Dermal - Adverse Effects
Fluorinated and Fluoride Pesticides

The use of high doses increases the likelihood that potentially significant toxic effects will be identified. Findings of adverse effects in any one species do not necessarily indicate such effects might be generated in humans. From a conservative risk assessment perspective however, adverse findings in animal species are assumed to represent potential effects in humans, unless convincing evidence of species specificity is available.

-- Food and Agricultural Organization of the United Nations

Note: This is not an exhaustive list.
When time allows more information will be added.

Chlorfenapyr - Acaricide, Insecticide - CAS No. 122453-73-0

-- MRID No. 43492838 (1994). Carcinogenicity mouse. NOAEL = 2.8/3.7 mg/kg/day, M/F. LOAEL = 16.6/21.9 mg/kg/day, M/F, based on decreased body weight gains, brain vacuolation, and scabbing of the skin (males) No evidence of carcinogenicity.
-- Chronic neurotoxicity study - rat. LOAEL = 13.6/18 mg/kg/ day, M/F, based on the presence of myelinopathic alterations in the CNS in male rats and decreased average body weights, body weigh gains, food efficiency, absolute food c
onsumption (F), and water consumption (M). Supporting this endpoint are similar CNS lesions and skin lesions observed in the mouse carcinogenicity study (NOAEL = 2.8).
Ref: Federal Register: September 26, 2003. Chlorfenapyr; Pesticide Tolerance. Final Rule.

Clodinafop-propargyl - Herbicide - CAS No. 105512-06-9

Proposal for classification as a "extrmeme sensitizer" to skin.
n an optimization test, clodinafop-propargyl was sensitising to the skin of guinea pig. The concentration used for repeated intradermal induction was 0.1% and this resulted in 100% sensitisation using dermal or intradermal challenge.
No information is provided by the sensitisation expert group for potency categorisation based on the optimization test. However, the induction concentration of 0.1% is equal to or below the concentration needed to grade a substance as an extreme sensitizer in all other sensitisation tests for which a proposal for potency categorisation was provided in ECBI/81/02 Rev.2. Therefore, categorisation of clodinafop-propargyl as an extreme sensitizer is proposed. This results in a specific concentration limit of 0.001% for R43.
Ref: March 2005. Clodinafop-propargyl (P623/NL). Proposal for specific concentration limits for the R43 classification, The Netherlands. Doc document: ECBI/155/04 Add. 2.

-- 870.3150 90-Day Oral Toxicity in Dogs NOAEL = M: 0.346 mg/kg/day, F: 1.89 mg/kg/day. LOAEL = M: 1.73 mg/kg/day ; F: 7.16 mg/kg/day based on occurrence of skin lesions.
-- 870.4100b Chronic Toxicity -Nonrodent NOAEL = M: 3.38 mg/kg/day; F: 3.37 mg/kg/day LOAEL = M: 15.2 mg/kg/day ; F: 16.7 mg/kg/day based on occurrence of skin lesions, clinical signs, and reduced body weight gain and food consumption.

Ref: US EPA Pesticide Fact Sheet. Reason for Issuance: Conditional Registration. June 6, 2000

Chronic toxicity. In a 12-month feeding study in dogs, 500 ppm resulted in transient dermatitis and reduced body weight gain. Two females were more severely affected and showed inappetence, body weight loss, tremors and severe dermatitis, and necessitated an interruption of the treatment in order to avoid mortality. Histopathology revealed slight hepatocellular hypertrophy in one male and one female. The NOEL of 100 ppm was equivalent to a mean daily intake of 3.38 mg/kg in males and 3.37 mg/kg in female.
Ref: Federal Register: June 5, 1998 [Page 30750-30756]. Notice of Filing of Pesticide Petitions.

