ARCHER NOTES

1. DERMATOLOGY
Archer’s Online USMLE Reviews
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Dermatology
Pityriasis versicolor
Scabies
Psoriasis
Rosacea ( Rhinopyoma)
Acne and treatment
Secondary syphilis – skin rash
Pemphigus vulgaris & Bullous pemphigoid
Impetigo
Lichen Planus
Warafarin / hepain skin necrosis
Malignant Melanoma
Squamous cell ca
Basal cell Ca
Contact Dermatitis

3. This adolescent boy complained of chronic and recurrent scaly white spots on
his trunk for years. The scaling cleared with topical selenium sulfide lotion
but the pigment took 4 months to recover.

4. Pityriasis Versicolor
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Also called Tinea Versicolor  not a true dermatophyte infection.Etiology
includes Pityrosporum orbiculare , Pityrosporum ovale
and Malassezia furfur (prior name for organisms above)
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Charecterized by scaly macules with fine scale. They can be hyper/ hypo
pigmented  “do not tan in summer”  involves trunks and proximal
extremities
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Diagnosis : is by KOH mount.  Spaghetti (hyphae) and meatball (yeast)
appearance
Wood's Lamp may show irregular pale yellow fluorescence.
Differential Diagnosis : Vitiligo , Seborrheacdermatitis , Tinea Corporis &
Pityriasis Rosea
Rx: Hypopigmentation resolves slowly after Treatment!!
First choice rx : Topical selenium sulfide 2.5% lotion daily for 7 days.
Alternatively, can use ketoconozole 2% cream daily x 14 days
Second choice : systemic antifungal – ketoconozole, itraconozole, fluconozole
Recurrence rate is very high  consider repeat Rx prior to summer / discard or
boil suspected clothing that might be harboring the fungus

5. What do u do about
Acne?
Advise to pts, medical management,
exacerbating factors etc

6. Acne - Ask Pts to avoid These!
Exacerbating factors to avoid
• Medications that exacerbate acne
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Androgenic steroids (e.g. Danazol Testosterone )
Corticosteroids
Lithium
Oral Contraceptives  If Acne, Change Oral Contraceptive  Increase Estrogen (50ug
Ethinyl Estradiol minimum) and Decrease androgenic effects of Progestin ( switch to 3rd
generation)
– Isoniazid
– Phenytoin (Dilantin) – choose carbamazepine for seizure control in teenagers.
Oil based Cosmetics  Cosmetics with Lanolin or petroleum jelly / Oil based
shampoos or Sunscreen  Change cosmetics to water based products
• Emotional Stress
• Physical Pressure (acne mechanica)  Tight chinstrap , Helmet
Clear the Myths
• Foods DO NOT worsen acne  Pizza , Nuts , Sweets , Chocolate  nope, they
don’t have anything to do with acne
• Acne is not a result of poor hygiene
– Constant washing does not improve acne  Limit washing face to 2-3 times per day
– Scrubbing dries and irritates skin further

7. Moderate Acne Vulgaris
Management
Indications  moderate Acne vulgaris, Comedonal
Acne vulgaris
1: OTC topical medications for 6 weeks eg: Topical
Benzoyl Peroxide gel
If fails,
2: Comedolytics and Topical Antibiotics for 6 weeks
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When there is comedonal acne, always Start
Comedolytic (discontinue Benzoyl Peroxide)
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First-line options  Topical Tretinoin Warn regarding
redness and irritation/ contraception
Consider adding a topical antibiotic
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Topical Erythromycin or Clindamycin

8. Severe Acne Vulgaris
• Includes Moderate to severe Acne Vulgaris & Nodular,
pustular, or cystic Acne Vulgaris
• RX: Start Comedolytic ( Retin A) & topical antibiotic as
above. Also start oral antibiotic  first line
tetracycline/ erythromycin. Second line are doxycycline,
bactrim
• In very severe cases ( nodulocystic acne)  maximal
medical therapy ( here side effects are high )
• Antiandrogens : spironolactone
• Isotretinoin 1mg/kg/d for 20 weeks  extremely
teratogenic. Be aware to monitor liver function tests
and triglycerides

