dermatology Flashcards
what is a Pyogenic Granuloma? how does it present?
What are the triggers for it ?
where does it mainly occur?
what important differential needs to be excluded ?
It is a benign rapidly growing tumour of capillaries that presents as a discrete lump with a red or dark appearance that grows rapidly upto 1-2 cm in size.
Triggers:
Follows trauma
pregnancy
hormonal contraception
infection
occurs on fingers/ upper chest/ back / neck/ head
Nodular melanoma needs to be excluded
what are the areas commonly affected by acne rosacea ? how does it present
typically affects nose, cheeks and forehead
first symptom : flushing
telangiectasia : common
develops into erythema with papules and pustules
how would you manage acne Vulgaris that has not responded to topical and oral therapies
refer to dermatology for prescription of Isotretinoin
what is an alternative to tetracyclines that can be used in pregnant women for the management of acne vulgaris
erythromycin
how does idiopathic livedo reticularis present
purple, lace patterned discolouration of the skin and worsening of the symptoms in the cold.
how does miliaria present
rash characterised by small, raised spots that are often red on white skin and colourless on brown and black skin
what is the first line management of scalp psoriasis
topical corticosteroid
what is the Koebner phenomenon ? What conditions does it appear in?
skin lesions that appear at the site of injury
psoriasis, vitiligo, warts, lichen planus, lichen sclerosus, molluscum contagiosum
what is guttate psoriasis
psoriatic condition clasically occuring after infections such as strep throat
how soon after an strep infection does guttate psoriasis present
2-4 weeks after infection
how does a venous ulcer present ?
aching lower limb
ulceration in the ‘‘gaiter region’’
night cramps or cramps that occur after sitting or active standing
symptom relief from leg elevation
skin discolouration
how do you investigate a venous ulcer ?what value indicates arterial disease ?
ABPI ( Value < 0.9 indicates arterial disease)
what is the management of venous ulcer
compression bandage
what is the difference between bullous pemphigoid and pemphigus
Both are auto-immune blistering disorders affecting the elderly.
a Pemphigus presents with blisters and erosions involving the mucous membranes whereas a pemphigoid does not involve the mucosa
which parts does rosacea affect
nose cheeks and forehead
give 3 features of rosacea
flushing, Erythema, telangiectasia
how is pityriasis versicolor managed
Ketoconazole shampoo
give 4 features of pityriasis versicolor
affects trunk
hypo-pigmented, pink or brown patches
more prominent after a suntan
scale
pruritis
first line management of scabies
Permethin
what is Nikolsky sign ? In which condition is it present ?
Blisters and Erosions that appear when the skin is rubbed gently . Seen in Stevens Johnson syndrome, toxic epidermal necrolysis
what is the classical sign seen in Erythema multiforme
Target sign
what is Erythema Multiforme triggered by
Infection
What is Actinic Keratosis
It is a common Pre-malignant condition that develops as a consequence of chronic sun exposure.
where does actinic keratosis commonly occur and how does it present ?
Small crusty or scaly lesions on sun exposed areas like the temple of head
what are the management options for actinic keratosis
prevention : Sun cream
Florouracil : 2-3 week course
topical diclofenac / topical imiquimod
whats a condition that features hair loss after pregnancy
Alopecia areata
give 3 features of pyoderma gangrenosum
Initially a small red papule
followed by deep, red, necrotic ulcer with a violaceous border
idiopathic in 50% of cases and can be seen in IBD, Connective tissue disorders and Myeloproliferative disorders
A man presents with a growing round raised flesh colored lesion with central depression and Telangiectasia . What is the diagnosis ?
BCC
which condition presents with the formation of corkscrew shaped collateral vessels distally- What is the strongest association for this condition
Buerger’s disease
smoking
what is the treatment of -
mild/moderate acne Rosacea
severe/ resistance Rosacea
mild : Topical Ivermectin
Severe/ resistant : combination of topical Ivermectin and oral doxycycline
which is the single most important prognostic factor in malignant melanoma ?