Fipronil - Acaricide, Insecticide, Wood Preservative - CAS No.120068-37-3

Australia: The APVMA has received a number of human and animal adverse experience reports involving products containing fipronil. Reports include skin reactions in animals and humans, neurological signs and deaths in target animals (often involving concurrent infestations with paralysis ticks) and deaths following off- label use in domesticated rabbits... The first reports of adverse effects in humans were received in 1996 for the veterinary spray formulation and involved reactions in humans who had applied the spray to pets. Since then, 53 reports of suspected adverse effects in humans involving both the spray and the concentrated spot-on formulation have been received (Table 1). Of these reports 43 have been considered by the APVMA as possibly or probably linked to product use. The link to product use is considered to be “unlikely or unknown” for the remaining ten reports (Table 2). Skin reactions are the predominant adverse experience reported for pet owners. Some reactions did not occur during the application of the products but after skin contact with the treated cat fur or dog hair... The existing toxicological database does not predict an immune- mediated reaction in humans or the incidences of dermal reactions in animals... Products containing fipronil for use in agriculture or on animals are registered world- wide. In the United States, the Department of Pesticide Regulation (Californian Environmental Protection Agency) initiated a review of registered pesticide products containing fipronil in November 2001 based on human health concerns. Review findings have not yet been released...
Ref: September 2003 - The Reconsideration of Approvals and Registrations Relating to FIPRONIL. REVIEW SCOPE DOCUMENT. Australian Pesticides & Veterinary Medicines Authority Canberra Australia.

Fluazinam - Fungicide - CAS No. 79622-59-6

Abstract: In spring 1992, several farmers in the western part of The Netherlands developed dermatitis on their hands, forearms and face. In some, the legs, trunk and genitals were also affected. Complaints ranged from a mildly itchy, papular rash to a painful, weeping and blistering dermatitis. Medical aid was needed by 5/9 of them. Some of the farmers grew seed potatoes, the others cultivated lilies. All of them had in common that their complaints emerged after repeated application of a new fungicide over several weeks. The fungicide was Shirlan, with fluazinam as its active ingredient. 9 farmers were patch tested with a concentration range of the whole formulation (aq.) and of the active ingredient (pet.). In 7 of 9 farmers, positive patch tests were scored with both the whole formulation (down to 0.01% aq.) and fluazinam itself (down to 0.1% pet.). Patch tests in consecutive control patients (n = 10) were all negative. As it was impossible to substitute fluazinam as the active ingredient, farmers are now supplied with detailed information as to how to avoid skin contact as much as feasible.
Ref: Contact Dermatitis 1995 Mar;32(3):160-2;
Allergic contact dermatitis from the newly introduced fungicide fluazinam; by van Ginkel CJ, Sabapathy NN.

Flumethrin - Acaricide - CAS No. 69770-45-2

A single case report was located in which a 47-year-old farmer developed a hypersensitive response that included a widespread dermal rash after dipping sheep in a solution, the active component of which was flumethrin (Box and Lee 1996). The relative contributions of dermal and inhalation exposure were not indicated in the report.
Ref: DRAFT TOXICOLOGICAL PROFILE FOR PYRETHRINS AND PYRETHROIDS. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. Public Health Service Agency for Toxic Substances and Disease Registry. September 2001.

-- Groups of 15/sex/dose Wistar rats were fed diets containing 0, 10, 50 or 250/150 mg/kg feed for 13 weeks. The test substance was a 50% premix with colloidal SiO2 carrier... Skin lesions, described as ulcerative dermatitis, were observed in the 50 and 150 mg/kg feed groups and were dose-related in severity. The NOEL was 10 mg/kg feed, equivalent to 0.7/0.8 mg/kg bw per day...
-- IN GLP repeated-dose toxicity study, groups of 20/sex/dose Wistar rats were fed diets containing 0, 10, 40 or 160 mg/kg feed flumethrin for up to 15 weeks. During mixing of the diets, 1% peanut oil was added to minimise dust formation. At 160 mg/kg feed, body weight gain was significantly reduced. Sever skin lesions were observed in the 160 mg/kg feed group. Some mild skin lesions were also observed in the 40 mg/kg feed group. Decreased red cell values and increased leucocyte counts in the 160 mg/kg feed group were probably associated with the skin lesions. At termination, histopathological examination revealed ulcerative skin lesions in all rats given 160 mg/kg feed and some rats from the 40 mg/kg feed group. Increased extramedullary haematopoiesis and reduced haemosiderin storage in the spleen were also observed in the 160 mg/kg feed group. The NOEL was 10 mg/kg feed, equivalent to 0.7/0.8 mg/kg bw per day in males/females respectively.
-- Groups of 4/sex/dose Beagle dogs were fed diets containing 0, 50, 100 or 200 mg/kg feed flumethrin for 13 weeks. The test substance was a 45.3% premix with colloidal SiO2 carrier. Skin lesions and emesis were observed in the groups receiving 50 mg/kg feed and above and were dose-related in incidence and severity. Over the 13 weeks, the mean body weight of males given 200 mg/kg feed was decreased and females in this group gained less weight than the controls... Blood urea nitrogen (BUN) concentrations were significantly increased in dogs given 200 mg/kg feed and slightly increased in dogs given 100 mg/kg feed. At termination, treatment-related skin lesions were observed in all treated groups; the epithelial layer of the epidermis was thickened and covered with hyperkeratotic material in places. In 2 dogs given 200 mg/kg feed, the epidermis was ulcerated. No NOEL was established in this study.
Ref: Committee for Veterinary Medicinal Products. Flumethrin. Summary Report (1). June 1998. EMEA/MRL/469/98-FINAL. The European Agency for the Evaluation of Medicinal Products.

