Skip to main content

Overview on Current Status of Alternative Methods and Testing Approaches for Skin Irritation Testing

  • Chapter
  • First Online:
Alternatives for Dermal Toxicity Testing

Abstract

In vitro test methods for skin irritation have been validated and regulatory adopted as early as 2009 in the EU and 2010 at the OECD level. Current internationally agreed approaches recommend the use of Integrated Approach for Testing and Assessment (IATA), that allow to replace or minimize to the extent possible the use of in vivo animal testing (OECD Guidance Document 203). The IATA comprises in a sequential way (1) the use of existing information, physico-chemical properties and non-testing methods, (2) a weigh-of-evidence evaluation of the existing data, and (3) if needed, the conduct of prospective testing. Although no single in vitro test method can cover across the full range of skin corrosion and irritation responses from the traditional in vivo Draize rabbit test, the currently validated and adopted in vitro methods for skin irritation and corrosion can replace the in vivo test when combined within tiered testing strategies in either a top-down or a bottom-up approach for predicting the potential skin irritation and corrosion hazard of a test chemical.

Skin irritation hazard as defined by the United Nations Globally Harmonized System for classification (UN GHS) can be predicted by the scientific valid reconstructed human epidermis (RhE) models that have been internationally adopted (OECD Test Guideline 439) including the EPISKIN™ Skin Irritation Test (SIT), the EpiDerm™ EPI-200-SIT, the SkinEthic™ RHE SIT42bis and the Labcyte EPI-MODEL 24SIT. These methods are comprised of non-transformed human-derived epidermal keratinocytes cells which have been cultured in an air-liquid interface to form a multilayered, highly differentiated model of the human epidermis. The RhE-based test methods measure the initiating events in the cascade of skin irritation, e.g. cell/tissue damage, using cell viability as readout.

Depending on the regulatory framework and the classification system in use, these test methods can be used to determine the skin irritancy of chemicals either as a stand-alone replacement test of the in vivo skin irritation testing or as a partial replacement test within a testing strategy (OECD Guidance Document 203). Test chemicals are applied topically to the RhE models and cell viability is measured by enzymatic conversion of the vital dye MTT into a blue formazan salt that is quantitatively measured after extraction from tissues. Irritant chemicals are identified by their ability to decrease cell viability below defined threshold levels (i.e. ≤50%, for UN GHS category 2 skin irritants). In regions that do not adopt the optional UN GHS Category 3 (mild irritants), such as in the EU, test chemicals that produce cell viabilities above the defined threshold level, are identified as not requiring classification (i.e. >50%).

A number of similar RhE models are being developed including the epiCS® SIT method that underwent a Performance Standards based validation followed by an independent peer-review. Furthermore novel assays based on parameters other than cell viability show promise to distinguish not only irritants from non irritants but also to determine the skin irritancy potential of chemicals including for example the discrimination of mild-irritants (Cat. 3). This is the case for example of the IRR-IS assay, which is based on the quantitative analysis of expression profiles of relevant genes.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. OECD. OECD guidelines for the testing of chemicals no. 404. Acute dermal irritation/corrosion. Paris, France: organisation for economic cooperation and development. Originally adopted in 1981. 2015. Available at: http://www.oecd-ilibrary.org/environment/oecd-guidelines-for-the-testing-of-chemicals-section-4-health-effects_20745788.

  2. OECD. Guidance document no. 203: Integrated Approaches to Testing and Assessment for Skin Irritation/Corrosion. Environment, health and safety publications, series on testing and assessment. Organisation for economic cooperation and development, Paris. 2014. Available at: http://www.oecd.org/env/ehs/testing/series-testing-assessment-publications-number.htm.

  3. EC. Regulation 1223/2009 of the European Parliament and of the council of 30 November 2009 on cosmetic products. Off J Eur Union. 2009;L342:59–209.

    Google Scholar 

  4. EC. Regulation 1907/2006 of the European Parliament and of the council of 18 December 2006 concerning the Registration, evaluation, Authorisation and Restriction of chemicals (REACH), establishing a European chemicals agency, amending Directive 1999/45/EC and repealing council regulation 793/93 and Commission regulation 1488/94 as well as council Directive 76/769/EEC and Commission directives 91/155/EEC, 93/67/EEC, 93/105/EC and 2000/21/EC. Off J Eur Union L. 2006;396:1–849.

