clinical pediatrics - toronto dermatology centre review...bentley, barankin, guenther thinner...
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Clinical Pediatrics
DOI: 10.1177/000992280304200601 2003; 42; 475 Clin Pediatr (Phila)
Janna M. Bentley, Benjamin Barankin and Lyn C. Guenther Impetigo, Mucoceles, and Hemangiomas
A Review of Common Pediatric Lip Lesions: Herpes Simplex/Recurrent Herpes Labialis,
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A Review of Common Pediatric Lip Lesions:
Herpes Simplex/Recurrent Herpes Labialis,
Impetigo, Mucoceles, and Hemangiomas
Janna M. Bentley, BSc1Benjamin Barankin, MD' 2Lyn C. Guenther, MD, FRCPC3
Summary: Lip lesions are a common presentation to the pediatrician's office. These lesions are
often benign in children, without significant functional morbidity. However, owing to the
prominent placement of lips and their role in communication, lip lesions can be alarming to
patients as well as to their parents. For these reasons the pediatrician has an important role in
recognizing, diagnosing, and treating the various types of labial dermatoses that commonly present
to a pediatric practice. Four of the most common lip lesions a pediatrician will see are herpes
simplex/recurrent herpes labialis, impetigo, mucoceles, and hemangiomas. This paper reviews
the current literature on the diagnosis, treatment, and management of these 4 lesions.
Clin Pediatr. 2003;42:475-482
Introduction
L ips provide entrance to theoral cavity and are promi-nently placed in the center
of the face. They help manipulateingested food into the oral cavity,are involved with speech articula-tion and communication, reflectsexuality, and are important iden-tifying facial features. Any abnor-mality or blemish is easily notice-able and a potential source ofembarrassment. Diagnosis andtreatment of lip abnormalities is
important, not only to prevent
disease morbidity and mortality,but also to restore social accep-
tance and self-esteem.During the 7th week of in-
trauterine life the lips start to de-velop; by the 9th week, they are fullydeveloped. The upper lip is the re-
sult of fusion of the medial nasalprominences and maxillary promi-nence. The lower lip comes fromthe mandibular prominence of thefirst branchial arch with the upper.'
The upper lip has the shape ofa "Cupid's bow," while the lower
'Department of Medicine; 2Division of Dermatology, University of Alberta; and 3Division of
Dermatology, Univeristy of Western Ontario, London, Ontario, Canada.
Correspondence to: Lyn C. Guenther, MD, FRCPC, The Guenther Dermatology Research
Centre, 835 Richmond St., London, Ontario N6A 3H7 Canada.
2003 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.
lip is semi-elliptical. At the com-
missure, the lips meet laterally.Each lip is attached to the adja-cent alveolus by the frenulum.The orbicularis oris muscle circlesboth lips. A number of other mus-cles interdigitate with this muscleand move the lips in other direc-tions. The 7th cranial nerve in-nervates these muscles. Themandibular branch of the 5th cra-
nial nerve supplies the sensory in-nervation. Lips are highly vascu-
larized and hairless. The vascularsupply is from the labial branchesof the facial artery.
Lips have a "wet" internal mu-cosa and "dry" external mucosa.
The junction appears as a "whiteline." The mucosa has a numberof labial glands. Unlike other ar-
eas of the body covered by skin,the external mucosa lacks thetough keratin covering, has a
JULY AUGUST 2003CLINICAL PEDIATRICS 475
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Bentley, Barankin, Guenther
thinner epithelium, less melanin,and lacks sebaceous and sweat
glands, all of which have a protec-
tive function. These characteris-tics cause the lips to be more sus-
ceptible to damage from theelements, environment, trauma,
and infection.A comprehensive English lan-
guage literature search of MED-LINE from 1966 to 2002 was per-
formed. Initially, the followingMeSH terms were used: "lips,""pediatrics," and "prevalence," to
establish 4 of the most common
lesions. An informal survey of pri-mary care physicians in Edmon-ton, Alberta, Canada, was alsoperformed to identify which le-sions were most commonly seen
clinically, and these results fur-ther reinforced the MEDLINEsearch. Following the determina-tion of common pediatric lip le-sions, the term "pediatrics,"along with "recurrent herpes labi-alis," "impetigo," "mucocele," or
"hemangioma" were searched.The majority of the papers in-
cluded in this review were cur-
rent randomized, controlled tri-als, prospective or retrospective
population-based studies, case re-
ports, and reviews. This paper re-
views 4 common pediatric lip le-sions: herpes simplex/recurrentherpes labialis, impetigo, muco-
celes, and hemangiomas.