Fluosilicic acid - Wood Preservative - CAS No. 16961-83-4

-- Rats, guinea pigs, and swine tested as a group; no other data were provided, percutaneous; The intact skin was not affected. When areas were injured before application of the acid, necrosis, continuously spreading, occurred in the deeper regions. Hypocellular necrosis, consisting of sharp leukocyte demarcations, and edema up to the subcutis were observed. Alhassan and Zink (1982; cited by HSDB, 2000a)
-- Rabbits, New Zealand; 0.5 mL (4 mol) to the intact and abraded skin for 1, 24, or 72 h Severe erythema and edema were observed, indicating the material to be a primary irritant. Rhone- Poulenc Inc. (1971)
Ref: Review of Toxicological Literature. October 2001. Sodium Hexafluorosilicate [CASRN 16893-85-9] and Fluorosilicic Acid [CASRN 16961-83-4]. Prepared for Scott Masten, Ph.D. National Institute of Environmental Health Sciences P.O. Box 12233 Research Triangle Park, North Carolina 27709. Contract No. N01-ES-65402. Submitted by Karen E. Haneke, M.S. (Principal Investigator) Bonnie L. Carson, M.S. (Co-Principal Investigator) Integrated Laboratory Systems P.O. Box 13501 Research Triangle Park, North Carolina 27709.

Fluridone - Herbicide - CAS No. 59756-60-4

ONCOGENICITY, MOUSE ** 014, 028; 44090, 64272; "A Two-year Chronic Dietary Toxicity Study of EL-171 (Fluridone) in the Mouse." (G.S.Probst et. al., Toxicology Division, Lilly Research Lab., Greenfield, IN, studies M-9407, 9417 and M-9397, 12/81); Fluridone (97.2-97.8% purity); administered to ICR mice at 0, 33, 100 or 330 ppm in the diet equivalent to 0, 3.5, 10.9 or 30.7 mg/kg/day in males and 0, 4.0, 12.3 or 34.5 mg/kg/day in females; liver enzyme induction at high dose, borderline decrease in survival in the high dose group. Possible adverse effect: increased skin fibrosarcomas in high dose females. acceptable; 64272 is the 1-year report on 15/sex/group at the same concentrations in the diet. (Carlisle, 7/2/86 and Gee, 4/11/88).
Ref: Summary of Toxicology Data. Fluridone. California EPA, Department of Pesticide Regulation, Medical Toxicology Branch, Revised: 2/9/00.