Invasion of the tumour
2 key features of Toxic epidermal necrolysis
systemically unwell ( pyrexia, tachycardia)
Positive Nikolsky’s sign : epidermis separates with mild lateral pressure
name 2 complications of toxic epidermal necrolysis
Volume loss
Electrolyte derangement
name 6medication triggers of TEN
PSA PCN
Phenytoin
Sulphonamides
Allopurinol
Penicillins
Carbamazepine
NSAIDs
Under what circumstances would you refer a patient with molluscum contagiosum
HIV +ve with extensive lesions
what is the name of the rash caused by TB
Erythema nodosum
which malignancy is most commonly associated with acanthosis nigricans
Gastrointestinal adenocarcinoma
first line treatment for non bullous impetigo
Hydrogen peroxide 1% cream
do you need a break when prescribing topical steroids in patients with psoriasis ?
yes, 4 week break in between courses
what is the antibiotic of choice for acne in pregnancy? Can it be used alone
Oral erythromycin, to be used with Benzoyl peroxide. do not use Abx alone as it can lead to antibiotic resistance.
which medications should not be used in combination in the management of acne vulgaris
Topical and oral antibiotics
what is an alternative to oral antibiotics in the management of acne in women
COCP
_____________ is a contraindication to topical and oral retinoid treatment
pregnancy
what is the first line management of mild-moderate acne
12 week course of topical combination therapy such as :
- topical adapalene with topical benzoyl peroxide
- Topical tretinoin with topical clindamycin
- topical benzoyl peroxide with topical clindamycin
which malignancy are patients who have undergone renal transplant most at risk of developing
skin cancer ( Squamous cell carcinoma)
What is the first line medical manegement of actinic keratosis
Florouracil cream ( 2-3 week course)
what are Curling’s ulcers ? How do they present ?
Gastric ulcers that develop in response to severe physiological stress such as burns. presents as haematemesis
give 3 characteristic features of acne vulgaris
Open and closed comedones
Pustules
Nodules
Name 5 nail changes that may be present in psoriasis
Pitting
Onycholysis
Subungal Hyperkeratosis
loss of the nail
dactylitis and enthesitis
name 5 nail changes that maybe seen in psoriasis
Pitting
Onycholysis ( seperation of nail from nail bed)
subungual hyperkeratosis
loss of the nail
dactylitis and enthesitis
what is the first line management of Bowens disease
5- Fluorouracil
where is venous ulceration most commonly seen
above the medial malleolus
what medications exacerbate psoriasis
MALIN B
( anti) Malarials
ACEi
Lithium
Infliximab
NSAID’s
Beta blockers
what is the nature of inheritance of hereditary haemorrhagic telangiectasia ? describe it.
autosomal dominant. Characterised by telangiectasia over the skin and mucous membranes as well as features like epistaxis, visceral lesions and a family history
what are the 4 diagnostic criteria used to diagnose HHT
- Epistaxis : Spontaneous, recurrent nosebleeds
Telangiectasias : multiple at different sites ( Lips, oral cavity, fingers, nose)
visceral lesions ( AVM’s)
Fhx : 1st degree relative
how would you differentiate pyogenic granuloma from amelanotic melanoma
pyogenic granuloma has a history of trauma
how do you investigate contact dermatitis
Patch testing
how long does it take for the pityriasis rosea rash to resolve
6-12 weeks
classical sign of pityriasis rosea
herald sign
Wikham striae are present in which condition
lichen planus
which gi condition is pyoderma gangrenosum associated with
IBD
which condition is high voltage burns associated with ?
Rhabdomyolysis
what are the 2 types of Comedones
top closed–> whitehead
top open –> blackhead
when follicles burst releasing irritants, the following types of inflammatory lesions are formed
nodules and cyst
what are the 2 types of scars that can be formed due to excessive inflammatory response in acne vulgaris
ice pick scars
hypertrophic scars
what is acne fulminans
severe acne associated with systemic upset ( fever)
what is a consequence of long term antibiotic use in acne. how do you treat this
gram negative folliculitis. treat with high dose oral trimethoprim
________ is a contraindication to topical and oral retinoid treatment
Pregnancy
To reduce the risk of antibiotic resistance developing the following should not be used to treat acne:
-monotherapy with a topical antibiotic
-monotherapy with an oral antibiotic
-a combination of a topical antibiotic and an oral antibiotic
what is the management of mild to moderate acne that has not responded to 2 completed courses of treatment
consider referral
what is the first line management of plaque psoriasis ?
potent corticosteroid such as betamethasone applied once daily plus vitamin D analogue applied OD
what are dermoid cysts and what can they be lined by
embryological remnants and may be lined by hair and squamous epithelium
what are the 4 p’s of lichen planus
purple
pruritic
papular
polygonal
how do you manage dermatophyte nail infections
oral terbinafine
which medications can cause depigmentation in patients with darker skin
topical corticosteroids such as clobetasone
what is the management of mild to moderate acne rosacea with pustules and papules ?