    Google Scholar 

  5. EC. Regulation 2016/863 amending annexes VII and VIII to regulation 1907/2006 of the European Parliament and of the council on the Registration, evaluation, Authorisation and Restriction of chemicals (REACH) as regards skin corrosion/irritation, serious eye damage/eye irritation and acute toxicity. Off J Eur Union L. 2016;144:27–31.

    Google Scholar 

  6. EC. Regulation 1272/2008 of the European Parliament and of the council of 16 December 2008 on classification, labelling and packaging of substances and mixtures, amending and repealing directives 67/548/EEC and 1999/45/EC, and amending regulation 1907/2006. Off J Eur Union. 2008;L353:1–1355.

    Google Scholar 

  7. EC. Regulation 2016/918 amending, for the purposes of its adaptation to technical and scientific progress, regulation 1272/2008 of the European Parliament and of the council on classification, labelling and packaging of substances and mixtures. Off J Eur Union L. 2016;156:1–103.

    Google Scholar 

  8. EC. Directive 2010/63/EU of the European Parliament and of the council of 22 September 2010 on the protection of animals used for scientific purposes. Off J Eur Union. 2010;L276:33.

    Google Scholar 

  9. United Nations (UN). Globally harmonized system of classification and labelling of chemicals (GHS). Sixth revised edition. Part 3: health hazards–chapter 3.2 skin corrosion/irritation. New York, USA, and Geneva, Switzerland: United Nations; 2015. p. 125–136. Available at: http://www.unece.org/fileadmin/DAM/trans/danger/publi/ghs/ghs_rev06/English/ST-SG-AC10-30-Rev6e.pdf.

  10. Draize JH, Woodard G, Calvery HO. Methods for the study of irritation and toxicity of substances applied topically to the skin and mucous membranes. J Pharmacol Exp Ther. 1944;82:377–90.

    CAS  Google Scholar 

  11. EC. Commission Directive 2001/59/EC of 6 august 2001 adapting to technical progress for the 28th time council Directive 67/548/EEC on the approximation of laws, regulations and administrative provisions relating to the classification, packaging and labelling of dangerous substances. Off J Eur Commun L. 2001;225:1–333.

    Google Scholar 

  12. EC. Directive 1999/45/EC of the European Parliament and of the council of 31 May 1999 concerning the approximation of laws, regulations and administrative provisions of the member states relating to the classification, packaging and labelling of dangerous preparations. Off J Eur Commun L. 1999;200:1–68.

    Google Scholar 

  13. NIH. Corrositex®: an in vitro test method for assessing dermal corrosivity potential of chemicals, NIH Publication No. 99-4495. Research Triangle Park, NC: NIEHS; 1999.

    Google Scholar 

  14. EC. Regulation 440/2008 laying down test methods pursuant to regulation 1907/2006 of the European Parliament and of the council on the Registration, evaluation, Authorisation and Restriction of chemicals (REACH). Off J Eur Union. 2008;L142:1–739.

    Google Scholar 

  15. ECHA. Guidance on information requirements and chemical safety assessment. Chapter R.7a: endpoint specific guidance. Version 4.0. Subchapter R.7.2. Skin corrosion/irritation, serious eye damage/eye irritation and respiratory tract corrosion/irritation; 2015. p168–99. Available at: http://echa.europa.eu/documents/10162/13632/information_requirements_r7a_en.pdf.

  16. Alépée N, Grandidier MH, Tornier C, Cotovio J. An integrated testing strategy for in vitro skin corrosion and irritation assessment using SkinEthic™ reconstructed human epidermis. Toxicol In Vitro. 2015;29:179–1792.

    Google Scholar 

  17. OECD. Guidance document no. 34: validation and international acceptance of new or updated test methods for hazard assessment. environmental health and safety monograph series on testing and assessment. 2005. Available at: http://www.oecd.org/env/ehs/testing/series-testing-assessment-publications-number.htm.

