dermatology Flashcards

Question

Plaque psoriasis

Answer 1

thickened erythematous plaques with silver scales, commonly seen on the extensor surfaces and scalp. The plaques are 1cm – 10cm in diameter. Most common form of psoriasis in adults

Answer 2

commonly occurs in children. - many small raised papules across the trunk and limbs - mildly erythematous and can be slightly scaly. - RAINDROPS - over time the papules -> plaques. - often triggered by a STREPTOCOCCAL THROAT INFECTION, stress or medications. - resolves spontaneously within 3 – 4 months.

Answer 3

rare severe form of psoriasis where pustules form under areas of erythematous skin. The pus in these areas is not infectious. Patients can be systemically unwell. Medical emergency -> admission to hx

Answer 4

infection (espesh guttate) local skin injury - Koebner phenomenon (KP) = is the appearance of new skin lesions on previously unaffected skin secondary to trauma obesity smoking alcohol stress HIV

Answer 5

BBs lithium antimalarials abx NSAIDs ACEi Anti TNFs systemic steroid withdrawal

Answer 6

small points of bleeding when plaques are scraped off

Answer 7

nail pitting leukonychia (white nails) thickening, discolouration, ridging onycholysis (separation of the nail from the nail bed)

Answer 8

ie. inverse psoriasis - in axilla, groin, breasts etc well demarcated shiny smooth plaques often lacking scale fissuring

Answer 9

things that increase the risk of CVD -particularly obesity, hyperlipidaemia, HTN and DMT2

Answer 10

topicals = emollients steroids coal tar vitamin D analogues calcineurin inhib phototherapy conventional systemics = ciclosporin methotrexate acitretin biologics = all the -umabs

Answer 11

where a disproportional immune response causes epidermal necrosis -> blistering and shedding of the top layer of skin. Generally SJS affects <10% of body surface area + TEN affects >10%

Answer 12

Medications = Anti-epileptics Antibiotics Allopurinol NSAIDs Infections = Herpes simplex Mycoplasma pneumonia Cytomegalovirus HIV

Answer 13

spectrum of severity px start with non-specific symptoms of fever, cough, sore throat, sore mouth, sore eyes and itchy skin. then develop a purple or red rash that spreads across the skin and starts to blister. a few says after this skin starts to break away + shed leaving the raw tissue underneath pain, erythema, blistering to lips + mucus membranes irritates + ulcerated eyes can also affect the urinary tract, lungs and internal organs

Answer 14

medical emergencies - admitted to a suitable dermatology or burns unit for treatment. Supportive care - nutritional care, antiseptics, analgesia and ophthalmology input. Treatment options include steroids, immunoglobulins and immunosuppressant medications guided by a specialist.

Answer 15

hives - small itchy lumps that appear on the skin (maybe w rash, angioedema and flushing of the skin) caused the release of histamine and other pro-inflammatory chemicals by mast cells in the skin (type 1 reaction - exaggerated IgE mediated immune responses) - may be part of an allergic reaction in acute urticaria or an autoimmune reaction in chronic idiopathic urticaria.

Answer 16

triggered by something that stimulates the mast cells to release histamine. This may be: Allergies to food, medications or animals Contact with chemicals, latex or stinging nettles Medications (common culprit drugs are the 'As': anticonvulsants, antibiotics, anti-inflammatories (NSAIDs), and allopurinol) Viral infections Insect bites Dermatographism (rubbing of the skin)

Answer 17

an AI condition where autoantibodies target mast cells and trigger them to release histamines and other chemicals Chronic idiopathic urticaria Chronic inducible urticaria Autoimmune urticaria (w other condition)

Answer 18

Sunlight Temperature change Exercise Strong emotions Hot or cold weather Pressure (dermatographism)

Answer 19

non-sedating antihistamines (e.g. loratadine or cetirizine) - for up to 6 weeks following an episode a sedating antihistamine (e.g. chlorphenamine) may be considered for night-time use (in addition to day-time non-sedating antihistamine) for troublesome sleep symptoms CKS prednisolone is used for severe or resistant episodes

Answer 20

an infection of the skin and the soft tissues underneath will be breach in skin barrier

Answer 21

Erythema Warm or hot to touch Tense Thickened Oedematous Bullae (fluid-filled blisters) A golden-yellow crust indicates a staph aureus infection systemically unwell - sepsis?