Topical ivermectin
what is the management of moderate to severe papules and pustules
combination of topical ivermectin and oral Doxycycine
how is erythema and flushing managed in acne rosacea ?
Topical brimonidine gel
which condition presents with orange peel shins
graves disease
How many weeks should be given between courses of topical corticosteroids
4 week break
what is the first line management of chronic plaque psoriasis ? How long is the treatment continued ?
potent corticosteroid applied once daily plus vitamin D Analogue applied once daily - for up to 4 weeks
what is the first line management of urticaria
non sedating anti histamines such as certizine
what is used for severe / resistant cases of urticaria
Prednisolone
what is used in the long term management of chronic plaque psoriasis
vitamin D Analogues such as calcipotriol, calcitriol
which medications exacerbate psoriasis
beta blocker
lithium
anti malarial
NSAIDs
ACEi
Infliximab
which malignancy are patients who undergo renal transplant at risk of
squamous cell carcinoma of the skin
what test is most appropriate for diagnosing contact dermatititis ?
Skin patch testing
what type of hypersensitivity reaction is allergic contact dermatitis?
Type 4
which factors may exacerbate psoriasis
trauma
alcohol
drugs
withdrawal of systemic steroids
what are school exclusion rules for impetigo?
exclude child from school until the lesions are crusted over and healed / 48 hours after commencing antibiotic treatment
what medications can be used in severe impetigo?
Oral flucloxacillin
oral erythromycin if penicillin allergic
where does erythema nodosum most commonly occur?
shins
what is the main cause of actinic keratosis
chronic sun exposure
what factors can worsen acne rosacea ?
alcohol
sunlight
give 2 precipitating factors of pompolyx
humidity ( sweating)
high temperatures
how does pompholyx present?
small blisters on palms and soles
pruritis - intensely itchy/ burning sensation
how do cherry hemangiomas present ?
small bright red raised bumps usually found on the skin of adults over 30 years
how does pemphigoid gestationis present ? At what stage of pregnancy do they present? what is the management ?
pruritic blistering lesions in periumbilical region later spreading to trunk, back , buttocks and arms.
2nd/3rd trimester
oral corticosteroids
how do you distinguish polymorphic eruption of pregnancy from pemphigoid gestationis?
polymorphic eruption of pregnancy : no blistering
pemphigoid gestationis : blistering
what is the commonest skin disorder of pregnancy
atopic eruption of pregnancy
give 3 skin disorders associated with pregnancy
atopic eruption of pregnancy
polymorphic eruption of pregnancy
Pemphigoid gestationis
how does atopic eruption of pregnancy present ?
itchy erythematous papules on face, neck , chest and extensor surfaces of the limbs
urticaria not being managed with cetirizine?
add 5 day course of oral prednisolone
what type of medication is used for urticaria ? give an example.
non sedating anti-histamine such as loratadine
what is the antihistamine of choice for chronic urticaria?
Fexofenadine
when should early intubation be considered in the management of burns
deep burns to the face or neck, blisters or oedema of the oropharynx, stridor etc.
what is the most common cause of erythema multiforme?
herpes simplex virus
which drugs can precipitate erythema multiforme?
Penicillin
Sulphonamides
Carbamezapine
allopurinol
NSAID’s
oral contraceptive pill
nevirapine
what is erythrasma? what is it caused by ? what is the first and second line management ?
asymptomatic, flat, slightly scaly pink or brown rash generally found in groin or axillae.
caused by an overgrowth of diptheroid cornyebacterium mutissimum.
1st line : topical miconazole
2nd line: oral erythromycin
which is the most aggressive kind of melanoma
Nodular melanoma
which is the most common subtype of melanoma
superficial spreading
what virus is molluscum contagiosum caused by?
Poxvirus
what are 2 complications of seborrhoeic dermatitis?