9. Isotretinoin ( Accutane)
Indicated in Refractory acne vulgaris/ Nodulo cystic Acne
Adverse Effects
• Very Teratogenic (even 1 pill)  Needs two forms
Contraception while taking , Counsel extensively before
use
• Cheilitis, Dry or chapped skin ,Dry nose and eyes
• Elevated serum Triglycerides (25%)
• Arthralgias and Myalgias
• Elevated liver transaminases
• Peeling of palms and soles (5%)
• Intracranial Hypertension
• Night blindness

10. Isotretinoin
Monitoring
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Check Liver transaminases & Triglycerides at baseline and
every 2-4 weeks
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System Manage Accutane Related Teratogenicity
(SMART) -Accutane
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Only SMART registered members may prescribe Accutane
Prescription limited to 30 days
Mandates 2 forms of Birth Control
Both forms started >1 month before Accutane and continue
Contraception for 1 month after stopping
One form must be primary Contraception
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Tubal Ligation or partner's Vasectomy
Intrauterine Device
Oral Contraceptive
Depo Provera, Norplant or similar
Mandatory urine pregnancy timing
Initial urine Pregnancy Test and Urine Pregnancy Test immediately before
Accutane and Urine Pregnancy Test monthly at time of refill
Prescriptions must carry qualification sticker  Yellow Accutane
Qualification Sticker ( to obtain the sticker the provider has to
complete the best practices booklet)

11. This 45-year-old woman developed erythema, papules, pustules, and
telangiectasias on the cheeks and forehead. The eruptions worsened with
by high ambient temperature, hot drink, alcohol, spicy foods.
What is this ?
A. Nodulo cystic acne
B. Acne Rosacea
C. Folliculitis

12. Acne rosacea
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Most common in 30 to 5o yrs of age
Precipitated by Sun Exposure, hot weather, and hot baths, Emotional stressors , Alcohol ,Hot
drinks & Exercise
Symptoms : stinging pain with facial flushing
Signs : Affects middle third of face (forehead to chin)
Stage 1: Initial presentation  Intermittent facial Flushing
Stage 2: Early vascular changes  Facial erythema , Telangiectasis , Eye changes ( conjunctivitis, dry eyes,
keratitis)
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Stage 3: Inflammatory changes  Papules, Sterile Pustules  Comedones are typically absent
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Stage 4: Rhinophyma (Red bulbous nose) More common in men , Thickening of facial skin (especially
nose due to connective tissue hypertrophy & Sebaceous Gland hypertrophy )
TREATMENT
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Avoid alcohol , prolonged heat exposure, hot liquids (coffee, tea), heavy cosmetics and Use sun screen
regularly
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Avoid provocative medications  Benzoyl Peroxide and Topical Corticosteroid
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For Papular & Pustular Rosacea
First choice  topical agents Metronidazole gel or Azelaic acid gel. Alternatively u can use
clindamyicin gel or permethrin 5% cream
Oral antibiotics for 1 month and then taper dose  useful in rxng severe rosacea or ocular
rosacea with blepharitis, keratitis  doxycycline 100 bid or erythromycin 250 bid. Because of the
higher risk of adverse reactions associated with long-term use of oral antibiotics, topical therapy
is usually preferred long-term
In refractory cases consider topical retinoic acid
For Rhinopyoma  Early cases treat with antibiotics, Advanced cases – surgery
For Ocular Rosacea  Artificial tears and oral antibiotics are first choice
For vasomotor symptoms like facial flushing and erythema  u still use first choice
antibiotics as above. For symptomatic relief you may add clonidine or propranolol

13. Acne Rosacea – D/D
Differential Diagnosis
• Late-onset Acne Vulgaris  Comedones present, No
telangiectasis & No eye symptoms or signs
• Steroid-induced Acne - Results from Corticosteroid use on face
 Charecterized by occurrence after steroid use, lack of
comedones and presence of Perioral dermatitis
• Perioral Dermatitis
• Systemic Lupus Erythematosu
• Allergic Conjunctivitis
• Seborrheic Dermatitis ( can affect the same areas  does not
have pustules, but has a scale, does not have flushing)
• Carcinoid Syndrome (severe facial Flushing)

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Rosacea may be associated with enlargement of the nose from excess tissue, a condition
known as rhinophyma  includes thickening of the skin and irregular surface nodules
Rx
Early cases  antibiotics
Late cases  surgery