Answer 22

Staphylococcus aureus Group A streptococcus (mainly streptococcus pyogenes) Group C streptococcus (mainly streptococcus dysgalactiae) consider MRSA

Answer 23

Class 1 – no systemic toxicity or comorbidity Class 2 – systemic toxicity or comorbidity Class 3 – significant systemic toxicity or significant comorbidity Class 4 – sepsis or life-threatening infection

Answer 24

class 3/4/v old/v young/immunocomp/near face= admission for IV abx abx = FLUCLOXACILLIN (oral or IV) alts = Clarithromycin Clindamycin Co-amoxiclav (the usual first choice for cellulitis near the eyes or nose)

Answer 25

malignant neoplasm of melanocytes

Answer 26

age UV exposure skin type (paler) >100 melanocytic naevi (having lots of moles) >5 atypical naevi multiple solar lentigines FHx personal hx

Answer 27

asymmetry irregular border multiple colours >7mm diameter evolution

Answer 28

need 3+ for referral major features (2 pts each) change in size irreg shape irreg colour minor features (1) largest diameter >7mm inflam oozing or crusting change in sensation (inc itch)

Answer 29

palms soles or nails no connection to UV equal incidence in all skin (so most common for darker skin to get) presents late so worse prog

Answer 30

elders chronic accum sun exposure on face on sun damaged skin (darkened bits)

Answer 31

red/black lump which bleeds/oozes early vertical growth phase most aggressive males trunk, head, neck (can seem more symm w reg borders but is pigmented + growing)

Answer 32

most common prolonged radial growth phase trunk in males legs in females

Answer 33

hx rapid growth residual pigment look pink and stick out

Answer 34

breslow thickness

Answer 35

thinner tumours confined to skin (almost 100% 5+ yr survival)

Answer 36

thicker tumours confined to skin (80%)

Answer 37

lymph node involvement (70%)

Answer 38

distant mets (30%)

Answer 39

GP 2 wk wait referral diagnostic excision of pigmented skin lesion w 2mm peripheral margin wide local excision test for BRAF mutation (causes it to grow more aggressively)

Answer 40

take out nearest draining lymph node as well (use dye to see)

Answer 41

Targeted therapy: BRAF (protein that helps control cell growth) inhibitors - dabrafenib MEK inhibitors - trametinib Immunotherapy Anti CTLA4 antibody Anti PD1 antibody rarely use radio or chemo

Answer 42

UV exposure - SCCs = chronic cumulative - BCCs = intermittent intense pale skin age immune suppression (SCC) ionising radiation chronic wounds (SCC) smoking (SCC) HPC (SCC) genetic syndromes

Answer 43

dry, scaly patches of skin that have been damaged by the sun partial thickness dysplasia of epidermal keratinocytes begins in basal layer no BM invasion flesh-coloured, irregularly shaped, small macules/plaques small devs over yrs at sun exposed sites v small no progress to SCC no reg flag sx

Answer 44

prev further risk topical tx -fluorouracil cream - diclofenac - imiquimod Photodynamic therapy (PDT) discrete lesions: cryotherapy C&C refer if does not resolve/unsure dx

Answer 45

precancerous dermatosis SCC IN SITU full thickness dysplasia of epidermal keratinocytes more of a well defined plaque cant met develop over yrs at sun exposed sites

Answer 46

INITIAL = 5-flurouracil cryotherpy C&C PDT

Answer 47

2nd most common skin cancer abnormal, accelerated growth of squamous cells now invasion past BM potential to met

Answer 48

rapid growth - wks/mths raised base keratotic/scaly lesions may ulcerate/bleed may be painful sun exposed sites - face, lips, ears, hands, forearms, lower legs

Answer 49

surgery - standard excision, Mohs surgery (removes skin layers at a time) radiotherapy

Answer 50

most common type of skin cancer abnormal, accelerated growth of basal cells

Answer 51

slowly growing plaque/nodule skin coloured, pink/pigmented, often shiny / pearly rolled edges telangiectasia ulceration + spontan bleeding rarely mets