  18. Cotovio J, Grandidier M-H, Portes P, Roguet R, Rubinstenn G. The in vitro acute skin irritation of chemicals: optimisation of the EPISKIN prediction model within the framework of the ECVAM validation process. ATLA. 2005;33:329–49.

    PubMed  CAS  Google Scholar 

  19. Fentem JH, Briggs D, Chesné C, Elliott GR, Harbell JW, Heylings JR, Portes P, Roguet R, Van De Sandt JJM, Botham PA. A prevalidation study on in vitro tests for acute skin irritation: results and evaluation by the management team. Toxicol In Vitro. 2001;15:57–93.

    Article  CAS  PubMed  Google Scholar 

  20. Portes P, Grandidier MH, Cohen C, Roguet R. Refinement of the EPISKIN protocol for the assessment of acute skin irritation of chemicals: follow-up to the ECVAM prevalidation study. Toxicol In Vitro. 2002;16:765–70.

    Article  CAS  PubMed  Google Scholar 

  21. Zuang V, Balls M, Botham PA, Coquette A, Corsini E, Curren RD, Elliott GR, Fentem JH, Heylings JR, Liebsch M, Medina J, Roguet R, van de Sandt H, Wiemann C, Worth AP. Follow-up to the ECVAM prevalidation study on in vitro tests for acute skin irritation. ECVAM skin irritation task force report 2. ATLA. 2002;30:109–29.

    PubMed  CAS  Google Scholar 

  22. Eskes C, Cole T, Hoffmann S, Worth A, Cockshott A, Gerner I, Zuang V. The ECVAM international validation study on in vitro tests for acute skin irritation: selection of test chemicals. ATLA. 2007;35:603–19.

    PubMed  CAS  Google Scholar 

  23. Spielmann H, Hoffmann S, Liebsch M, Botham P, Fentem JH, Eskes C, Roguet R, Cotovio J, Cole T, Worth A, Heylings J, Jones P, Robles C, Kandárová H, Gamer A, Remmele M, Curren R, Raabe H, Cockshott A, Gerner I, Zuang V. The ECVAM international validation study on in vitro tests for acute skin irritation: report on the validity of the EPISKIN and EpiDerm assays and on the skin integrity function test. ATLA. 2007;35:559–601.

    PubMed  CAS  Google Scholar 

  24. ESAC Statement on the validity of in vitro tests for skin irritation. Available at: http://ecvam.jrc.ec.europa.eu/ under “Publications”, “ESAC statements”. 2007.

  25. Alépée N, Tornier C, Rober C, Amsellem C, Roux MH, Doucet O, Pachot J, Méloni M, de Brugerolle de Fraissinette A. A catch-u validation study on reconstructed human epidermis (SkinEthic RHE) for full replacement of the Draize skin irritation test. Toxicol In Vitro. 2010;24:257–66.

    Article  CAS  PubMed  Google Scholar 

  26. Kandárová H, Hayden P, Klausner M, Kubilus J, Sheasgreen J. An in vitro skin irritation test (SIT) using the EpiDerm reconstructed human epidermal (RHE) model. J Vis Exp. 2009;29 doi:10.3791/1366.

  27. Kandárová H, Hayden P, Klausner M, Kubilus J, Kearney P, Sheasgreen J. In vitro skin irritation testing: improving the sensitivity of the EpiDerm skin irritation test protocol. ATLA. 2009;37:671–89.

    PubMed  Google Scholar 

  28. OECD. Guidance document no. 137: Explanatory background document to the OECD test guideline on in vitro skin irritation testing. Environment, health, and safety publications, series on testing and assessment. organisation for economic cooperation and development, Paris. 2010. Available at: http://www.oecd.org/env/ehs/testing/series-testing-assessment-publications-number.htm.

  29. Tornier C, Amsellem C, de Brugerolle de Fraissinette A, Alépée N. Assessment of the optimized SkinEthic reconstructed human epidermis (RHE) 42bis skin irritation protocol over 39 substances. Toxicol In Vitro. 2010;24:245–56.

