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Dermatology Flashcards

1
Q

Bacteria that proliferate immediately after a burn

A

Gram-positive skin flora (Staph Aureus)

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2
Q

> 5 days after a burn, most infections are caused by

A

Gram-negative organisms (Pseudomonas)

Fungi (Candida)

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3
Q

Early signs of wound infection

A

Change in appearance (partial thickness becomes full thickness)
Loss of viable skin graft

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4
Q

Burn wound sepsis

A

Can develop rapidly

Findings:
Temperature < 36.5 (97.7) or > 39 (102.2) - Low temperature counts too! Weird!
Progressive tachycardia (>90)
Progressive tachypnea (>30)
Refractory hypotension (SBP < 90)
Also common:
Oliguria
Unexplained hyperglycemia
Thrombocytopenia
AMS
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5
Q

Diagnosis of Burn Wound Sepsis

A

Quantitative Wound Culture (> 10^5 bacteria/g tissue)

Biopsy (determine tissue invasion depth)

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6
Q

Treatment of Burn Wound Sepsis

A

Empiric broad spectrum IV antibiotics

Pip/Taz
Carbapenem
Potentially include Vanc for MRSA coverage
Potentially include Aminoglycoside for MDR Pseudomonas

Local wound care & debridement

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7
Q

Definition of a large burn

A

> 20% of body surface area

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8
Q

You see a pediatric burn patient with uniformity of burned skin, sharp lines of demarcation & flexor surface sparing. What do you do?

A

Call child protective services

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9
Q 
Child with:
Recent infection
Hematuria
Abdominal Pain
Lower extremity purpuric rash
No thrombocytopenia
A

Vasculitis (probably HSP)

Treat with hyrdation & NSAIDS

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10
Q

Major risk factor for Actinic Keratosis

A

Chronic sun exposure

Surrounding skin often shows features of solar damage (telangiectasias, hyperpigmentation)

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11
Q

Clinical significance of Actinic Keratosis

A

Potential progression to squamous cell carcinoma

Likelihood of malignant progression of an individual lesion is low

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12
Q

When is a biopsy of Actinic Keratosis indicated?

A 
> 1cm diameter
Indurated
Ulceration
Rapidly growing
Fail appropriate treatment (Cryotherapy or fluorouracil if large)
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13
Q

Histopathology of Actinic Keratosis

A

Acanthosis (Thickening of epidermis)
Parakeratosis (Retention of nuclei in stratum corneum)
Nuclear atypia
Abnormal keratinization w/ thickening of stratum corneum

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14
Q

Treatment for Actinic Keratosis

A

Cryotherapy

Large area may require field therapy (Fluorouracil)

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15
Q

Characteristics of Allergic Contact Dermatitis

A

Erythematous papules or vesicles

Lichenification in chronic cases

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16
Q

Triggers of Allergic Contact Dermatitis

A

Toxicodendron Plants (Poison Ivy)
Nickel
Rubber
Topical medications

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17
Q

Characteristics of Pityriasis Rosea

A

Numerous
Oval
Scaly
Plaques

Follow cleavage lines of the trunk
Begins with initial lesion (“Herald Patch”) larger than later lesions

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18
Q

Characteristics of Psoriasis

A

Well-circumscribed
Plaques
Silvery scales
Predominantly extensor surfaces & scalp

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19
Q

Characteristics of Seborrheic Dermatitis

A

Scaly
Oily
Erythematous rash

Skinfolds around:
Nose
Eyebrows
Ears
Scalp
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20
Q

Characteristics of Seborrheic Keratosis

A

Benign
Pigmented
Well-demarcated border
Velvety / Greasy surface

“Stuck On” appearance

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21
Q

Mongolian Spot

A

Benign
Flat
Blue-grey patches

Usually over lower back & buttocks
Can be seen elsewhere

Look like bruises, but are nontender. Document them so future providers know.

Nonwhite children have them at birth, spontaneously fades during first decade. So benign. Reassure.

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22
Q

When does colic (prolonged periods of inconsolable crying) peak?