Fluvalinate - Acaricide, Insecticide - CAS No. 69409-94-5

In a range finding study, dietary administration of 50 mg/kg/day for 30 days produced skin lesions in rats. The NOEL was not determined. A 2-year rat feeding study was terminated at 64 weeks due to dermal lesions produced in animals at 15 mg/kg/day. The NOEL was 2 mg/kg/day. Dietary administration of 10 mg/kg/day (LOEL for effect) to mice for 2 years produced scabbing and dermal abrasion. No NOEL for these effects was established. An increase in plantar ulcers was observed in rats fed 2.5 mg/kg/day (LOEL) for 2 years. The NOEL was 1 mg/kg/day. Decreases in body weight gain were also observed in this study. Based on the NOEL of the study, an oral RfD of 0.01 mg/kg/day was derived. In a 2- generation rat reproduction study, dietary administration of 5 mg/kg/ day produced decreased body weight gain and skin lesions in parents and offspring. Dietary administration of 2.5 mg/kg/day to rats for 13 weeks produced anemia in blood parameters (decreased hematocrit, hemaglobin, and red blood cells). The NOEL was 1.0 mg/kg/day... EPA believes that there is sufficient evidence for listing fluvinate on EPCRA section 313 pursuant to EPCRA section 313(d)(2)(B) based on the available developmental, dermal, and hematological toxicity data for this chemical.
Ref: USEPA/OPP. Support Document for the Addition of Chemicals from Federal Insecticide, Fungicide, Rodenticide Act (FIFRA) Active Ingredients to EPCRA Section 313. U. S. Environmental Protection Agency, Washington, DC (1993). As cited by US EPA in: Federal Register: January 12, 1994. Part IV. 40 CFR Part 372. Addition of Certain Chemicals; Toxic Chemical Release Reporting; Community Right-to-Know; Proposed Rule.
Note from FAN; Plantar ulcers
- sometimes called "Diabetic Foot"

Gamma-cyhalothrin - Insecticide - CAS No. 76703-62-3

13-Week Dietary - Rat. NOAEL: male/female =3.4/4.2 mg/kg/day
LOAEL: male/female = 6.6/8.8 mg/kg/day (mortality in males, neuromuscular effects in both sexes, dermatitis, and gross and microscopic skin lesions in females).
Ref: April 8, 2004. Federal Register. Lambda-Cyhalothrin and Gamma-Cyhalothrin. Tolerances for Residues. FINAL RULE.

Penoxsulam - Herbicide - CAS No. 219714-96-2

(Page 22-23): In a developmental toxicity study (MRID 45830917) XDE-638 (Penoxsulam; 97.5% ai, lot #ND05167938, TSN101773) was administered to 25 time-mated female CD rats/dose by gavage in 0.5% aqueous METHOCEL at dose levels of 0, 100, 500, or 1000 mg/kg bw/day on gestation days (GD) 6 through 20, inclusive. On GD 21, surviving females were sacrificed and necropsied. All fetuses were weighed sexed, and examined for external alterations. Approximately one-half of the fetuses from each litter were subjected to visceral examination, and the remaining one-half were subjected to skeletal examinaiton... Malformations were observed in 0, 2, 2 and 3 fetuses and in 0/24, 2/24, 1/25, and 2/22 litters from the control, low-, mid-, and high-dose groups, respectively.... An apparently rare external malformation (cutis laxis*) was observed in 2 fetuses in single litters at both the 500 and 1000 mg/kg/day dose levels. However, based on a weight-of-the-evidence consideration of all the available information/data, it is concluded that the cutis laxis observed inthis study most likely has a genetic etiology. There is insufficient information to conclude that it is a treatment-related effect due to the test material. Therefore, the development toxicity LOAEL for penoxsulam in CD rats is not identied (>1000 mg/kg day), and the developmental toxicity NOAEL is 1000 mg/kg day.
Ref: June 18, 2007 - Penoxsulam. Human Health Risk Assessment for Proposed Uses on Fish and Shellfish. Docket: EPA-HQ-OPP-2006-0076-0004. USEPA.

NOTE FROM FAN: We could not find the term cutix laxis, only the term Cutis Laxa.
* Definition of Cutis laxa
: Pathophysiology: Cutix laxa is characterized by degenerative changes in the elastic fibers resulting in loose, pendulous skin. The skin is sagging, redundant, and stretchable, with reduced elastic recoil.
Ref: eMedicine site: Cutis Laxa (Elastolysis).
from : Cutis laxa is a rare disorder of connective tissue that causes the skin to stretch easily and hang in loose folds... Sometimes only the skin is affected, but connective tissues throughout the body can be affected. Cutis laxa is usually hereditary. In some kinds of cutis laxa, the abnormal genes cause problems unrelated to connective tissues - for example, mental retardation....