15. Alopecia Areata
Non-scarring autoimmune Alopecia - Most common
under age 30
Types
• Alopecia areata: Patches of Hair Loss
• Alopeca totalis: Hair Loss over entire scalp
• Alopecia universalis: Hair Loss over entire body
Signs  Well-demarcated oval patches of Hair
Loss
• Exclamation point hairs at edges of Hair Loss,
Club shaped Hair Root, Thin proximal Hair
Shafft, Normal caliber distal Hair Shaft
Lab Evaluation (Consider)
• KOH Scraping of patch
• Thyroid Stimulating Hormone (TSH)
• Rapid Plasma Reagin (RPR)
• CBC, ESR
• Antinuclear Antibody (ANA) and Rheumatoid
Factr (RF)
Differential Diagnosis  Other non-scarring
Alopecia , Tinea Capitis
Associated Conditions
• Atopic Dermatitis , Vitiligo , Thyroid disease
and Pernicious Anemia

16. Alopecia areata - Rx
Moderate Involvement (<50% of scalp involved)  DOC is
Intralesional ( not topical) Triamcinolone. Spontaneous
resolution occurs in most cases.
• Adjunctive therapy  Apply Minoxidil 5% solution twice daily
or Mid-potency Topical Corticosteroid (eg. Kenalog 0.1%)
Severe Involvement (>50% of scalp involved)  refer to
dermatology, use combination therapy with intralesional kenalog
+ topical contact sensitizer. Contact sensitizers  minoxidil 5%
with topical steroids or Anthralin
Prognosis: the following indicates poor prognosis
• Disease duration > one year
• Onset of Alopecia prior to Puberty
• Family History of Alopecia areata
• Atopic Patients
• Down Syndrome

17. Topical Corticosteroids

18. Topical Steroids
Corticosteroid Potency Selection
• Low potency topical Corticosteroids
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– Face , Groin , Intertriginous areas
Mid-potency topical Corticosteroids
– Thin skin trunk areas
– Extremity lesions
High potency topical Corticosteroids
( clobetasol 0.05%)
– Thick skin trunk areas
– Extremity lesions
Very high or super-potent
Corticosteroids
– Very thick-skinned areas
– Palms and soles
Adverse Effects of Topical
Steroids
• Percutaneous absorption
• Skin atrophy
• Steroid Acne
• Rebound papular dermatitis
after medium-high potency
– Avoid high potency steroid on
genital or face
• Striae formation
Fluorinated CS are more
effective but have high risk
of side effects

19. Vitiligo

20. Koebner Phenomenon - vitilgo

21. Treatment - Vitiligo
A. Localized Vitiligo (involving <20% of total body
surface area )
– Topical corticosteroids - first-line treatment in localized
vitiligo  Start with medium potency CS ( betamethasone
0.1)
– Calcipotriol can be used as adjunctive therapy but never as
monotherapy.
– Use tacrolimus, a topical T-cell immunomodulator
(calcineurin inhibitor), as an alternative to topical steroids in
the treatment of localized vitiligo.
B. Wide spread vitiligo ( > 50% depigmentation)
- Consider complete depigmentation using monobenzone
rather than repigmentation, especially if repigmentation
therapies have failed. If monobenzone fails  laser
repigmentation

22. Scabies

23. Scabies

24. Scabies - Clues
• Itching, particularly at night
• Family members, friends, or relatives with unexplained pruritus or scabies
• Recent visits to a nursing home, hospital, or day care center and the time
interval between onset of pruritus and the visit
Look for:
• Burrows
– Wavy, threadlike, grayish-white, skin elevations measuring 1 to 10 mm
• Excoriations , Vesicles , Indurated nodules , Eczematous dermatitis
• Common sites : the interdigital webbing of the hands , Axillae , Waist
Feet , Buttocks , areola in women, scrotal area in men
Examine Skin scrapings from suspicious lesions  put KOH in burrow, scrape
it and examine under microscope for mites or obtain skin biopsy from
burrows for diagnosis
In a patient with generalized pruritis  If the diagnosis is uncertain, obtain a skin
biopsy to look for mites and eggs within the stratum corneum of the
epidermis along with a dermal inflammatory infiltrate.