Otitis externa
Blepharitis
give a list of causes of erythema nodosum
NODOSUM
NO cause ( Idiopathic)
Drugs ( sulphonamides)
Oral contraceptive pill
Sarcoidosis
UC , Crohns
Microorganisms : TB, Streptococcus, toxoplasmosis
give a short history on how pityriasis rosea may present ?
acute, self limiting rash caused by HHV-7 , some may give a history of a viral infection followed by a herald patch and erythematous, oval scaly patches. generally self limiting.
what are keloid scars ?
tumour like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound
what ethnicity are keloid scars more common in?
dark skin
what is the management of keloid
early - intralesional steroids
late-excision
what is a differential of keratoacanthoma
squamous cell carcinoma
what are the features of keratoacanthoma?
looks like volcano or crater
smooth dome shaped papule that grows to become a crater centrally filled with keratin.
what are the characteristic features of granulomatosis with polyangiitis
haemoptysis
sinusitis
nasal discharge
malaise
joint pain
vasculitic rash
2 key features of eosinophilic granulomatosis with polyangiitis
asthma and eosinophilia
what are the characteristic features of polyarteritis nodusa
non specific features
history of hepatitis b
which skin types are squamous cell carcinomas most common in
Fitzpatrick skin types 5,6
what is the key feature of a dermatofibroma?
it is an asymptomatic papule that dimples when squeezed
A GP needs to prescribe medication for severe acne ? what is an appropriate treatment regime ?
Topical retinoid + Topical benzoyl peroxide + oral doxycycline
what are the 2 key clinical features of dermatomyositis
muscle weakness
skin manifestations
give 5 skin manifestations of dermatomyositis
heliotrope rash - lilac discolouration around eyes
Gottron’s papules - purple nodules on knuckles
Shawl rash / sign - fixed erythematous rash on torso
V sign - photosensitive rash on chest
nailfold erythema
what is the diagnostic investigation for dermatomyositis
muscle biopsy
what antibodies and markers may be present in dermatomyositis ?
Anti-Mi2
Anti-Jo1
Anti SRP
CK, ALT, AST, LDH
give 2 ways dermatomyositis is managed ?
oral steroids
malignancy screening
give 5 side effects of ciclosporin
hypertrophy of gums
hypertrichosis
hypertension
hyperkalaemia
hyperglycaemia
give 2 medications used in the systemic management of chronic plaque psoriasis
methotrexate
cyclosporin
give 5 cutaneous manifestations of SLE
Malar rash - butterfly rash
Discoid Lupus Erythematous
photosensitivity
alopecia
ulcers and vasculitis
what is the first and second line management of cellulitis and the management if patient is pregnant
1st line Flucloxacillin
2nd line Doxycycline / Clarithromycin
pregnancy Erythromycin
what is erythroderma? what are its triggers? how would you investigate and manage it.
dermatological emergency with widespread erythema affecting > 90% of skin surface.
signs and symptoms include skin redness and systemic symptoms.
triggers include
dermatitis
psoriasis
drug allergies
investigation and management includes fluid replacement and emollients alongside treatment of underlying cause.
what other manifestations can be present in acne rosacea apart from skin manifestations?
ocular features such as blepharitis and conjunctivitis
rhinophyma - swelling of nose
what is auspitz sign
pinpoint bleeding on removal of a layer of scale seen in chronic plaque psoriasis
what are some causes of acanthosis nigricans
T2DM
Gi cancer
PCOS
Obesity
endocrine disorders like acromegaly, Cushing’s, Hypothyroidism
what is tinea? what is it characteristically known as ? how is it managed?
Superficial fungal infection caused by dermatophytes. It is commonly known as ringworm due to its characteristic ring shaped rash.
managed with topical antifungals such as clotrimazole and ketoconazole.
give the treatment summary for eczema
- Mild : emollients + mild topical corticosteroid ( such as hydrocortisone 1%)
- Moderate eczema : emollients + moderate topical steroid ( Clobetasone butyrate 0.5% ( Eumovate)) for 5 days + hydrocortisone for face
severe eczema : emollients + strong topical steroid ( Betamethasone valerate 0.1% ( Betnovate) ( Eumovate for face)
what is CREST syndrome ? What is it also known as ? What antibodies are present ?