Herpes SiWmlex/Rcurrent Herpes
Labialis
The herpes simplex virusesare responsible for a large num-
ber of cutaneous infections in hu-mans. There are 2 types of herpesinfections recognized clinically:primary and recurrent. The pri-mary infection is often missed as
it commonly occurs during ado-lescence and may be asympto-
matic. An infected mother can
transmit viral particles to her fetusvertically during delivery, due to
asymptomatic cervical shedding.The ensuing neonatal infection isdifficult to diagnose clinically as
the symptoms are very nonspe-
cific and may not be recognized.It has been shown that motherswho experience a primary genitalherpes simplex virus (HSV)-infec-tion in the third trimester of theirpregnancy, who are seronegativeat delivery, have a 33-50% chanceof transmitting the virus to theirinfant.2 Conversely, secondary re-
activation ofHSV in a seropositivewoman during the intrapartumperiod incurs a 3% risk of verticaltransmission to her infant.2
Herpes simplex virus type 1
(HSV-1) classically causes the"above the waist" lesions, includ-ing the oral and perioral lesions,and keratoconjunctivitis.3 It isthus implicated in most cases ofrecurrent herpes labialis, whileHSV-2 is responsible in 10% to
15% of recurrent oral ulcera-tions.4 Ninety percent of the USpopulation is seropositive forHSV-1 by the time they reach theirteenage years, with at least 90% of
these patients seroconverting byage 5 years.5f6 Similarly, a Britishstudy in 1999 reported a preva-
lence of almost 100% seroconver-
sion by the age of 15 years.7 It hasbeen estimated that up to 40% ofseropositive individuals developrecrudescent disease, resulting insite-specific, recurrent ulcera-tions such as herpes labialis, or
"cold sores."8On initial infection, oral her-
pes classically presents as a gin-givostomatitis, affecting the oralmucosa with small vesicles thatrapidly break open releasing a yel-lowish exudates (Figure 1). Thevesicles are replaced by painful ul-cerations, along with edematous,punched-out lesions of the gingi-val margin. Primary oral herpesinfection can occur on the innermucosal border of the lips, butthe pathognomonic "cold sore,"which manifests extraorally on
the vermilion border of the lip, isa recurrent herpes simplex infec-tion, or "herpes labialis." It occursfollowing reactivation of latentherpes virus in the cells of thetrigeminal ganglia.
Unlike the primary gingivos-tomatitis, recurrent herpes labi-
Figure 1. Primary herpes simplex gingivostomatitis.
47CLNCLPDARCSJL/UUT20476 CLINICAL PEDIATRICS JULY/AUGUST 2003
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Common Pediatric Lip Lesions
alis is much milder in its manifes-tation, without the systemic symp-
toms. A tingling, burning, or itch-ing feeling may occur
prodromally at the site of the im-pending lesions, 12-36 hours be-fore eruption.4 Classically, a sin-gle, well-localized cluster of 3-5vesicles appears containing thevirus.9 With recruitment of in-flammatory cells the vesicles ul-cerate and crusting occurs withinthe first 24-48 hours after appear-ance of the initial lesions.4 It is at
the time of vesicular rupture thatlesions are most contagious9 andthe lesions remain contagious un-
til healed. In order for transmis-sion of HSV to occur between a
seronegative and a seropositive in-
dividual, shed virus must come
into direct contact with mucosalsurfaces or abraded skin on thesusceptible individual. Transmis-sion between a seropositive and a
seronegative individual can stilloccur even without the presence
of active lesions. One study of oth-erwise healthy adults in Japanfound that active shedding ofHSV-1 into saliva occurred andpersisted on average 1.2 days over
the course of 2 months, withoutsymptomatic lesions.'0 There was
no demonstrable causative link to
the shedding in these subjects.10Recurrences of herpes labialis inaffected individuals typically oc-
cur 2 or 3 times a year, with ultra-violet (UV) light, trauma, andphysical and emotional stress
serving as possible triggers.4,11Vesicles usually heal in 8 to 10days in immunocompetent peo-
ple, without leaving a scar."IThe diagnosis of recurrent
herpes labialis is clinical, owing to
the classic presentation of the le-sions and lack of constitutionalsymptoms. Followinig diaginosis,early treatment of erupted recur-
rent lesions is of questionablebenefit in children and is up to