A

2 months

Parents get exhausted, increases risk of abuse

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23
Q

Cafe-au-lait macules are associated with

A

Neurofibromatosis

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24
Q

Ash-leaf spots are associated with

A

Tuberous Sclerosis

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25
Port-wine stains are associated with
Sturge-Weber syndrome
26
Cafe-au-lait macules Ash-leaf spots Port-wine stains These skin findings make you want to look for
Intracranial lesions Epilepsy They are all associated with neurocutaneous syndromes
27
When is Babinski reflex normal?
< 1 year
28
When are Seborrheic Keratoses not benign?
When several appear all at once, they may indicate occult internal malignancy (Leser-Trelat sign). Usually, they're benign AF, though.
29
Treatment for Seborrheic Keratoses
Observation If bothersome, excision, cryosurgery or electrodessication may be performed.
30
Acrochordon
Skin Tag Seen in regions subjected to friction (neck, axilla, inner thigh)
31
Most common presentation of Basal Cell Carcinoma
Slow- growing papule or nodule Pearly, rolled border Overlying telangiectasias Ulceration common Bleeding following minor trauma common
32
Cutaneous warts
Most common in children & young adults Seen on hands, elbows & feet Not usually pigmented
33
Biopsy findings of Seborrheic Keratosis
So rarely done Small cells (resembling basal cells) Variable pigmentation Hyperkeratosis Keratin-containing cysts
34
Differentiating Melanoma from Seborrheic Keratosis
Melanoma has: Indistinct or irregular border Smooth or nodular surface Changing appearance over time Predilection for sun-exposed areas Biopsy is occasionally required to tell the difference.
35
What causes Molluscum Contagiosum?
Poxvirus
36
Characteristics of Molluscum Contagiosum
Small, pruritic, skin-colored papules Umbilicated centers Diagnosis is clinical Affects mostly children Adults & adolescents can develop them too
37
How is Molluscum Contagiosum transmitted?
Skin-to-skin Contaminated fomites Autoinoculation to additional sites
38
Where do Molluscum Contagiosum lesions appear in kids?
Extremities Face Trunk
39
Where do Molluscum Contagiosum lesions appear in adults?
Anogenital region (sexxxxxx)
40
Molluscum Contagiosum treatment
Self-limited illness (6 - 12 months) To prevent further spread, reduce symptoms or for cosmetic reasons, you can do: Curettage Cryotherapy Topical agents (podophyllotoxin)
41
Who has a prolonged course with Molluscum Contagiosum?
Patients with impaired cellular immunity | Poorly controlled HIV patients can have hundreds of lesions.
42
If Molluscum Contagiosum has excessively large, numerous or widespread lesions, what do you do?
HIV Test
43
Hypersensitivity rash with blisters or bullae
Type 2 (Antibody-dependent cellular cytotoxicity)
44
Erythematous maculopapular hypersensitivity rash
Type 3 (Immune complex deposition)
45
C3 deficiency predisposes you to
Pyogenic bacterial respiratory tract & sinus infections
46
C5 - C8 deficiency predisposes you to
Recurrent Neisseria infections
47
Disorders of Phagocytosis
Chronic Granulomatous Disease Chediak-Higashi Job Syndrome Defective leukocyte adhesion proteins) Present with severe pyogenic bacterial infections
48
Selective IgA deficiency predisposes you to
Recurrent respiratory infections | Chronic giardiasis
49
Most common form of Tinea Capitis in the USA
Black Dot Tinea Capitis Most common in African Americans Trichophyton Tonsurans is the cause, but other dermatophytes can cause TC as well
50
Transmission of Tinea Capitis
Human-to-human | Fomites (shared combs)
51
Characteristics of Tinea Capitis
Scaly, erythematous plaque on the scalp Progresses to patchy alopecia w/ residual black dot (broken hair) ``` Other findings: Inflammation Pruritus Occipital or postauricular lymphadenopathy Scarring ```
52
Diagnosis of Tinea Capitis
Clinical diagnosis Can confirm with KOH exam of hair stubs
53
Treatment of Tinea Capitis
PO Griseofulvin or Terbinaine Many experts recommend household contacts be treated with Selenium Sulfide or Ketoconazole Shampoo