Answer 52

surgery radiotherapy

Answer 53

if high risk : tumour site = central face, eyes, nose, ears size (>2cm) histology sub type (morphoetic, infiltrative, micronodular, basosqaumous) poor clinical definition of tumour margins recurrent lesions perineural/perivascular involvement

Answer 54

C&C Cryotherapy Topical - imiquimod, 5-flurouracil Photodynamic therapy

Answer 55

pruritic condition associated with last trimester lesions often first appear in abdominal striae mx depends on severity: emollients, mild potency topical steroids and oral steroids

Answer 56

is the commonest skin disorder found in pregnancy it typically presents as an eczematous, itchy red rash. no specific tx needed

Answer 57

pruritic blistering lesions often develop in peri-umbilical region, later spreading to the trunk, back, buttocks and arms usually presents 2nd or 3rd trimester and is rarely seen in the first pregnancy oral corticosteroids are usually required

Answer 58

6-12 weeks

Answer 59

Minority may give a hx of a recent viral infection herald patch (single larger pink/red oval patch usually on trunk) followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer = 'fir-tree' appearance

Answer 60

chronic inflammation, with or without localised infection, in pockets within the skin known as the pilosebaceous unit (tiny dimples on skin that contain hair follicles + sebaceous glands - produce sebum) There is increased sebum production, trapping of keratin + blockage -> swelling + inflam Swollen and inflamed units are called comedones.

Answer 61

explore the psychosocial burden No tx may be acceptable if mild TOPICAL BENZOYL PEROXIDE reduces inflammation, helps unblock the skin and is toxic to the P. acnes bacteria TOPICAL RETINOIDS (chemicals related to vitamin A) slow the production of sebum (women of childbearing age need effective contraception) - e.g. ADAPALENE TOPICAL antibiotics such as CLINDAMYCIN (prescribed with benzoyl peroxide to reduce bacterial resistance) ORAL antibiotics such as LYMECYCLINE use erythromycin in pregnancy DONT USE ABX AS MONOTHERAPY Oral contraceptive pill can help PX stabilise their hormones and slow the production of sebum

Answer 62

oral retinoid e.g. isotretinoin ie roaccutane (TERATOGENIC) - only prescribed by specialist after other methods fail

Answer 63

Dry skin and lips Photosensitivity of the skin to sunlight Depression, anxiety, aggression and suicidal ideation. Patients should be screened for mental health issues prior to starting treatment. Rarely Stevens-Johnson syndrome and toxic epidermal necrolysis

Answer 64

common benign lesion caused by HPV spread through direct skin contact

Answer 65

Severe acne (scarring, hyperpigmentation and widespread pustules)

Answer 66

none soaking/paring chemicals -salicyclic acid cryotheraoy c&c laser

Answer 67

a viral skin infection caused by the molluscum contagiosum virus, which is a type of poxvirus self-resolving but can take yrs spread through direct contact

Answer 68

small, flesh coloured papules (raised individual bumps on the skin) that characteristically have a central dimple. They typically appear in “crops” of multiple lesions in a local area

Answer 69

benign cyst derived from infundibulum of hair follicle have a central punctum

Answer 70

benign keratin filled cyst derived from outer hair root sheath often runs in fams - AD

Answer 71

v common benign lesion well-circumscribed plaques or papules with a 'stuck on' appearance brown, black or light tan. look waxy or scaly and slightly raised They appear gradually, usually on the face, neck, chest or back a sign of Leser-Trélat disorder asx

Answer 72

from cumulative sun exposure on back of hand + face

Answer 73

common benign lesion usually on legs get at middle age has a tethering/pinch sign can get from mild trauma

Answer 74

common benign tumour made of fat cells soft/smooth dome shaped subcut lesion

Answer 75

acquired proliferation of BVs

Answer 76

inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mould, or flakes of skin from certain animals causes cold-like sx tx w salt water rinsing/antihistamines

Answer 77

pediculus humanus capitis parasite

Answer 78

dimeticone 4% lotion can be applied to the hair and left to dry. This is left on for 8 hours, then washed off. This process is repeated 7 days later to kill any head lice that have hatched since treatment. fine combs

Answer 79

tiny mites called Sarcoptes scabiei that burrow under the skin causing infection and intense itching lay eggs in the skin can take 8 wks to get sx/rash from initial infestation

Answer 80

incredibly itchy small red spots, possibly with track marks where the mites have burrowed. The classic location of the rash is between the finger webs, can be whole body does anyone they live w have similar rash?