the physician's discretion.'2 Todate, no studies directed at thebenefits of acute treatment ofsuch lesions have been completedin the pediatric population. How-ever, if the decision to treat an
acute eruption is made, first linetreatment is generally an oral an-
tiviral medication such as acy-
clovir. In children less than 12years of age, the recommendeddose of oral acyclovir is 20 mg/kgevery 8 hours.'2 In postpubertalchildren (>12 years old), adultdosing schedules can be fol-lowed.12 Besides acyclovir, fami-clovir and valacyclovir have alsobeen found to be efficacious in
adult patients. In adult patients,Spruance et all3 showed that oncethe lesions of herpes labialis haveerupted, early treatment withhigh-dose famciclovir (250 mg 3times per day for 5 days) de-creases the size and duration ofthe lesions. Similarly, a double-blind study of 3,151 patients withcold sores showed a reduction inthe duration of the eruption by1.3 days in the group using 2 g ofvalacyclovir twice daily for 1 day.'4Another group in this same studyhad a lesion-time reduction of 1.2days after receiving 2 g of valacy-clovir twice daily for 1 day, then 1
day of 1 g valacyclovir twicedaily.'4 Approximately half of the3,151 patients in this study were
prevented from progressing to
the macular/papular stage of theherpes eruption following admin-istration of the valacyclovir.14
Besides oral antiviral treat-
ment, some benefit has beenshown following topical adminis-tration of acyclovir, but only forprimary infection. This method isslightly less efficacious than oralformulations owing to the primar-ily neural nature of HSV infec-tions and less opportunity for thetopical treatment to exert its ef-fects.'5 Again, no studies have
been performed in children at
this point. Application of topical1% penciclovir cream every 2hours when awake for 4 days was
shown to decrease the duration ofhealing (1-day reduction in heal-ing time as compared to vehicle),pain, and viral shedding in adultpatients. 16
Controlled studies have beenperformed in adults showing thatprophylactic treatment for herpeslabialis is beneficial using oral acy-
clovir or famciclovir.12'17'8 Adultstudies show that short-term pro-
phylactic therapy is warranted insome situations such as when theaffected individual experiencesepisodes of herpes labialismonthly, or if the individual is an-ticipating an unavoidable knowntrigger, or if the patient experi-ences erythema multiforme fol-lowing herpes labialis attacks.'7'18Prophylactic doses of oral acy-
clovir 400 to 1,000 mg per daywere recommended, taken at thetime of exposure to known trig-gers.'7"18 In children prophylaxisis rarely indicated and again, thedecision to treat is up to the pedi-atrician's discretion.
Impetigo
Impetigo is a contagious bac-terial infection of the superficiallayers of the epidermis, often oc-
curring periorally. There are 3clinical presentations, all ofwhichare most often observed in the pe-
diatric population: impetigo con-
tagiosa (nonbullous), bullous im-petigo, and common impetigo.'9Impetigo contagiosa is the most
common skin infection in chil-dren,'9 especially between theages of 2 to 5 years old.20 Bullousimpetigo is usually an infection ofneonates and more commonly oc-
curs on the trunk and the extrem-
ities.19 Common impetigo occurs
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Bentley, Barankin, Guenther
in adults as a complication of der-matological conditions causing a
break in the skin or systemic dis-eases such as diabetes mellitusand acquired immunodeficiencysyndrome (AIDS).19
Impetigo contagiosa and com-
mon impetigo present initially as
a single 2 to 4 mm erythematousmacule that rapidly turns into a
vesicle or a pustule. The vesiclesrupture and a "honey-colored"crusted exudate remains. Spreadto adjacent skin occurs rapidly as
the lesions extend and coalesce,producing eroded macules inpatches (Figure 2). It has beenspeculated that the site prefer-ence for impetigo eruption in theperioral and nare areas is due to
their high exposure to environ-mental trauma.19 Insect bites,contact dermatitis, or minor abra-sions are often found demonstrat-ing the portal of entry for the bac-teria. Secondary infection withimpetigo in children sufferingfrom atopic dermatitis often re-
sults in rapid spread of the lesionsto other cutaneous sites, owing inpart to the compromised nature
of their skin barrier,'9,21 de-pressed cutaneous immune func-
tion,21 and a lack of normal-floralipophilic bacteria.2' More aggres-
sive treatment is warranted inthese instances.