    Article  CAS  PubMed  Google Scholar 

  30. ESAC. Statement on the scientific validity of in vitro tests for skin irriation testing (SkinEthic and modified EpiDerm). Available at: http://ecvam.jrc.ec.europa.eu/under “Publications”, “ESAC statements”. 2008

  31. ESAC. Statement on the performance under UN GHS of three in vitro assays for skin irritation testing and the adaptation of the reference chemicals and defined accuracy values of the ECVAM skin irritation performance standards. Available at: http://ecvam.jrc.ec.europa.eu/under “Publications”, “ESAC statements”. 2009.

  32. OECD. OECD guidelines for the testing of chemicals no. 439. In vitro skin irritation: reconstructed human epidermis test method. Paris, France: Organisation for economic cooperation and development. Originally adopted in 2010. 2015. Available at: http://www.oecd-ilibrary.org/environment/oecd-guidelines-for-the-testing-of-chemicals-section-4-health-effects_20745788.

  33. Katoh M, Hamajima F, Ogasawara T, Hata K. Assessment of human epidermal model LabCyte EPI-MODEL for in vitro skin irritation testing according to European Centre for the Validation of alternative methods (ECVAM)-validated protocol. J Toxicol Sci. 2009;34:327–34.

    Article  CAS  PubMed  Google Scholar 

  34. Katoh M, Hata K. Refinement of LabCyte EPI-MODEL24 skin irritation test method for adaptation to the requirements of OECD test guideline 439. AATEX. 2011;16:111–22.

    Google Scholar 

  35. Kojima H, Ando Y, Idehara K, Katoh M, Kosaka T, Miyaoka E, Shinoda S, Suzuki T, Yamaguchi Y, Yoshimura I, Yuasa A, Watanabe Y, Omori T. Validation study of the in vitro skin irritation test with the LabCyte EPI-MODEL24. ATLA. 2012;40:33–50.

    PubMed  CAS  Google Scholar 

  36. Kojima H, Katoh M, Shinoda S, Hagiwara S, Suzuki T, Izumi R, Yamaguchi Y, Nakamura M, Kasahawa T, Shibai A. A catchu-up validation study of an in vitro skin irritation test method using reconstructed human epidermis LabCyte EPI-MODEL24. J Appl Toxicol. 2014;34:766–74.

    Article  CAS  PubMed  Google Scholar 

  37. OECD. Guidance document no. 155: Peer review report of validation of the skin irritation test using LabCyte EPI-MODEL24. Environment, health and safety publications, series on testing and assessment, organisation for economic cooperation and development, Paris. 2011. Available at: http://www.oecd.org/env/ehs/testing/series-testing-assessment-publications-number.htm.

  38. EpiSkin™ SIT. SOP Version 1.8. In:ECVAM skin irritation validation study: validation of the EpiSkin™ test method 15 min–42 hours for the prediction of acute skin irritation of chemicals; 2009. Available at: https://eurl-ecvam.jrc.ec.europa.eu/validation-regulatory-acceptance/docs-skin-irritation-1/DOC11-SOP%20EpiSkin_revised_MTT.pdf.

    Google Scholar 

  39. EpiDerm™ EPI-200-SIT (2009). SOP version MK-24-007-0023. Protocol for: in vitro EpiDerm™ skin irritation test (EPI-200-SIT), for use with MatTek Corporation's reconstructed human epidermal model EpiDerm (EPI-200). Available at: https://eurl-ecvam.jrc.ec.europa.eu/validation-regulatory-acceptance/docs-skin-irritation-1/DOC13-SOP%20modified%20EpiDerm%20MTT.pdf.

    Google Scholar 

  40. SkinEthic™ RHE SIT-42bis. SOP version 2.0. skinethic skin irritation test-42bis test method for the prediction of acute skin irritation of chemicals: 42 minutes application + 42 hours post-incubation; 2009. Available at: https://eurl-ecvam.jrc.ec.europa.eu/validation-regulatory-acceptance/docs-skin-irritation-1/DOC14-SOP%20SkinEthic%20MTT.pdf.