Answer 81

PERMETHRIN cream - apply to whole body when cool, leave for 8 – 12 hours then wash off repeat 1 wk later Oral IVERMECTIN as a single dose that can be repeated a week later is an option for difficult to treat or crusted scabies. tx household + close contacts in the same way wash clothes + bedding on hot, hoover carpets

Answer 82

Itching can continue for up to 4 weeks after successful treatment Crotamiton cream and chlorphenamine at night at night can help with the itching.

Answer 83

serious infestation with scabies in px that are immunocompromised. - may have over a million mites in their skin - extremely contagious - patches of red skin that turn into scaly plaques - can be misdiagnosed as psoriasis - may not have an itch as they do not mount an immune response to the infestation - may need admission for tx as an inpatient with oral ivermectin and isolation.

Answer 84

superficial bacterial skin infection, usually caused by the staphylococcus aureus bacteria contagious non-bullous or bullous

Answer 85

typically occurs around the nose or mouth. The exudate from the lesions dries to form a “golden crust”. Do not usually cause systemic symptoms or make the person unwell.

Answer 86

Antiseptic cream (hydrogen peroxide 1% cream) first line Topical fusidic acid (abx) Oral flucloxacillin is used to treat more wide spread or severe impetigo

Answer 87

always s. aureus this bacteria can produce epidermolytic toxins that break down the proteins that hold skin cells together -> 1–2 cm fluid filled vesicles to form on the skin. These vesicles grow in size and then burst, forming a “golden crust”. Eventually they heal without scarring. These lesions can be painful and itchy. more common in neonates + <2yrs more likely to get systemic sx

Answer 88

Swabs of the vesicles can confirm the diagnosis, bacteria and antibiotic sensitivities. Tx w antibiotics, usually flucloxacillin. This may be given orally or intravenously if they are very unwell or at risk of complications. The condition is very contagious and patients should be isolated where possible.

Answer 89

a condition caused by a type of s. aureus bacteria that produces epidermolytic toxins (they are protease enzymes that break down the proteins that hold skin cells together). When a skin infection occurs and these toxins are produced, the skin is damaged and breaks down. affects children under 5 years (older have developed immunity to the toxins)

Answer 90

- generalised patches of erythema on the skin - then skin gets thin + wrinkled. - then the formation of fluid filled blisters (bullae) - burst + leave v sore, erythematous skin below similar appearance to a burn or scald. Nikolsky sign = v gentle rubbing of the skin causes it to peel away Systemic sx = fever, irritability, lethargy + dehydration. If untreated it can lead to sepsis and potentially death.

Answer 91

admission + tx with IV abx. Fluid and electrolyte balance is key to management as patients are prone to dehydration. When adequately tx, usually make a full recovery without scarring.

Answer 92

infection - streptococci - tuberculosis - brucellosis systemic disease -- sarcoidosis - inflammatory bowel disease - Behcet's malignancy/lymphoma drugs - penicillins - sulphonamides - COCP pregnancy

Answer 93

typically affects nose, cheeks and forehead flushing is often first symptom telangiectasia are common later develops into persistent erythema with papules and pustules rhinophyma (large bulbous nose) ocular involvement: blepharitis SUNLIGHT exacerbates symptoms

Answer 94

direct sunlight oil based products alcohol spicy food hot drinks sudden temp changes excessive exercise

Answer 95

daily application of a high-factor sunscreen predominant erythema/flushing: topical BRIMONIDINE gel brimonidine (topical alpha-adrenergic agonist) - 'as required basis' mild-to-moderate papules and/or pustules: topical IVERMECTIN is first-line alternatives include: topical METRONIDAZOLE or topical azelaic acid moderate-to-severe papules and/or pustules: combination of topical ivermectin + oral DOXYCYCLINE laser therapy may be appropriate for patients with prominent telangiectasia avoid topical steroids

Answer 96

(herpes zoster infection) is an acute, unilateral, painful blistering rash caused by reactivation of the varicella-zoster virus (VZV).