There are 2 pathogens impli-cated in impetigo, Staphylococcusaureus and Streptococcus pyogenes.20In the past, most cases of impetigocontagiosa were caused by S. pyo-genes; however, more recent stud-ies have shown that S. aureus isnow the organism most fre-quently cultured from lesions.22,23Mixed Staphylococcus and Strepto-coccus infections are common as
well. Penicillin and ampicillin re-
sistance have been shown in mostStaphylococcus infections of thismixed nature.22,23
Cultures of impetigo are nec-
essary only when treatment hasfailed and methicillin-resistantStaphylococcus aureus is suspected.
In localized cases, topicaltreatment with fusidic acid or 2%mupirocin applied 3 times dailyfor 7 to 10 days24 is sufficient. Re-moval of crusts before applicationis controversial. Emerging resis-tance to mupirocin has beennoted with S. aureus, especially incases of prolonged use, warrant-
ing judicious use of this antibi-
otic.25 Cloxacillin (40-50 mg/kg/day, q.i.d.) or cephalexin (40mg/kg/day, q.i.d.) is used as oraltherapy for 7 days in generalizedcases.26 Erythromycin is no longerthe treatment of choice owing to
emerging resistance.20 Lesionsshould resolve without scarring. Ifthe impetigo does not resolve af-ter a 7- to 10-day course of antibi-otics, it is important to test for na-
sopharyngeal carriage of S.aureus.24 Elimination of the car-
rier state can be accomplishedempirically by application ofmupirocin, until the infection
clears.24
One important complicationofimpetigo caused by S. pyogenes isacute poststreptococcal glomeru-lonephritis. This occurs in ap-
proximately 2-5% of cases ofstreptococcal impetigo, most
commonly in children 2 to 4 years
old.20 Antibiotic treatment of theinfection does not alter thecourse of this form of glomeru-lonephritis. Fortunately, there isusually resolution without seque-
lae in children.20
Mucoceles
Mucoceles are common mu-
cous membrane lesions associ-ated with minor or accessory sali-vary glands. There are 2 types ofmucoceles: mucous extravasationcysts and mucous retentioncysts.2728 Mucous extravasationcysts are the most common andare found in children and adoles-cents, most commonly in the 2nddecade of life.27'29 These lesionsare much more likely to occur on
the lower lip, with 1 study report-
ing a site predilection for thelower lip of 58% over all otheroral mucous membranes.30 Mu-cous retention cysts are less com-
mon, with an incidence of ap-
proximately 3% of mucoceles.29Figure 2. Impetigo.
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Common Pediatric Lip Lesions
Mucoceles of the extravasationtype are caused by trauma thatshears a minor or accessory sali-vary gland duct. This results insaliva accumulating between theepithelium and the adjacent softtissue. A pseudocapsule of fibrousconnective tissue forms, walling offthe mucocele. Extravasated muco-
celes are not true cysts, for they donot have an epithelial lining.28
Mucoceles will most often pre-
sent opposite the upper incisoron the lower lip as painless,smooth, freely movable, soft, fluc-tuant masses, measuring on aver-
age approximately 1 cm (Figure3).31 They can be found on the up-
per lip as well. Mucoceles on thelower lip are often bitten by thepatient, and consequently theydrain and heal; however, theswelling eventually recurs.31 Themore superficial lesions can havea bluish tinge, while deeper mu-
coceles are more likely to be thecolor of normal mucosa.27 Thefluid-filled nature of the deepermucoceles is less obvious.