54
Alopecia Areata
Smooth circular areas of hair loss | No scaling
55
Discoid Lupus Erythematosus
``` Well-demarcated inflammatory plaques Hypo- or Hyperpigmented lesions Scarring Photosensitivity Alopecia ```
56
Cutaneous candidiasis
Erythematous Vesiculopapular rash Warm, moist areas (Skin folds)
57
Pressure-induced alopecia
From prolonged pressure on scalp during surgical procedures Transient hair loss develops a few weeks postop Regrowth ensues without significant residual alopecia
58
Hair pattern of trichotillomania
Irregular pattern | Broken hair strands of varying length
59
Seborrheic Dermatitis of the Scalp
Dandruff
60
Etiologies of Urticaria
Infections (Viral, bacterial, parasitic) IgE Mediated (Antibiotics, insect bites, latex, food, blood products) Direct mast cell activation (Narcotics, muscle relaxers, radiocontrast medium) NSAIDs Idiopathic (up to 50% of patients)
61
Most commonly affected sites for atopic dermatitis in adults
Flexural areas (neck, antecubital, popliteal) Face Wrist Forearms
62
Timeline of Contact Dermatitis
Symptoms develop over hours-to-days | Symptoms resolve within several days
63
Erythema Multiforme
``` Target lesion Erythematous, iris shaped macules Can also contain vesicles or bullae Can be painful or pruritic Symmetrically distributed on extensor surfaces of extremities. Also palms and soles ```
64
Etiology of Pityriasis Rosea
Likely viral | Self-limited
65
Difference between Stevens-Johnson Syndrome & TEN
SJS is when it affects < 10% of body surface area TEN is when it affects > 30% of body surface area Anything in between is an overlap
66
Onset of SJS / TEN
4 - 28 days after exposure to trigger (2 days after repeat exposure) Acute flu-like prodrome Rapid onset erythematous macules, vesciles, bullae Necrosis & sloughing of epidermis Mucosal involvement
67
Drug triggers of SJS/TEN
``` Allopurinol Antibiotics (Sulfonamides) Anticonvulsants (Carbamazepine, Lamotrigine, Phenytoin) NSAIDs (Piroxicam) Sulfasalazine ```
68
Non-drug triggers of SJS/TEN
Mycoplasma Pneumoniae Vaccination Graft vs. Host Disease
69
Clinical features of Stevens Johnson Syndrome
Coalescing erythematous macules Bullae Desquamation Mucositis
70
Systemic signs of Stevens Johnson Syndrome
``` Fever Tachycardia Hypotension AMS Seizures Coma ```
71
When does Erythema Multiforme typically present?
After herpes simplex infection
72
What causes impetigo?
Staph or strep
73
What causes Pemphigus Vulgaris?
Autoantibodies to desmosomes Chronic Oral lesions appear weeks to months prior to skin lesions
74
Who is affected by scalded skin syndrome?
Children < 6
75
Diffuse erythema resembling sunburn | Desquamation of palms & soles
Toxic Shock Syndrome
76
Eczema Herpeticum
Potential complication of severe atopic dermatitis Superinfection with herpes simplex Vesicular eruption on already inflamed skin
77
Scabies
Small pruritic papules in linear arrangement (burrows) | Web spaces, wrists, ankles, genitals, nipples, waistline
78
Cradle Cap
Seborheic Dermatitis in infants
79
First line treatment for atopic dermatitis
Topical emollients
80
How do you get allergic contact dermatitis on your eyelids?
Low concentrations of nickel in some cosmetics
81
Hypersensitivity of Allergic Contact Dermatitis
Type IV (Cell-mediated) Hypersensitivity
82
Common triggers of drug induced acne
``` Glucocorticoids Androgens Immunomodulators (Azathioprine, EGFR Inhibitors) Anticonvulsants (Phenytoin) Antipsychotics Antituberculous drugs (Isoniazid) ```
83
Presentation of drug-induced agne
Monomorphic papules or pustules Lack of comedones, cysts & nodules Location & age may be atypical for acne
84
Management of drug-induced acne
Discontinue offending medication | Standard acne therapy unlikely to be effective
85
Chloracne
From exposure to halogenated hydrocarbons (occupational exposure to dioxin) Inflammatory nodules Large comedones Affects head, neck, axillae
86
Rash of disseminated gonococcal infection
Vesiculopapular rash Tenosynovitis Migratory polyarthralgias Most patients febrile Lesions are mostly on distal extremities and last only a few days
