dietician
Dermatologist
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Skin integrity
Circulation
Pain
Sensation
Joint ROM
Muscle strength
Functional mobility
Self-care
Home management
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Integumentary integrity
Pigmentation
Shape and size of skin involvement
Presence of rash, fungi, blistering, ecchymosis, hair growth, signs of infection
Skin temperature
Tissue mobility: Turgor, texture
Circulation
Volume and girth measurement for edema and effusion
Pain: Subjective report, visual analog pain (VAS) scale, or verbal report
Sensation
Joint ROM
Strength and muscle endurance
Functional mobility
Orthotic: Protective and supportive devices
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Not typically treated by PT, but PT should be able to recognize the condition and check the skin before and after application of modalities
Depending on the extent of the condition and secondary impairments, the following may apply:
Dressings (e.g., wound coverings)
Topical agents (e.g., ointments, moisturizers, creams, cleansers, sealants)
Athermal modalities (e.g., pulsed ultrasound, pulsed electromagnetic fields)
Hydrotherapy
Phototherapy (e.g., ultraviolet)
Compression therapies (e.g., vasopneumatic compression devices, compression bandaging, compression garments)
Orthotic: Protective and supportive devices
Electrical muscle stimulation
Transcutaneous electrical nerve stimulation (TENS)
Functional training
ADL/IADL training
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Chronic condition, but is controllable with treatment.
With childhood onset, it often resolves in the teens.
In adults, it is often long term and reoccurring.
Flare-ups are most likely in the winter when there is dry, cold air.
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3. +
Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR. Treatment. In:Hay
WW, Levin
MJ, Sondheimer
JM, Deterding
RR CURRENT Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/content/6589527. Accessed June 2, 2013.
+++
ADDITIONAL REFERENCES
+
Cork
MJ, Danby
SG, Vasilopoulos
Y
et al. Epidermal barrier dysfunction in atopic dermatitis. J Invest Dermatol. 2009;129(8):1892–1908. doi:10.1038/jid.2009.133.
[PubMed: 19494826]
CrossRef +
Nicol
NH, Boguniewicz
M. Successful strategies in atopic dermatitis management. Dermatol Nurs. 2008;(Suppl);3–18.
Shari Rone-Adams, DBA, MHSA, PT
++
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CONDITION/DISORDER SYNONYMS
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Superficial pyoderma
Streptococcal impetigo
Impetigo contagiosa
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PREFERRED PRACTICE PATTERN1
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PATIENT PRESENTATION
A 62-year-old male presents with swelling, pain, and discoloration of the right foot. His wife reports that he stepped on a sharp object on the floor 3 days ago. He now has fever, diarrhea, and is showing some confusion. The patient has no complaints of pain. He has a history of type II diabetes. Because of the possible associated and unidentifiable fever and confusion the patient was referred to a walk in medical clinic.
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Streptococcus pyogenes (group A Streptococcus) is responsible for infections in the skin
Group A infections
Highly infectious skin rash, spreads rapidly
It occurs most often in tropical climates or during the summer months in nontropical climates
With this infection, the patient is usually afebrile and has no pain
Lesions are most often on the face and extremities and may become a mild but chronic illness if untreated
Most common in children, particularly those in unhealthy living conditions
In adults, it may follow other skin disorders or a recent upper respiratory infection, such as a cold or other virus
Preceding a streptococcal respiratory infection
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Essentials of Diagnosis
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Diagnosis is usually made by considering medical history and signs and symptoms, including the distinctive sores.
A culture may be used to confirm the diagnosis or to rule out another cause.
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General Considerations
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Highly contagious and can be spread through close contact or sharing items.
Scratching can spread the sores to other parts of the body.
It can be difficult to distinguish clinically between skin infection caused by streptococci and other bacteria such as Staphylococcus
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Highest prevalence in children 2 to 5 years of age
Can be seen in adults, but is more prevalent in children
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SIGNS AND SYMPTOMS
Impetigo
Erysipelas
Rash
Blisters filled with pus
Fever
Malaise
Vomiting: Childhood type
Itching blister
Erythematous denuded areas
Honey-colored crusts
Localized area of redness
Purulent vesicles covered with a thick, confluent, honey-colored fluid
Swollen lymph nodes near the infection
Lesions most often on face, lips, arms, and legs
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Functional Implications
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Possible Contributing Causes
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Differential Diagnosis
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MEANS OF CONFIRMATION OR DIAGNOSIS
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FINDINGS AND INTERPRETATION
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Streptozyme screening test to detect antibodies
Antistreptolysin O titer (ASO), increased levels are seen
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REFERRALS/ADMITTANCE
Allergist/immunologist
Dermatologist
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Skin integrity
Circulation
Pain
Sensation
Joint ROM
Muscle strength
Functional mobility
Self-care
Home management
++
++
++
Integumentary integrity
Pigmentation
Shape and size of skin involvement
Presence of rash, fungi, blistering, ecchymosis, hair growth, signs of infection
Skin temperature
Tissue mobility: Turgor, texture
Circulation
Volume and girth measurement for edema and effusion
Pain: Subjective report, Visual Analog Scale (VAS) or verbal report
Sensation
Joint ROM
Strength and muscle endurance
Functional mobility
Orthotic: Protective and supportive devices
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Not typically treated by PT, but PT should be able to recognize the condition and understand that the condition is highly contagious.
Precautions should be taken to prevent the spread of the disease to healthcare professionals and other patients.
Depending on the extent of the condition and secondary impairments, the following may apply:
Dressings (e.g., wound coverings)
Topical agents (e.g., ointments, moisturizers, creams, cleansers, sealants)
Athermal modalities (e.g., pulsed ultrasound, pulsed electromagnetic fields)
Hydrotherapy
Phototherapy (e.g., ultraviolet)
Compression therapies (e.g., vasopneumatic compression devices, compression bandaging, compression garments
Orthotic: Protective and supportive devices
Electrical muscle stimulation
Transcutaneous electrical nerve stimulation (TENS)
Functional training
ADL/IADL training
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With treatment, usually heals within 2 to 3 weeks.
Lesions usually resolve after 7 to 10 days.
Cellulitis, lymphangitis, and suppurative lymphadenitis occur in about 10% of patients.
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ADDITIONAL REFERENCES
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Denegar
CR, Prentice
WE. Managing pain with therapeutic modalities. In:Prentice
WE, Quillen
WS, Underwood
F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011.
http://www.accessphysiotherapy.com/content/8135782. Accessed June 5, 2013.
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Panus
PC, Jobst
EE, Masters
SB, Katzung
B, Tinsley
SL, Trevor
AJ. Antibacterial agents. In:Panus
PC, Jobst
EE, Masters
SB, Katzung
B, Tinsley
SL, Trevor
AJ Pharmacology for the Physical Therapist. New York, NY: McGraw-Hill; 2009.
http://www.accessphysiotherapy.com/content/6093975. Accessed June 5, 2013.
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Pattern 7B: impaired integumentary integrity associated with superficial skin involvement. In: Guide to Physical Therapist Practice 2003. 2nd ed. Alexandria,
VA: American Physical Therapy Association; 2003. doi: 10.2522/ptguide.3.4_2