Calcinosis
Raynauds
oEsophageal dysmotility
Sclerodacyly
Telangiectasia
Also known as systemic sclerosis
ANA +ve
Anti centromeric antibodies
what medications trigger Stevens Johnsons syndrome
sulfonamides
beta lactams - penicillins and cephalosporins
antiepileptics
allopurinol
NSAIDs
what are the classical features of SJS
symptoms of a URTI
mucosal ulceration and erythematous macules
what are the warning signs of malingnant melanoma
Asymmetry
Borders ( irregular)
Colour variegation
Diameter > 6 mm
Elevation
how much of the skin surface is affected in Erythroderma ?
Erythema of > 90% of the skin
which cancer can actinic keratosis precede ?
Squamous cell carcinoma
what pathogen causes scabies
sarcoptes scabiei
give the clinical manifestations of lichen planus
purple
pruritic
papular
polygonal
planar
how would you distinguish between plaque psoriasis and atopic eczema
atopic eczema presents with an erythematous pruritic dry rash whereas plaque psoriasis presents with silver scale plaques
What bacteria is folliculitis caused by ? how does it present
staphylococcus aureus
pustules and papules
in which patients does eosinophilic folliculitis occur
immunosuppressed patients - hiv
how does a pyogenic granuloma present ? where does it most commonly occur ?
single, shiny red nodule described as raspberry like
generally located on fingers and hands
give 4 causes of pyogenic granuloma
minor trauma ( pin prick)
infection ( Staph. Aureus)
pregnancy
medications like oral retinoids
which disorders need to be screened for before commencing isotretinoin
mental health disorders
what is erythema ab igne
chronic skin condition caused by prolonged exposure to infrared radiations - often with a history of prolonged hot water bottle use.
what is erythema toxicum
common rash seen in newborn infants on face, chest, arms and legs presenting in the first few days after birth
what is erythema migrans
underlying lyme disease
bulls eye appearance
how do you manage staphylococcus skin scalded syndrome ?
IV flucloxacillin
how is pyoderma gangenosum managed
high dose oral corticosteroids / other immunosuppressives
would care
what type of reaction is allergic contact dermatitis
delayed type 4 hypersensitivity reaction mediated by t lymphocytes
what is the nature of inheritance of tuberous sclerosis
autosomal dominant
what are some key manifestations of tuberous sclerosis
angiofibromas : dome shaped papules in butterfly distribution
ashleaf macules : hypopigmented skin
shagreen patch: leathery plaque on sacrum
ungal fibromas : fleshy tumours that grow from the nail folds
cafe au lait spots : hyperpigmented macules on the body
how is lichen planus with oral involvement managed
potent topical steroids and benzydamine mouthwash
what is a classical feature of pemphigus vulgaris
involvement of the oral mucosa
distinguish between pemphigus vulgaris and bullous pemphigoid
bullous pemphigoid
negative nikolsky’s sign
mucous membrane spared
itchy rash with tense blisters
pemphigus vulgaris
+ve nikolsky’s sign
mucous membrane may be involved
thin walled blisters causing erosions
both treated with topical potent steroids
what is the name of the term used to predict recurrence of a melanoma
Breslow thickness - measures the depth of the melanoma from the top of the granular layer of the epidermis to the deepest cancerous cell
which condition causes a scarring alopecia
folliculitis decalvans
what type of an appearance does have an arterial ulcer have
punched out appearance
how long does it take for molluscum contagiosum to clear up spontaneously
18 months
which medication is used to manage symptoms of dermatitis herpetiformis
dapsone
which part of the body is spared by folliculitis
hands
smoking - rf for bcc or scc
scc
how is shingles managed in immunocompromised patient
valaciclovir
what is the management of pyoderma gangrenosum
Oral steroids such as oral prednisolone
which conditions are associated with seborrheic dermatitis
HIV
Parkinson’s
what is the management of genital warts ?
Podophyllotoxin
what are features of arterial ulcers ?