  41. Labcyte EPI-MODEL 24SIT. EPI-MODEL24 SIT SOP, Version 8.3, skin irritation test using the reconstructed human model “LabCyte EPI-MODEL24”; 2011. Available at: http://www.jpte.co.jp/english/business/LabCyte/Testprotocol.pdf.

  42. OECD. Document no. 220: performance standards for the assessment of proposed similar or modified in vitro reconstructed human epidermis (RHE) test methods for skin irritation testing as described in TG 439. OECD environmental health and safety publications, Series on testing and assessment; 2015c. Available at: http://www.oecd.org/env/ehs/testing/series-testing-assessment-publications-number.htm.

  43. Welss T, Basketter DA, Schroder KR. In vitro skin irritation: facts and future. State of the art review of mechanisms and models. Toxicol In Vitro. 2004;18:231–43.

    Article  CAS  PubMed  Google Scholar 

  44. Eskes C, Detappe V, Koeter H, Kreysa J, Liebsch M, Zuang V, Amcoff P, Barroso J, Cotovio J, Guest R, Hermann M, Hoffmann S, Masson P, Alepee N, Arce LA, Bruschweiler B, Catone T, Cihak R, Clouzeau J, D’Abrosca F, Delveaux C, Derouette JP, Engelking O, Facchini D, Frohlicher M, Hofmann M, Hopf N, Molinari J, Oberli A, Ott M, Peter R, Sa-Rocha VM, Schenk D, Tomicic C, Vanparys P, Verdon B, Wallenhorst T, Winkler GC, Depallens O. Regulatory assessment of in vitro skin corrosion & irritation data within the european framework: workshop recommendations. Regul Toxicol Pharmacol. 2012;62:393–403.

    Article  PubMed  Google Scholar 

  45. Alépée N, Barroso J, De Smedt A, De Wever B, Hibatallah J, Klaric M, Mewes KR, Millet M, Pfannenbecker U, Tailhardat M, Templier M, McNamee P. Use of HPLC/UPLC-spectrophotometry for detection of formazan in in vitro reconstructed human tissue (RhT)-based test methods employing the MTT-reduction assay to expand their applicability to strongly coloured test chemicals. Toxicol In Vitro. 2015;29:741–61.

    Article  CAS  PubMed  Google Scholar 

  46. Alépée N, Hibatallah J, Klaric M, Mewes KR, Pfannenbecker U, McNamee P. Assessment of cosmetic ingredients in the in vitro reconstructed human epidermis test method EpiSkin™ using HPLC/UPLC-spectrophotometry in the MTT-reduction assay. Toxicol In Vitro. 2016;33:105–17.

    Article  CAS  PubMed  Google Scholar 

  47. Hewitt NJ, Edwards RJ, Fritsche E, Goebel C, Aeby P, Scheel J, Reisinger K, Ouédraogo G, Duche D, Eilstein J, Latil A, Kenny J, Moore C, Kuehnl J, Barroso J, Fautz R, Pfuhler S. Use of human in vitro skin models for accurate and ethical risk assessment: metabolic considerations. Toxicol Sci. 2013;133:209–17.

    Article  CAS  PubMed  Google Scholar 

  48. Welss T, Matthies W, Schroeder KR. Compatibility testing in vitro: a comparison with in vivo patch test data. Int J Cosmet Sci. 2007;29:143.

    Article  Google Scholar 

  49. Jírová D, Basketter D, Liebsch M, Bendová H, Kejlová K, Marriott M, Kandárová H. Comparison of human skin irritation patch test data with in vitro skin irritation assays and animal data. Contact Dermatitis. 2010;62:109–16.

    Article  PubMed  Google Scholar 

  50. Basketter D, Jírová D, Kandárová H. Review of skin irritation/corrosion hazards on the basis of human data: a regulatory perspective. Interdiscip Toxicol. 2012;5:98–104.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Groeber F, Schober L, Schmid FF, Traube A, Kolbus-Hernandez S, Daton K, Hoffmann S, Petersohn D, Schäfer-Korting M, Walles H, Mewes KR. Catch-up validation study of an in vitro skin irritation test method based on an open source reconstructed epidermis (phase II). Toxicol In Vitro. 2016;36:254–61.