25. Mineral Oil Scraping Under Light
Microscope
• Shows fecal pellets (scybala) and eggs. These are
diagnostic even without a live mite

26. Scabies in Nursing Home pts
• As commonly happens, this patient's scabies was
misdiagnosed for many months as psoriasis

27. Scabies Drug therapy
• Choose one of the following agents:  Permethrin,
Lindane, Topical malathion , Benzyl benzoate or
Topical ivermectin
• Oral therapy – alternative to topical Rx - Ivermectin
• Apply the preparation overnight to the entire body
surface, regardless of the location of the lesions.
• Itching could persist for 2 weeks after successful
treatment because the dead mite and its antigens
gradually slough off with the dead skin layers 
Reassure patients about this!
• Treat all family members and close contacts, even if
they are unaffected or asymptomatic, simultaneously 
Asymptomatic mite carriers in the household are very
common and are the reason for recurrence

28. Lichen Planus
White lacy WICKHAM
STRIAE are your clue for
diagnosis.
May have pruritic cutaneous
Papules on body
No RX required as most forms
are asymptomatic.
Erosive form of lichen planus
can cause pain  Erosive
form is treated with topical
steroids.
Diagnosis
• Biopsy lichenoid lesions!

29. Advise Pts – Lichen Planus
• Advise patients to avoid scratching cutaneous
lesions and eating Irritant food ( sharp-edged,
spicy, or acidic food ) as trauma can lead to
spread of lesions ( Kobner phenomenon)
• If pruritic papules are present, use oral
antihistamines to reduce pruritus.

30. This patient has joint pains and scaly patch behind his ear.
What is the most likely cause of his findings?

31. Psoriasis
• Plaques characterized by Scaling, erythema and induration.
• Chronic plaque psoriasis : erythematous, thick plaques with silvery scale,
can be found anywhere on the body.
• Guttate Psoriasis : mostly seen on the trunk, multiple , small drop-like
papules and plaques
• Erythrodermic Psoriasis  severe erythema, scaling involving most of the
body surface / exfoliation of skin can occur leading to fluid loss and
infections
• Common areas affected  scalps, ears, nails, intertriginous
folds and flexural surfaces.
• Nail changes  pitting, thickening or yellowing
• Joints  arthritis, tendonitis, dactylitis ( DIP joint
inflammation, sausage shaped finger), “pencil-in cup”
deformity on the x-ray ( occurs when the distal end of the
bone becomes pointed appearing as if it had been sharpened
and the surrounding articular surfaces become “saucerized”
due to “Erosions”. Also, seen in RA )

32. Psoriasis - Rx
• Localized plaques  topical corticosteroids. Can
be alternated with anthralin, tar preperations,
retinoids or topical vitamin D analogs. Never
use systemic corticosteroids
• Plaque or Guttate psoriasis involving more than
5% body area or in case of poor response to
topical agents  use phototherapy.
• Erythrodermic Psoriasis  refer to
dermatologist STAT – it’s a dermatological
emergency!

33. Atopic dermatitis
• Picture – on forearm
• Rx

34. Tinea cruris + picture
• Test to diagnose ? – koh preperation

35. A 25 y/o man presents with the lesion shown on his lower lip.
What is the treatment?

36. Herpes Labialis
• Caused by Herpes simplex Virus Type I.
• Most people are asymptomatic but only few
people have recurrent outbreaks.
• Triggers for outbreak are cold weather, stress,
trauma.
• Rx
• Topical Penciclovir as your first choice.
• Recurrent severe cases can be treated with oral Acyclovir.

37. A healthy 20 year old female come with history of paroxysmal lip swelling. In the past , her doctor
tried solumedrol and benasdryl but they never seem to make it better. She says the swelling comes
and goes spontaneously. She has had negative skin prick testing

38. Angioedema
• Angioedema is a skin reaction similar to hives or urticaria.  characterized by an
abrupt and short-lived swelling of the skin and mucous membranes  Any body
part may be affected but swelling most often occurs around the eyes and lips, In
severe cases the upper respiratory tract and intestinal mucosa may also be affected.
 Can be hereditary or acquired
• Know about ACEI induced angioedema – no more ACEI or ARBs
• Know thEe main differences b/w urticaria and Angioedema
1.Tissues involved: Angioedema Subcutaneous and submucosal surfaces(beneath the
dermis). Urticaria involves only the epidermis (outer layer of skin) and dermis (inner
layer of skin)
2.Organs affected: Angioedema involve skin and mucosa, particularly the eyelids and
lips . Urticaria involves skin only
2.Duration: Angioedema is Transitory (usually lasts between 24-48 hours). Urticaria is
transitory (usually lasts < 24 hours)
3. Physical signs: Angioedema involves red or skin coloured swellings occurring
below the surface of the skin. Urticaria has Red patches and weals on the surface of
skin
4. Symptoms: Angioedema may or may not be itchy. Often accompanied by pain and
tenderness. Urticaria is usually associated with an itch -Pain and tenderness
uncommon.