The diagnosis of mucoceles ismade clinically, with the patientdescribing some traumatic event
to the lip. The appearance of these
lesions is pathognomonic, and pal-pation helps to confirm the freelymovable, soft nature of mucoce-
les.27 Biopsy is unnecessary butwould confirm the diagnosis.
Following diagnosis, treat-
ment is often not needed as thesmaller and more superficial mu-coceles are likely to rupture spon-
taneously and then heal.27 Themost common treatment of largeror recurrent mucoceles is surgicalexcision, with subsequent re-
moval of the associated salivaryglands.32 This helps to prevent re-
currences. Prognosis of mucoce-
les is good, whether treatment isneeded or not.
Hemangiomas
Hemangiomas are vascularanomalies cited as the most com-
mon benign, neoplastic lesions ininfants. They are noted most com-monly on the head and neck(50-60%), and this site prefer-ence is most likely due to the un-
derlying intricate vasculature ofthis region.33,34 They are a fre-quent cause of presentation to thepediatrician since hemangiomas
Figure 3. Mucocele on the lower lip (photo courtesy of Dr. Wysocki).
develop in 2.6% of neonates, withthe prevalence increasing to 10%by 12 months of age.35,36 Femalesare most often affected, with re-
ported rates 2 to 5 times greater
than males.37 Prematurity and lowbirth weight (500 to 1,000 g) are
associated with the developmentof these lesions as well, with a 1.5to 2 times greater occurrence rate
than in normal infants.37 Infantsweighing 1,500 g or more at birthhave the same incidence as regu-
lar birth weight babies.37There are 2 types of heman-
giomas, defined by the depth oftheir penetration into the der-mis.34 The superficial lesions are
bright red, blanchable noduleswith well-defined borders, andthese comprise approximately65% of all hemangiomas.34 Deeplesions represent 15% of thesevascular anomalies, and they ap-
pear as bluish nodules with lessdistinct borders.34 The remaining20% are considered 'mixed' and
present as a combination of su-
perficial and deep lesions.34 Anexample of a superficial (straw-berry) hemangioma is shown inFigure 4.
There are typically 5 stages inthe development of heman-giomas including eruption, prolif-eration, plateau, involution, andregression. At approximately 2 to 4weeks of age the nodules erupt, ap-
pearing either red in color withtelangiectasia, or hypopigmented.33From approximately 6 to 12months, the endothelial cells pro-
liferate, with the hemangiomareaching a maximal size at around12 months of age.34 A plateau isreached and the lesion remains sta-
tionary from roughly 12 to 15months of age.33'34 Approximately50% will involute and regress byage 5 years, 70% by age 7 years, and90% by age 9 years.34 Residual at-
rophic or redundant skin may fol-low involution and regression.
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Bentley, Barankin, Guenther
Figure 4. Strawberry hemangioma on the upper lip.
Superficial hemangiomas are
composed of blood vessels resem-
bling capillaries, with thin wallsand a thin endothelium lining,while the deep variant of heman-giomas results from dilatation ofvascular channels at a deeperlevel.38
The diagnosis of heman-giomas is clinical, with distressedparents presenting to their pedia-tricians with infants in the earlystages of lesion development.Ninety percent of hemangiomasare diagnosed in the 1st month oflife.34 Parents will often express
feelings of guilt, shame, disbelief,mourning, and anxiety.39 Supportand reassurance must be given at
the time of diagnosis.As a result of the psychosocial
stressors of hemangiomas and thehigh rate of spontaneous involu-
tion, education, reassurance, andmonitoring are the mainstays oftreatment. It is useful to show par-
ents photos of before and after le-sions following spontaneous invo-lution, and a wait-and-seeapproach is often best. Decisionsto treat are based on preventionof loss of life or function, and thepossibility of scarring. The major-
ity of hemangiomas are small andsuperficial. However, some may
grow rapidly and impinge on or-
gan systems, resulting in life-
threatening complications. In
particular, hemangiomas of thehead and neck are worrisome if
they have the potential to ob-struct the infant's airway or im-
pair vision at a crucial time in the