Sodium fluorosilicate (Sodium Hexafluorosilicate) - Insecticiide; Wood Preservative; EPA List 3 Inert - CAS No. 16893-85-9

-- Within one week after beginning work in a foam rubber plant, a 23-year-old man exhibited skin lesions consisting of "diffuse, poorly delineated, erythematous plaques with lichenoid papules and large pustules" on his arms, wrists, thighs, and trunk. Although scratch and patch tests with sodium hexafluorosilicate (2% aqueous) were negative, animal testing showed the compound to be a pustulogen. When rabbits received topical application of a 1, 5, 10, and 25% solution of sodium hexafluorosilicate in petroleum, pustules occurred on normal skin only with the high concentration, while all concentrations produced pustules on stabbed skin (Dooms-Goossens et al., 1985).
-- -- Rabbits, New Zealand; 0.5 mL (4 mol) to the intact and abraded skin for 1, 24, or 72 h Severe erythema and edema were observed, indicating the material to be a primary irritant. Rhone- Poulenc Inc. (1971)
Ref: Review of Toxicological Literature. October 2001. Sodium Hexafluorosilicate [CASRN 16893-85-9] and Fluorosilicic Acid [CASRN 16961-83-4]. Prepared for Scott Masten, Ph.D. National Institute of Environmental Health Sciences P.O. Box 12233 Research Triangle Park, North Carolina 27709. Contract No. N01-ES-65402. Submitted by Karen E. Haneke, M.S. (Principal Investigator) Bonnie L. Carson, M.S. (Co-Principal Investigator) Integrated Laboratory Systems P.O. Box 13501 Research Triangle Park, North Carolina 27709.
Definition for Erythema - abnormal redness of the skin resulting from dilation of blood vessels (as in sunburn or inflammation)

tau-Fluvalinate - Acaricide, Insecticide - CAS No. 102851-06-9

-- The acute dermal toxicity of tau fluvalinate in rabbits was low (LD 50> 20 g/kg/bw) with little percutaneous absorption...
-- In 13-week toxicity studies in rats tau fluvalinate was given in the diet or per gavage in corn oil. Pharmacotoxic effects and skin lesions were observed at a dose of 1 mg/kg bw/day by gavage (NOEL proposed by expert). Dietary exposure to the same dose also produced skin lesions... Similar findings were recorded in mice receiving tau fluvalinate in the diet for 13 weeks (lowest dose tested: 1 mg/kg bw). The NOEL in the rat study was 0.3 mg/kg bw.
-- 6-month toxicity studies on tau fluvalinate were not submitted. Administratin of racemic fluvalinate in gelatine capsules for 6 months to dogs resulted in skin lesions at the lowest dose tested and emesis, depression, diarrhoea, and dehydration at higher doses.
-- A NOEL of 1 mg/kg bw for tau fluvalinate, derived from a 13-week gavage study in rats is not acceptable as this dose led to pharmacodynamic effects and skin problems. Only limited information about biological effects of tau fluvalinate in mammals, particularly in regard to acute neurotoxicity is given.

Ref: Revised Summary Report. EMEA/MRL/021-REV1/95. Committee for Veterinary Medicinal Products. The European Agency for the Evaluation of Medicinal Products.