39. Hereditary Angioedema
• Hereditary Angioedema  occurs due to
deficiency of c1 esterase inhibitor
• Diagnosis of HAE  C1 inhibitor level is low,
C4 level is low (C1-INH deficiency allows autoactivation of C1, with consumption of C4 and
C2 )
• Rx depends on the type.
• If it is hereditary you need to give C1 inhibitor
concentrate. If C1 concentrate is not available, give FFP.
Alternatively, you can use high dose steroids like Danazol.
• If laryngeal edema/ stridor  intubate!

40. Genital Warts
Only Pics
Therapy – refer I.D Slides

41. Genital warts - The real HPV Differentiate from Benign Lesions

42. Pearly Penile Papules - A benign Lesion at corona - do not
confuse with Warts! – Reassure patients!

43. Fordyce Spots - vulva – These are Sebaceous glands do not confuse with warts!

44. Scabies can occur in Genital Areas Do not confuse with warts!
• Questions like this are common on
Step 3. A genital scabies should not
be confused with other conditions
like warts, syphilis etc. Look for
clues in the history carefully - such
as itching especially in the nights,
family members with similar
problems. Also, look at other sites
on body - finger webs etc for
burrows which is typical of scabies.
• Look at finger webs! Common site
of involvement - scabies

45. Q.
• A 46-year-old fisherman and Vietnam veteran presented with a recurrent rash
on his arms and legs and a painful, swollen area on his left leg of several days'
duration. The rash had been a problem for about two years and was treated
with several courses of antibiotics for cellulitis. The patient reported that for
the past two years his skin had been prone to blister and tear with minor
trauma and that at times his urine appeared to be dark reddish in color. On
examination, he had a slight fever and an area of cellulitis on his left leg. His
face was erythematous. On his hands, arms, and legs were vesicles and small
bullae, some crusted lesions, and hypopigmented and hyperpigmented
macules. What is the most important next step in diagnosis?
• A. ANA
• B. Rheumatoid factor
• C. Skin biopsy
• D. Hepatitis C serology
• E. Hepatitis B serology

47. Porphyria Cutanea Tarda
• PCT is due to a defective enzyme (uroporphyrinogen
decarboxylase) in liver . ( the enzyme is involved in hem
synthesis)
• Genetic predisposition present
• PCT begins in mid-adult life especially after exposure to
substances that increase the production of porphyrins
(precursors of haem) in the liver.
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alcohol
oestrogen e.g. oral contraceptive, hormone replacement or liver disease
polychlorinated aromatic hydrocarbons (e.g. dioxins)
iron overload, due to excessive intake (orally or by blood transfusion), viral
infections (hepatitis) or chronic blood disorders such as thalassaemia
(acquired haemochromatosis), or hereditary haemochromatosis

48. C/F and Rx
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Sores (erosions) following relatively minor injuries
Fluid filled blisters (vesicles and bullae)
Tiny cysts (milia) arising as the blisters heal
Increased sensitivity to the sun
Characteristically, the urine is darker than usual, with a reddish or
tea-coloured hue
• If asked on the exam, consider the diagnosis of Hepatitis C infection
( imp association)
• DX – Elevated urinary porphyrins, wood’s light on urine gives
marked fluorescence
• RX
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Avoid alcohol
Use tanning creams in sun and avoid sun in acute flare.
Discontinue estrogens
Therapeutic phlebotomy to reduce iron stores (this improves heme synthesis
disturbed by ferroinhibition of UROD. )
• In patients in whom phlebotomy is not convenient or is contraindicated and in
those who have relatively mild iron overload  use oral chloroquine phosphate
(or ) hydroxychloroquine sulfate

49. Erythema Multiforme
• Target lesions
• Etiology : drugs ( penicillamine, sulfa) , HSV
• Rx the etiology – corticosteroids are not
effective.