'’punched out appearance’’
faint dorsalis pedis pulse
history of HTN - other features of PAD
distally occurring
Small and deep
what are features of venous ulcers ?
gaiter region
large and shallow
bleeding / oozing
other features of chronic venous insufficiency
investigation and diagnosis for arterial and venous ulcers
ABPI
<0.9 arterial disease
what is the management for arterial and venous ulcers ?
lifestyle factors
compression stockings
what is periorificial dermatitis
clustered erythematous papules and papulopustules in the perinasal , periocular region
management of perioroficial dermatitis
topical or oral abx
which complications are persons with psoriatic arthritis at higher risk of
cardiovascular disease
salmon patch
pink coloured vascular skin lesion that blanches on pressure
port wine stain
unilateral, deep red or purple that darken and become raised over time
sebaceous cysts
located in the scalp, contains central punctum
most common side effect of isotretinoin
dry skin
important side effect of ketoconazole
gynaecomastia
sign of acute deterioration in erythroderma
sob
what is pellagra caused by ? how does it present?
nicotinic acid deficiency
Presents with - dermatitis, diarrhoea, dementia due to isoniazid therapy
how to differentiate hypertrophic and keloid scars
hypertrophic = do not extend past margins of damaged skin
keloids = extend past margins of damaged skin
what is a dermatofibroma
common fibrous skin lesions often after a precipitating injury . common areas include arms and legs
solitary firm papule or nodule typically on a limb
keratoacanthoma
characteristic cap made of keratin scale and debris
what is alopecia areata
auto-immune condition causing localised well demarcated patches with small broken exclamation hair marks at the edge
pathophysiology of dermatitis herpetiformis
formation of IgA antibodies
Keloid scars are most common on the
sternum
what are the types of burns
superficial epidermal ( first degree) : red and painful, dry and no blisters
partial thickness - superficial - blistered and pink
partial thickness - deep dermal - white with areas of non blanching erythema with reduced sensation
full thickness - white and leathery, no blisters and no pain
how to assess the extent of burns
Wallace’s rule of nines
Lund and Browder - most accurate = palmar surface is equal to approx 1% of body surface
first aid management of burns
ABC
heat - remove source, irrigate within 20 mins for 10-30 mins and wrap using clingfilm
electrical - switch off source and remove person from the source
chemical - brush any powder off then irrigate with water
when do you refer burns to secondary care
all deep dermal and full thickness burns
face , feet, genitalia involved
inhalation injury, electrical or chemical
superficial burns that involve < 3% TBSA in adults or > 2% TBSA in children
Initial management of burns
superficial epidermal: symptomatic relief - analgesia, emollients etc
superficial dermal: cleanse wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours
wallaces rule of nines
head + neck = 9%
each arm = 9%
each anterior part of leg = 9%
each posterior part of the leg = 9%
anterior chest = 9%
posterior chest = 9%
posterior abdomen = 9%
what are the features of lipomas
smooth, mobile painless mass
what features are suggestive of liposarcomas
size > 5 cm
increasing size
pain
deep anatomical location
at what size is a suspected lipoma imaged
> 5 cm due to suspicion of liposarcomas
management of tinea pedis
topical miconazole
causes of hirsutism
Cushing’s syndrome
congenital adrenal hyperplasia
androgen therapy
obesity: thought to be due to insulin resistance
adrenal tumour
androgen secreting ovarian tumour
drugs: phenytoin, corticosteroids
which medications are associated with the development of spider naevi
COCP
zinc deficiency
hypogonadotrophic hypogonadism
perianal dermatitis
management of prominent telangiectasia in acne rosacea
laser therapy
The Koebner phenomenon describes skin lesions that appear at the site of injury. It is seen in:
psoriasis
vitiligo
warts
lichen planus
lichen sclerosis
molluscum contagiosum
management of vitiligo
sunblock
topical corticosteroids
topical tacrolimus and phototherapy
management of tinea
topical antifungal such as terbinafine
management of hirsutism in pcos
eflornithine
types of contact dermatitis
irritant contact dermatitis - non-allergic reaction ,erythema and crusting
allergic contact dermatitis - type 4 hypersensivity, eczema
curlings ulcer
stress ulcers occuring in the duodenum of burns patients and more common in children
what type of reaction is scabies
delayed type 4 hypersensitivity reaction
dermoid cysts
embryological remnants that may be lined by hair and squamous epithelium , dumbell shaped
desmoid tumours
develop in ligaments and tendon, aggressive and should be managed like sarcomas
management of squamous cell carcinomas
surgical excision with 4 mm margins if lesion < 20 mm
if tumour > 20 mm, then margins should be 6 mm
Mohs micrographic surgery in high risk / cosmetically important sites
athletes foot mx if imidazole fails
oral terbinafine