87
Ugly Duckling Sign
Patient has multiple pigmented lesions The lesion with a substantially different appearance compared to the others is the ugly duckling Sensitivity of up to 90% for melanoma
88
Non ABCDE criteria for concerning skin lesion
Ugly Duckling Sign Palpable nodularity Moles that itch or bleed
89
Most important prognostic indicator in malignant melanoma
Breslow depth
90
You suspect melanoma in a lesion
Perform excisional biopsy w/ initial margins of 1 - 3mm of normal tissue
91
Treatment of scabies
Topical 5% permethrin OR PO Ivermectin
92
Hypersensitivity of Scabies rash
Type IV Hypersensitivity to the mite, feces & eggs
93
What to do when you've treated scabies
Bedding & clothing should be cleaned or placed in a plastic bag for >= 3 days. The mites can't live away from human skin longer than 3 days
94
Rash of bed bugs
Small, punctate lesions Surrounding erythema Linear tracks or clusters (breakfast, lunch, dinner) Palms & soles are rare
95
Who is affected by Bullous pemphigoid?
> 60 years old Prodrome of eczematous or urticarial lesions Develop tense bullae & plaques Affects flexural areas, groin, axilla
96
Sporotrichosis
Fungal infection by direct traumatic inoculation of the skin Ulcerating pustular nodules at site of inoculation Affects associated lymphatic channels
97
First line treatment of vitiligo
Topical or systemic corticosteroids
98
Idiopathic Guttate Hypomelanosis
Common with aging Small macules in sun-exposed areas
99
Mycobacterium Leprae
Leprosy Areas of hypopigmentation with anesthesia
100
Tinea Versicolor
Lightly scaled macules Chest & upper back Post-inflammatory hypopigmentation
101
Piebaldism
Autosomal Dominant Patchy absence of melanocytes Usually discovered at birth Confined to head & trunk
102
Painful flaccid bullae Mucosal erosions Separation of epidermis from dermis by light friction
Pemphigus Vulgaris Autoimmune attack of Desmogleins 1 & 3 of desmosomes between epidermal keratinocytes
103
Light microscopy findings of pemphigus vulgaris lesion border
Intraepithelial cleavage Acantholysis (Detatched keratinocytes) Single layer of hemidesmosomes in basement membrane ("row of tombstones") IgG & C3 deposits in chicken wire pattern Serology for Abs to Desmoglein 1 & Desmoglein 3 can confirm diagnosis
104
Risk factors for Squamous Cell Carcinoma of the skin
UV, Ionizing radiation Immunosuppression Chronic scars/wounds/burn injuries
105
Clinical features of Squamous Cell Carcinoma of the skin
Scaly plaques/nodules +/- Hyperkeratosis or ulceration Neurologic signs with perineural invasion
106
Diagnosis of Squamous Cell Carcinoma of the skin
Biopsy: Dysplastic/anaplastic keratinocytes Biopsy can be punch, shave or excisional, but must include deep reticular dermis to assess depth of invasion.
107
Suspect Squamous Cell Carcinoma of the skin in patients with
Rough, scaly nodule | Nonhealing, painless ulcer that develops in a scar or chronic inflammatory lesion
108
Treatment of small or low-risk Squamous Cell Carcinoma lesions of the skin
Surgical excision or local destruction (cryotherapy, electrodessication)
109
Treatment of high-risk Squamous Cell Carcinoma lesions of the skin
Mohs micrographic surgery (Layered)
110
Unilateral vesicular hand lesion in patient who has herpes
Herpetic whitlow Tingling, burning & pain are common Epitrochlear or axillary lymphadenopathy possible
111
Dome-shaped Firm Freely movable cyst or nodule Central punctum Most commonly on face, neck, scalp or trunk
Epidermal Inclusion Cyst Discrete, benign nodule Lined with squamous epithelium Contains semisolid core of keratin & lipid May remain stable or gradually increase in size May produce cheesy white discharge Resolves spontaneously Excision is usually for cosmesis
112
When should sunscreen be put on?
15 - 30 minutes before sun exposure | Allows formation of a protective film
113
How often should sunscreen be reapplied?
Every 2 hours Also after swimming or sweating, even if it is "water resistant"
114
Who shouldn't wear sunscreen?