Transfluthrin - Insecticide - CAS No. 118712-89-3 Dermal. In a repeat dose study groupsof HC:NZW New Zealand white rabbits (5 animals/sex/group) received applications of 0, 20, 200 or 1000 mg kg transflurthrin (95% pure) in cremophor E1 (2 ml kg) under a gauze dressing for 6 h d 5 d w for 3 w. Further groups were treated with 0 and 1000 mg kg and then observed for a further 14 day. ... At necropsy white, yellow, glazing and/or cratering were noted in kidneys at the end of both the treatment and post treatment periods. Kidney weights were increased by ~ 35% relative in males at 20 mg kg at the end of the treatment period but not at the end of the post-treatment period. These were attributed to an infestation of Nosema cuniculi. Histopathological examination revealed effects on the kidney (unspecified nephropathy at the end of both treatment and post treatment in all groups). Epidermal thickening was noted in 7/10 animals at 200 mg kg and all animals at 1000 mg kg. Hyperkeratosis was observed in 2/10 animals at 200 mg kg and 7/10 a 1000 mg kg. Apart from 1 female case of epidermal erosion, skin pathology was absent at the end of the post-treatment period. The NOEL was 20 mg kg based on the epidermal thickening and hyperkeratosis seen at and above 200 mg kg in both sexes.
-- B6C3F1 mice (60/group/sex) received 0, 10, 100 or 1000 ppm mg kg transfluthrin (94.8-95%) pure in the diet for up to 104 weeks with 10/sex/dose killed after one yar. Two additional groups(10/sex) received 0 or 1000 ppm for 13 weeks... Serum cholesterol levels were significantly raised from 13 weeks at 1000 ppm (20% in males and 54% in females) and from 100 ppm from week 53 (approximately 11 - 30%) and at week 103 from 10 ppm in females (approximately 50 - 70%) and at 1000 ppm in males )~ 20%). ... Fluoride accumulation in bone and teeth of both sexes were observed (in the 13 week study at 1000 ppm) and at 53 and 104 weeks from 100 ppm (approximately 2 fold at 100 ppm and 4-5 fold at 1000 ppm with respect to controls). ... The only gross pathological findings considered to be treatment related were nodules in the livers of females at 1000 ppm (incidence 6/42, 4/39, 3/42 and 15/44). On histopathological examination, at 1000 ppm, non neoplastic findings were periacinar hepatocyte hypertropy was observed at 53 weeks (slight to moderate in all males and minimal in 6/10 females) and more marked but consistent with liver enzyme induction at 104 weeks (38/50 males, 26/50 females). ... The incidences of hepatocellular carcinoma were within the historical control range for the laboratory (1 - 5 in females for studies using 50 animals), whereas the adenoma incidence of 13/50 exceeded the range (1 - 9). The low incidences of other tumours (haemangiosarcoma in the spleen, sarcoma of the subcutis and adenoma of the harderian gland) observed at the top dose in females were not statistically significant. ... Based on the chronic toxicity, in males the NOEL is 10 ppm (2 mg kg d based on increases in liver weight and hepatocyte hypertrophy, at 1000 ppm and increased fluoride accumulation at 100 ppm). It is not possible to set a NOEL for females as increases in serum cholesterol, protein and albumin were reported at the lowest dose.
Ref: Evaluation on: Transfluthrin Use as a Public Hygiene Insecticide. September 1997. Prepared by: the UK Health and Safety Executive, Biocides & Pesticides Assessment Unit, Magdalen House, Stanley Precinct, Bootle, Merseyside L20 3QZ. Available from: Department for Environment, Food and Rural Affairs, Pesticides Safety Directorate, Mallard House, Kings Pool, 3 Peasholme Green, York YO1 7PX. UK. Also at
• Note: This was transcribed from the copy available on the web. While one can easily read this report on the web, the report is inaccessible, or locked, to any attempt to copy it. Any errors are mine. EC.

• Defintion of Subcutis: The skin has 3 layers called the epidermis, dermis, and subcutis. The last and deepest layer of the skin is called the subcutis. The subcutis and the lowest part of the dermis form a network of collagen and fat cells. The subcutis conserves heat and has a shock-absorbing effect that helps protect the body's organs from injury. (Ref: What is Nonmelanoma Skin Cancer? American Cancer Society.

Trifluralin - Herbicide - CAS No. 1582-09-8

Absorption, distribution, excretion and metabolism in mammals (Annex IIA, point 5.1). Widely distributed; highest concentration in adrenals, fat, kidneys, liver, skin and blood (page 45)
Ref: March 14, 2005. European Food Safety Authority: Conclusion regarding the peer review of the pesticide risk assessment of the active substance trifluralin. EFSA Scientific Report (2005) 28, 1-77.

Abstract: A case report was presented of a 61 year old male laboratory supervisor in a pesticide company with no reported history of hay fever, asthma or childhood eczema who experienced allergic contact dermatitis as a result of exposure to trifluralin (1582-09-8) and benefin (1861-40-1). He had been employed in the testing of pesticides since 1951. He presented with erythematous and pruritic dermatitis involving the exposed areas of skin on the face, neck, chest and arms. Although he was exposed to multiple pesticides, he was able to temporally link his reaction to exposure to several pesticides, including benefin and trifluralin. The patient was patch tested with a standard series, a pesticide series and the pesticides to which he was exposed. At 2 and 4 days, the tests elicited 2+ reactions to trifluralin and benefin. Patch tests in 12 control subjects with trifluralin and benefin showed no positive reactions. The authors note that although trifluralin and benefin have previously been reported to cause skin and eye irritation, no previous reports of allergic contact dermatitis have been made.
Ref: Pentel MT et al. (1994). Allergic Contact Dermatitis from the Herbicides Trifluralin and Benefin. Journal of the American Academy of Dermatology, Vol. 31, No. 6, pages 1057-1058.

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