Answer 97

increasing age HIV: strong risk factor, 15 times more common other immunosuppressive conditions (e.g. steroids, chemotherapy)

Answer 98

prodromal period - burning pain over the affected dermatome for 2-3 days rash - initially erythematous, macular rash over the affected dermatome - quickly becomes vesicular - well demarcated by the dermatome and does not cross the midline. However, some 'bleeding' into adjacent areas may be seen

Answer 99

infectious (avoid preg women + immunocomp ppl) until vesicles crusted over analgesia - paracetamol + NSAIDs first line - then neuropathic agents - consider oral steroids in first 2 wks if immunocomp + no res antivirals within 72 hours, unless the px is < 50 years and has a 'mild' truncal rash associated with mild pain and no underlying risk factors - aciclovir, famciclovir, or valaciclovir

Answer 100

scarring, hyperpigmentation and widespread pustules requires specialist dermatology referral

Answer 101

Propionibacterium acnes

Answer 102

tumour-like lesions that arise from the connective tissue of a scar and extend BEYOND the dimensions of the original wound

Answer 103

ethnicity: more common in people with dark skin occur more commonly in young adults, rare in the elderly common sites (in order of decreasing frequency): sternum, shoulder, neck, face, extensor surface of limbs, trunk

Answer 104

early keloids may be treated with intra-lesional steroids e.g. triamcinolone

Answer 105

an grow following trauma and can present similarly to keloid, they do not extend past the margins of the damaged skin.

Answer 106

scalp = ketoconazole 2% shampoo Face and body = topical antifungals: e.g. ketoconazole topical steroids: best used for short periods

Answer 107

mucosal involvement blistering/skin peeling off pain (common to be itchy but not usually pain) lymphadenopathy systemic upset - fever, abnormal LFTs, U&Es

Answer 108

documentation of all drugs + dates administered (inc OTC + complementary) dates of eruption create a drug time-line response to removal of suspected agent response to re-challenge (only if mild reaction + unsure of cause)

Answer 109

withdraw drug emollients topical corticosteroids in short term for sx relief antihistamines if urticaria

Answer 110

almost always caused by drugs - drug eruption TEN more severe distinct from erythema multiforme (normally caused by infections - HSV / mycoplasma ) more common in px w HIV

Answer 111

allopurinol carbamazepine lamotrigine phenobarbital phenytoin sulfasalazine sulfur abx NSAIDs nevirapine (HIV tx - ART)

Answer 112

new drug 7-21 days prev prodrome of resp tract sx fever PAIN dusky red lesions atypical targets (ie not 3 concentric rings) erythematous plaques

Answer 113

percentage of detachment of epidermis (which becomes necrotic + starts peeling off) SJS <10% TEN >30% - more likely to have systemic sx that are worse 10-30 = SJS-TEN crossover both have mucosal involvement

Answer 114

SCORTEN calc

Answer 115

ABCDE stop medication (all non-essential if don't know) admit to ICU / burn unit correct fluid + electrolytes caloric replacement protect from 2ndary infections w topical abx ointments (but not routine) ophthalmology consult + eye care urology consult if urethral inflam oral antacids + mouth care pulmonary hygiene if resp syndrome periodic cultures of mouth, eyes, skin, sputum physical therapy to prev contractures topical paraffin (50/50), non adherent dressings don't prescribe any meds w/o discussion w senior get lots of specialists involved

Answer 116

15-40 days after exposure (anticonvulsants, sulfonamides etc) high fever rash: morbilliform eruption (measles-like) sometimes w oedema (espesh on face), infiltration, purpura and scaling lymphadenopathy atypical lymphocytes eosinophilia internal organ involvement

Answer 117

withdrawal of drug systemic steroids for severe cases supportive tx - dressings - topical steroids - emollients - 50/50 (50% white soft paraffin 50 % liquid paraffin - v greasy!) - oral antihistamines - address: fluid status, electrolytes, temp, nutrition - tx 2ndary infection

