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20. 11. doc If yes please indicate treatments tried and failed Salicylic acid Sulfur preparations Erthyromycin / Benzoyl peroxide products Other For the Non- acne treatment If yes please specify below Lamellar ichthyosis Keratosis follicularis Darier s disease Pityriasis rubra pilaris PRP Palmoplantar keratoderma Keratosis palmaris et plantaris No Does the patient have the diagnosis of Folliculitis gram-negative 9. CONTAINS CONFIDENTIAL PATIENT INFORMATION Prior Authorization of Benefits PAB...
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