Babiez < 6 months Thin skin & high surface area-to-body ratio increases exposure to chemicals. Use a small amount if sun exposure is unavoidable
115
Scaly macules & papules Distributed obliquely along lines of tension "Christmas Tree" pattern on back
Pityriasis Rosea Self-limited, spontaneously resolves within weeks-to-months Symptomatic relief of pruritus = Antihistamines, topical corticosteroids
116
Erythematous target lesions Dusky center Precipitated by infection or medication
Erythema multiforme
117
Faintly erythematous Ring-like rash Comes & goes Manifestation of acute rheumatic fever
Erythema marginatum
118
Chronic rash Dry Erythematous Intensely pruritic patches on extremities
Nummular Eczema
119
Neonate Asymptomatic scattered erythematous macules, papules & pustules throughout the body Can change appearance Occurs in first 2 weeks of life
Erythema Toxcium Benign. Self-resolves within 2 weeks of life. Reassure.
120
Neonate | Vesicular clusters on skin, eyes & mucous membranes
Neonatal HSV Acyclovir
121
Neonate | CNS infection
Neonatal HSV Acyclovir
122
Neonate | Fulminant, disseminated multi-organ disease
Neonatal HSV Acyclovir
123
``` Neonate Fever Irritability Diffuse erythema Blistering & exfoliation Positive nikolsky sign ```
Scalded Skin Syndrome Oxacillin Nafcillin Vancomycin
124
Dome-shaped nodules | Central keratinous plug
Keratoacanthomas Benign Rare cases have progressed to malignant transformation & metastasis
125
Slowly enlarging Mobile SubQ mass Soft or ruberry
Lipoma Rarely malignant. Can observe.
126
Ring-shaped inflammatory lesion | Peripheral scaling
Tinea corporis
127
Widespread, scaly eruption of skin
Erythroderma (Exfoliative dermatitis) May be drug-induced May be idiopathic May be 2/2 underlying derm or systemic disease
128
``` Discrete Firm Nontender Hyperpigmented nodule <1cm in diameter Dimple in the center when area is pinched ```
Dermatofibroma Fibroblast proliferation Isolated or multiple lesions Most commonly on lower extremities Etiology unknown Some develop after trauma or insect bites
129
Multicentric Red, purple or brown Macules, plaques or nodules Trunk, extremities or face Associated with AIDS
Kaposi Sarcoma
130
Small red papule Grows rapidly over weeks to months Becomes pedunculated or sessile shiny mass
Pyogenic granuloma Occur on lip or oral mucosa Can bleed with minor trauma
131
Squamous Cell Carcinoma tends to overly
Ostemomyelitis Radiotherapy scars Venous ulcers
132
Scaly, pruritic patches or plaques
Cutaneous T-Cell Lymphoma
133
Marjolin Ulcer
Squamous Cell Carcinoma arising within burn wound
134
Rocky Mountain Spotted Fever
Tick-borne rickettsial illness Nonspecific signs (Fever, headache, malaise, myalgias) Diffuse macular rash that turns petichial
135
Grouped Herpetiform Clusters | Extensor surfaces of elbows, knees, back, buttocks
Dermatitis Herpetiformis Reaction to gluten Celiac disease
136
Biopsy findings in Dermatitis Herpetiformis
Subepidermal microabscesses at tips of dermal papillae | Immunofluorescence: Deposits of anti-epidermal transglutaminase IgA in the dermis
137
Treatment for Dermatitis Herpetiformis
Dapsone | Gluten-free diet
138
Treatment for condylomata acuminata
THIS IS HPV Chemical or physical agents (Trichloroacetic acid, podophyllin) Immune therapy (Imiquimod) Surgery (Cryosurgery, excision, laser treatment)
139
Small papules evenly distributed in a ring around the corona of the glans
Pearly pink penile papules Benign, non-infectious Patients often want removal to avoid appearance of an STI
140
Flattened pink or grey velvety papules | Mucous membranes & moist skin of genitals, perineum and mouth
Condyloma lata | THIS IS FROM Syphilis!
141
Most common skin cancer in the USA
Basal Cell Carcinoma
142
Ichthyosis Vulgaris
``` Chronic Inherited skin disorder Diffuse dermal scaling Mutations in the filaggrin gene Much worse in homozygous patients ``` Simple emollients first If those fail, keratolytics (coal tar, sialycylic acid) or topical retinoids may help
143
Blisters Bullae Scarring Hypopigmentation/hyperpigmentation of sun-exposed skin
Porphyria Cutanea Tarda Deficiency of uroporphyrinogen decarboxylase necessary for heme synthesis