development ofvisual pathways. If
the decision is made to treat the
hemangioma, options include sys-
temic corticosteroids (pred-nisone 2-4 mg/kg/day for 2-3weeks) for rapidly growing, life
threatening, or functionally im-
pairing lesions.34 The rate of re-
sponse to prednisone is 30% to
90% and is expected within 7 to
10 days of initiating treatment; a
good response is characterized bya fading of the color or slowedgrowth, as well as softening of the
hemangioma.34 Intralesional in-
jection of corticosteroids can alsobe safe and effective in properlyselected infants with heman-
giomas.40,41 If the hemangioma is
unresponsive to corticosteroids,therapy with subcutaneous inter-feron alpha-2a is the next line of
treatment.42 A 50% regression
rate has been reported in infantstreated with this method.42 How-ever, interferon alpha-2a has a
mean time to regression of 7months and requires monthlycomplete blood counts, as well as
hepatic and renal functiontests.42 Laser therapy and surgi-cal treatment are also possibili-ties if deemed necessary to re-
move the lesion, with a 60%43response rate of superficialstrawberry hemangiomas to fast-pulsed dye laser (FPDL).34 Thislaser can also be used to remove
residual telangiectasias after re-
gression of a hemangioma.34 Sur-gical excision is the treatment ofchoice in lesions extending to in-volve the eyes, which are unre-
sponsive to corticosteroids, andis also useful in removal of re-
dundant skin after spontaneous
involution of hemangiomas.44The prognosis is good with su-
perficial hemangiomas as most
spontaneously involute andregress with minimal residual atro-
phy. The outcome is worse withdeep or mixed hemangiomas as
the likelihood of incomplete invo-lution, with residual redundantskin that is wrinkled and telang-iectatic in appearance is greater.
Restoration of normal skin follow-ing spontaneous regression occurs
in only 50% of cases.45 If residualskin with telangiectasia remains,laser or surgical treatment is ap-
propriate and the final result ismore cosmetically pleasing.34
Table 1 summarizes the cur-
rent treatment options for recur-
rent herpes labialis, impetigo,mucoceles, and hemangiomas.
Conclusion
Lip lesions are a common pre-
sentation to the pediatrician's of-fice, often necessitating consulta-tion. In children, most lesions are
480 CLINICAL PEDIATRICSJULY/AUGUST
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Common Pediatric Lip Lesions
benign and should not cause sig-nificant morbidity. Treatment isoften conservative, with reassur-
ance being paramount. For thesereasons it is necessary to be ableto recognize, diagnose, and treat
the various types of labial der-matoses that commonly present
to a pediatric practice.
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JULY AUGUST 2003 CLINICAL PEDIATRICS 481
abl e; t
SUMMARY OF TREATMENT OPIONS --FOR PEDATI LIP LE1S
Lip Lesion TreNtment Options
Recurrent herpes lWbialis t*atpediatricians discretion: <12 years old orl acycloVir20 mg/kg q8h'2* >12 years old (postpubertal)Use adult dosing schedues12
Prophylaxis: ora acylovir 400100 mg q.i.du.started at tmh time Of exosure to known trigger 718Earl tretmenit of erupted lSions:orlW iclovir250mg t.i.d.0 for 5 days13 ayclovir 2 m b.id.for 1 day or1%lpenciclovir cream q2h for 4 days16
Impetigo *swabs forCS before commening treatmentn opfuncmlicated-cust removal a applicton of
fusidic acid or 2% mupircin for 7-110 days t.i.d.24* complicated -> cloxacillin 050tm aq.i.d.or cephalexin 40 m g q.i.d., for67 days26
Mucoceles : usual no treatment required* if largerecurrent -+ surgical extiston32
Hemangiomas * most spontaneously involute0* psychosocial suport andclose fbllow-up:if necessary to trt, consider meral todertmato s: 1 penitsone 2-4 m /a for2-3 weeks; expect response in 7-10 days;342. intralesional[steroids;404'3. interferona04Alpa- subcutaneously;42 4. laser therapy;345. surgical excision34
CLINICAL PEDIATRICS 481JULY/AUGUST 2003 © 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
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482 CLINICAL PEDIATRICS JULY/AUGUST 2003JULY/AUGUST 2003482 CLJNIC4L PFDIATRICS © 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
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