50. Erythema Nodosum
• Rx – NSAIDS
• Good prognosis in sarcoidosis
• Bad prognosis in ulcerative colitis

51. Actinic Keratoses
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Pre Malignant lesions for squamous cell carcinoma
Found more on sun exposed areas.
Flesh colored, red papules with whitish scale
Get biopsy
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If lesion > 5mm
Rapidly growing lesions
Thick, indurated papules
Lesions that grow rapidly in size
• Rx – If lesion looks suspicious for malignancy  excision is the
choice. For all others, Rx with cryotherapy or curettage
• If Actinic keratoses are numerous  use topical 5-Fluorouracil

52. Seborrheic Keratoses
• Stuck on appearacnce
• Yellowish, waxy plaques
• Benign lesions

53. Basal cell carcinoma
– Pink pearly papule with central ulceration – usually
on face
– Get biopsy
– Rx – MOHs micrographic surgery for BCC on face

54. Contact Dermatitis
• Inflammatory skin reaction resulting from DIRECT contact with an offending
agent. Two principal types:
• Irritant Contact Dermatitis ( ICD)
• Allergic Contact Deramatitis (ACD)
• ICD : Occurs from direct injury to the skin by a specific irritant.
• Acute ICD occurs immediately after exposure to the irritant ( acid, alkali)
and is associated with burning sensation, bright red edematous skin and
bullae/ vesicle formation.
• Chronic ICD occurs from prolonged exposure to a mild irritant (soaps
and prolonged exposure to water). This presents initially as dryness which
is followed by erythema and eventually, progress to lichenification,
cracking and formation of painful fissures. Edema is minimal
• ACD : Is strikingly different from ICD in the time of onset after exposure. ACD
occurs only in those people that were previously sensitized to the substance. It is
a delayed (cell-mediated, type IV) hypersensitivity reaction ( and presents within
24 to 72 hours after exposure to the allergen) ( poison ivy, nickel , potassium
dichromate). Associated with erythema, bullae formation and pruritis. Lasts for 3 to 4
weeks.

55. Contact Dermatitis
• Management :
• First step is to identify and avoid the irritant. – MOST
IMPORTANT STEP!
• Symptomatic treatment :
• Emollients ( petrolatum jelly) for chronic cases
• Wet compresses with an astringent such as Aluminium
acetate  gives soothing effect and helps pruritis
• H1 blockers (benadry) for erythema and itching
• Drug of choice for treating contact dermatitis are Topical
steroids eg: Triamcinolone acetate
• For severe cases ( contact dermatitis involving more than
10% of total body surface area or associated with
extensive bullae) eg: Prednisone orally  use at least for 2
to 3 weeks with slow tapering. Very short course can lead
to recurrence of the problem.

56. Subacute Contact Dermatitis from a mild irritant – like eg: Bacitracin in the first
picture and wool clothing in fig.2 – Note the prolonged exposure must have led to
dryness followed by erythema and lichenification
Fig # 1
Fig# 2

57. Nickel Contact Dermatitis
This boy presented with Itchy rash around the naval. Note the sharply
defined borders of the lesion consistent with the contact area of the
metal ( in this case, blue jeans button made of Nickel). Treatment is
Topical steroid and avoidance of nickel .

58. Question
• A 10 y/o boy is brought by his mother for extensive rash on his lower
extremities that started one day ago and has been worsening. There is no history
of fever . The family just returned four days ago from a camping trip and the
mother does not recall any exposure to ticks except that the boy stepped in to a
bush while walking downhill. On examination, there is extensive erythema along
with vesicles and bullae on the front and the back of bilateral lower extremities
up until the level of the knees. The upper portion of the lower extremities is
unaffected. The rest of the physical examination is normal. The best treatment
for the management of this child’s condition is :
• A. Topical triamcinolone
• B. Prednisone orally
• C. Ceftriaxone intra-muscular
• D. Diphenhydramine
• E. Observation

59. Ans. B
• Oral prednisone is the treatment of choice here
since the boy has greater than 10% involvement
of total body surface area and also, extensive
bullae.
• The lesions are too extensive for Topical steroid
use.
• Diphenhydramine may provide symptomatic
relief but will not address the underlying
pathology

60. Malignant Melanoma
• A 69-year-old woman was
evaluated for an enlarging
pigmented lesion of her right
cheek. A malignant lentigo
melanoma was clinically
suspected. Two biopsies were
performed with the help of
dermoscopy to outline the
borders of the lesion.
Pathology revealed a lentigo
maligna melanoma

61. RASHES
• All rashes – infectious
• Maculopapular etc

62. IMAGES
• OPHTHALMIC - Fundus
• DERM
• Some CT/ MRI