144
Conditions associated with Porphyria Cutanea Tarda
``` Hepatitis C HIV Excessive alcohol Estrogen use Smoking ```
145
Diagnosis of Porphyria
Mildly elevated liver enzymes & iron overload | Elevated plasma or urine porphyrin levels
146
Types of Rosacea
Erythemato-telangiectatic (facial erythema/flushing, telangiectasias) Papulopustular (Papules & pustules on central face) Ocular (Conjunctival hyperemia, lid margin telangiectasias)
147
Treatment of Rosacea
Avoidance of triggers (alcohol, spicy foods) Sun protection Gentle cleansers & emollients Topical metronidazole for papulopustular type Laser or topical brimonidine for erythematotelangiectatic type
148
Brimonidine
Vasoconstrictive Alpha-2 Agonist
149
Who gets erythematotelangiectatic rosacea?
Fair-skinned individuals | > 30 years old
150
Precipitants of Erythematotelangiectatic Rosacea
Hot drinks Alcohol Heat Emotion
151
Flushing associated with carcinoid
20 - 30 seconds Accompanied by hypotension & cyanosis in severe cases Diarrhea is also seen
152
Rash of Dermatomyositis
Dusky purple hue: ``` Eyelids Forehead Neck Chest hands ```
153
Photosensitivity is associated with which drugs?
Tetracyclines Diuretics Antiemetics Antipsychotics
154
Cherry Hemangioma
That thing you see on hella old people Benign
155
Strawberry hemangioma
Also called superficial infantile hemangioma First weeks of life Initially grow rapidly Frequently regress by age 5 - 8 If on eyelid, can cause strabismus If in trachea, can be life-threatening Beta blockers for patients at risk for complications
156
Cavernous hemangioma
Cavernous malformation Dilated vascular spaces with thin-walled endothelial cells Soft blue compressible masses up to a few cm
157
Cavernous hemangiomas of the brain & viscera are seen in
Von Hippel-Lindau
158
``` Soft Painless Compressible Neck mass Transilluminates ```
Cystic Hygroma Benign lymphangioma Associated with Turner, Down, Edwards, Patau
159
Blanchable Pink-red patches Eyelid, glabella, midline of nape of neck
Nevus Simplex Present at birth Fade by age 1 - 2 Neck lesions may persist with no sequellae
160
How long does it take to transmit lyme disease?
48 hours of tick attachment
161
When does Erythema migrans manifest?
7 days after infection
162
Microbe for Tinea Versicolor
Malassezia Furfur | Malassezia Globosa
163
Budding Yeast on KOH preparation | "Spaghetti & Meatballs" appearance
Malassezia Furfur | Malassezia Globosa
164
Treatment of Tinea Versicolor
Selenium Sulfide Ketoconazole Pigmentation changes may take months to resolve after treatment
165
Treatment for moderate-to-severe inflammatory acne
Topical Antibiotics: Erythromycin Clindamycin
166
Who mediates Type IV Hypersensitivity?
T Cells!!
167
What is Acanthosis Nigricans associated with?
Insulin-resistant states: DM Obesity PCOS Skin tags (acrochordons) are often seen with it
168
Skin conditions associated with Hepatitis C
Porphyria Cutanea Tarda | Cutaneous Leukocytoclastic Vasculitis (Palpable purpura) 2/2 cryoglobulinemia
169
Skin conditions associated with Insulin resistance
Acanthosis nigricans | Multiple skin tags
170
Skin conditions associated with GI Malignancy
Acanthosis nigricans | Excessive onset of multiple itchy seborrheic keratoses
171
Skin conditions associated with HIV
Severe sudden-onset psoriasis Recurrent Herpes Zoster Dissmeinated Molluscum Contagiosum Severe Seborrheic Dermatitis
172
Skin conditions associated with Parkinson's
Severe seborrheic dermatitis
173
Skin conditions associated with Inflammatory Bowel Disease
Pyoderma gangrenosum
174
Lentigo
Those dark spots on old people's faces | Intraepidermal melanocyte hyperplasia
175
Baby with eczema has localized vesicular rash, not diffusely spread around
HSV 1 | Give acyclovir IV
176
First line treatment for bullous pemphigoid
High-potency topical glucocorticoid (clobetasol)
177
Most common malignancy of the lip
Squamous cell carcinoma
178
Biopsy findings of Squamous Cell Carcinoma
Invasive cords of squamous cells with keratin pearls

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