Answer 118

<4 days after medication exposure - usually beta lactam abx high fever small sterile pustules arise within larger areas of oedematous erythema oedema hands + face, purpura, vesicles, bulla, target lesions, mucosal involvement marked leukocytosis w elevated neutrophils (can look similar to acute pustular psoriasis)

Answer 119

withdraw the drug (sld be enough) topical steroids emollients antihistamines systemic therapy rarely indicated

Answer 120

generalised erythema affecting >90% skin surface due to rapid epidermal cell turnover

Answer 121

eczema - espesh topical dermatitis psoriasis drug eruption - sulphonureas, isoniazid, sulfonamide cutaneous T cell lymphoma idiopathic

Answer 122

dehydration, infection and high-output heart failure

Answer 123

may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body. Associated with mild systemic upset more serious form is an acute deterioration. This may be triggered by a variety of factors such as withdrawal of systemic steroids. Patients need to be admitted to hospital for management

Answer 124

rare, severe, superficial blistering skin disorder which is characterised by epidermal detachment (more superficial than SJS/TEN) triggered by exotoxin release from specific strains of s.aureus normally in children <5

Answer 125

- usually starts with generalised patches of erythema on the skin - then the skin looks thin and wrinkled - then formation of fluid filled blisters called bullae, which burst and leave very sore, erythematous skin below. Nikolsky sign (where very gentle rubbing of the skin causes it to peel away) Systemic sx: fever, irritability, lethargy and dehydration. If untreated -> sepsis, death.

Answer 126

an AI condition causing sub-epidermal blistering of the skin more common in the ELDERLY a result of an attack on the BM of the epidermis by IgG +/- IgE immunoglobulins + activated T lymphocytes target is protein BP180

Answer 127

itchy, tense intact blisters typically around flexures the blisters usually heal without scarring there is stereotypically no mucosal involvement

Answer 128

Skin biopsy - immunofluorescence shows IgG and C3 at the dermoepidermal junction

Answer 129

AI blistering skin disease, painful blisters of the skin + mucus membranes ages 30-60 jews + indians antibodies directed against desmoglein 3 found on desmosomes

Answer 130

mucosal ulceration is common and often the presenting symptom (often oral) skin blistering - flaccid, easily ruptured vesicles and bullae Lesions are typically painful but not itchy. These may develop months after the initial mucosal symptoms. Nikolsky's = spread of bullae following application of horizontal, tangential pressure to the skin

Answer 131

acantholysis on biopsy

Answer 132

steroids are first-line immunosuppressants

Answer 133

referral to a dermatologist for biopsy and confirmation of diagnosis oral corticosteroids are the mainstay of treatment topical corticosteroids, immunosuppressants and antibiotics are also used

Answer 134

Topical aluminium chloride

Answer 135

T-cell mediated AI disorder

Answer 136

mucus membranes of mouth + vagina (inside vagina) nails wrists

Answer 137

white lines on surface of the rash - Wickham's striae is otherwise flat-topped, purple, polygonal papules and plaques itchy

Answer 138

saw-tooth pattern of epidermal hyperplasia t-cell infiltration of dermis reduced melanocytes globular deposits of IgM

Answer 139

potent topical steroids are the mainstay of treatment e.g. betnovate

Answer 140

symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin

Answer 141

insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)

Answer 142

T2DM GI cancer obesity PCOS acromegaly Cushing's disease hypothyroidism familial Prader-Willi syndrome drugs - COCP, nicotinic acid

Answer 143

topical antifungal - ketoconazole shampoo

Answer 144

pale white/brown/pink patches well-demarcated dry scaly usually on trunk

Answer 145

fungal infection caused by Malassezia furfur

Answer 146

autoimmune blistering skin disorder associated with coeliac disease caused by deposition of IgA in the dermis

Answer 147

itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks)

Answer 148

direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis

Answer 149

epistaxis : spontaneous, recurrent nosebleeds telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose) visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM family history: a first-degree relative with HHT

Answer 150

gynecomastia

Answer 151

dysfunc of bladder + bowel eye defects - cataracts, chorioretinitis limb hyperplasia cortical atrophy microcephaly 1 + = foetal varicella syndrome

Answer 152

oral terbinafine