    Article  CAS  PubMed  Google Scholar 

  52. Mewes KR, Fischer A, Zöller NN, Laubach V, Bernd A, Jacobs A, van Rompay A, Liebsch M, Pirow R, Petersohn D. Catch-up validation study of an in vitro skin irritation test method based on an open source reconstructed epidermis (phase I). Toxicol In Vitro. 2016;36:238–53.

    Article  CAS  PubMed  Google Scholar 

  53. El Ghalbzouri A, Siamari R, Willemze R, Ponec M. Leiden reconstructed human epidermal model as a tool for the evaluation of the skin corrosion and irritation potential according to the ECVAM guidelines. Toxicol In Vitro. 2008;22:1311–20.

    Article  CAS  PubMed  Google Scholar 

  54. Miles A, Berthet A, Hopf NB, Gilliet M, Raffoul W, Vernez D, Spring P. A new alternative method for testing skin irritation using a human skin model: a pilot study. Toxicol In Vitro. 2014;28:240–7.

    Article  CAS  PubMed  Google Scholar 

  55. Lönnqvist S, Briheim K, Kratz G. Non-occlusive topical exposure of human skin in vitro as model for cytotoxicity testing of irritant compounds. Toxicol Mech Methods. 2016;26:82–7.

    Article  CAS  PubMed  Google Scholar 

  56. Groux H., Lelievre D., Cottrez F., Auriault C., Alépée N., Meunier J.R., Cotovio J.. Evaluation of IRR-IS®, an EpiSkin™ based model for quantifying chemical irritation potency. Oral Communication N° 1.5, ESTIV2012, 17th October 2012, Lisbon, Portugal. In: Poster presented at 51st Annual Meeting of the Society of Toxicology, March 11–15, 2012, San Francisco, USA. The Toxicologist; 2012p. 286. Available at: http://www.toxicology.org/AI/Pub/Tox/2012Tox.pdf.

  57. Spiekstra SW, Dos Santos GG, Scheper RJ, Gibbs S. Potential method to determine irritant potency in vitro - comparison of two reconstructed epidermal culture models with different barrier competency. Toxicol In Vitro. 2009;23:349–55.

    Article  CAS  PubMed  Google Scholar 

  58. Zhang Q, Dai T, Zhang L, Zhang M, Xiao X, Hu H, Zou P, Liu X, Xiang Q, Su Z, Huang Y, He QY. Identification of potential biomarkers for predicting acute dermal irritation by proteomic analysis. J Appl Toxicol. 2011;31:762–72.

    Article  CAS  PubMed  Google Scholar 

  59. Borlon C, Godard P, Eskes C, Hartung T, Zuang V, Toussaint O. The usefulness of toxicogenomics for predicting acute skin irritation on in vitro reconstructed human epidermis. Toxicology. 2007;30:157–66.

    Article  CAS  Google Scholar 

  60. Niwa M, Nagai K, Oike H, Kobori M. Evaluation of the skin irritation using a DNA microarray on a reconstructed human epidermal model. Biol Pharm Bull. 2009;32:203–8.

    Article  CAS  PubMed  Google Scholar 

  61. Khammo N, Ogilvie J, Clothier RH. Development of an innervated model of human skin. ATLA. 2007;35:487–91.

    PubMed  CAS  Google Scholar 

  62. Garle MJ, Fry JR. Sensory nerves, neurogenic inflammation and pain: missing components of alternative irritation strategies? A review and a potential strategy. ATLA. 2003;31:295–316.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Chantra Eskes .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing AG

About this chapter

Cite this chapter

Eskes, C., Hofmann, M. (2017). Overview on Current Status of Alternative Methods and Testing Approaches for Skin Irritation Testing. In: Eskes, C., van Vliet, E., Maibach, H. (eds) Alternatives for Dermal Toxicity Testing. Springer, Cham. https://doi.org/10.1007/978-3-319-50353-0_1

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-50353-0_1

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-50351-6

  • Online ISBN: 978-3-319-50353-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics