? Describe the lesions
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? Multiple circumscribedverrucous papules on the thumb
? Surface shows black dots
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? Diagnosis:
? Verruca vulgaris
? blackish discoloration-
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? Capillary thrombosis? Wart resolves with no sequalae
? ?
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? Subungual verruca
? Causative agent?
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plantar wartsFiliform warts
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PALMAR WARTSVERRUCA PLANA
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? ?? Pseudokoebnerisation- Lesions
may be arranged linearly
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(pseudo Koebner's
phenomenon) due to auto-
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inoculation.Verruca plana
Verruca plana over a tattoo
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? Epidermodysplasia verruciformis
Rare inherited disorder,
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characterized by defective cell-
mediated immunity to certain
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types of HPV (3, 5, 8, 9) resultingin wide spread lesions.
? Plane wart-like lesion
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? Pityriasis versicolor-like irregular,scaly macules
? Anogenital warts
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? Sexually transmitted disease.? A variety of clinical variants, e.g.,
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condyloma acuminata, papularwarts, and Bowenoid papulosis.
? Most frequently on the glans,
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perianal region, vulva, andcervix.
? Differential.....
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? Condyloma lata
? Secondary syphilis
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? Diagnosis
? Characteristic warty appearance
with a rough, dry stippled
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surface.
? Presence of pseudo Koebner's
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phenomenon, especially in planewarts.
? Typical histology
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? Treatment
? More than 50% of warts resolve
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spontaneously
? Cryotherapy
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? Cryogens: Liquid nitrogen, carbondioxide, and nitrous oxide.
Technique: A cotton-tipped
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applicator dipped in cryogen is
applied firmly to the wart til a
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smal halo of freezing appears onadjoining normal skin. Or can be
sprayed using a cryocan.
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? Electric cautery and
? Wart paint: Contains salicylic
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radiofrequency ablation (RFA)
acid (a keratolytic agent) and
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lactic acid in a quick dryingcollodion or acrylate base.
? Topical agents
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? Salicylic acid (10?25%)? Retinoic acid (0.05?0.1%):
MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
? Diagnosis of MC is based on:
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? Presence of pearly whiteumbilicated papules.
? Extrusion of the cheesy core
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through the central crater;
characteristic cytological
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appearance of the expressedmaterial.
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? Pseudoisomorphic phenomenon? Course -Self-limiting.
? Anogenital region: what should you ? Except in immunosuppressed and
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suspect
atopics
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? Sexual y transmitted MC? In adult patients with extensive and
persistent lesions------- what should
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you suspect?
? underlying HIV infection should be
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ruled out.CHICKEN POX
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CHICKEN POX? Morphology:
? Crops of papules with erythematous halo; r
? apidly become vesicular (dew drops on rose petal appearance), then
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pustular.? Eruption at different stages present.
? Heal with minimal scarring unless complicated by secondary infection
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or hemorrhagic lesions (as seen in immunocompromised).? Adults usually have a more severe eruption.
? Site: Centripetal distribution.
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? Treatment: Specific antiviral therapy (acyclovir 800 mg, five times
daily ? 7?10 days) in adults and in immunocompromised individuals.
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? None needed in children.? ?
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? Herpes Zoster? Causative agent?
? Varicella-zoster virus
? Morphology?
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? Very painful, segmental eruption of grouped papules and vesicles on an
erythematous, slightly edematous base
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? Predisposing factors for reactivation are:? Old age.
? Lymphoreticular malignancies, e.g., Hodgkin's disease and leukemia.
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? Human immunodeficiency virus infection.
? Sometimes without apparent cause.
? Sites:
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? Thoracic intercostal nerves,
? ophthalmic division of trigeminal nerve.
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? Complications ?? Postherpetic neuralgia
? corneal ulcers and scarring------- Eye involvement is indicated when
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vesicles are present on the side of the nose (Hutchison's sign).
? Secondary bacterial infection
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? Generalized ----in immunocompromised individuals and in those withinternal malignancies.
? Investigations
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? giant cells on cytopathology is confirmatory.? if disseminated hemorrhagic lesions present----?
? Rule out an underlying immunodeficiency (lymphoreticular
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malignancies and HIV infection)
? Treatment:
? Self-limiting.
? Symptomatic treatment with analgesics.
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? Specific treatment with antivirals (acyclovir, famciclovir, andvalacyclovir) in: (a) ophthalmic zoster (b) immunocompromised (c)
severe zoster (hemorrhagic lesions), and (d) elderly (to reduce
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postherpetic neuralgia).
? Acyclovir: 800 mg, five times a day ? 7 days (adult dose).
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? Famciclovir: 500 mg, three times a day ? 7 days.? Valacyclovir: 1 g, three times a day ? 7 days
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HERPES LABIALIS? ?
? grouped vesicular lesions
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? ?
? erosions with polycyclic margins.
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? erosions with polycyclic margins.
? Cause?
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? HSV? Why difference in severity?
? Primary infection, more severe and
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associated with constitutional
symptoms.
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? Recurrent infection manifests asgrouped papulovesicular lesions which
rupture to form polycyclic erosions.
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? HSV (type I and type II).? Type I generally causes lesions above the waist,
? while type II causes genital infection.
? After primary infection (first infection), the virus lies dormant in
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sensory ganglion and? gets activated from time to time.
? ? Transmission
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? Direct contact: Usually occurs in children from an infected adult whois often asymptomatic yet shedding virus.
? Sexual contact: Usually in adults, herpes genitalis being the most
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common cause of infective genital ulcer disease. Again asymptomatic
shedding important.
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? ?
? Primary HSV infection
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? may present as acutegingivostomatitis: characterized by
closely grouped vesicles which
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rapidly form polycyclic ulcers
covered with a yel ow
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pseudomembrane. Heal in about afortnight
? Malaise, fever, and
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lymphadenopathy are frequent.
? ?
? Primary herpetic genital
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infection
? Bed side test that u would do ?
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? Tzanck smear -
? multinucleated giant cells
Tzanck smear, showing multinucleated giant
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cel s
? Serology:
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? Antibody titers rise with primary infection (IgM initially, IgG later).? Though IgM levels fall, IgG levels persist.
? Are of doubtful diagnostic significance in recurrent infections but
? help in primary infection.
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? Morphology?
? painful oblong vesicles on hands
? erosions in oral mucosa
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? Hand, Foot, and Mouth Disease? Treatment: Symptomatic.
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FUNGAL INFECTIONS? ?
? ANNULAR PLAQUES
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? relative clearing in the center.? edge of the lesion showing
papulovesiculation and scaling.
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? TINEAT. CORPORIS
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T. CAPITIST.CAPITIS
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? Noninflammatory tinea capitis:? Caused by anthropophilic organisms (e.g., T. verrucosum), so less
inflammation.
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? Inflammatory tinea capitis (kerion)
? Caused by zoophilic dermatophytes (e.g., M. canis), which elicit
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intense inflammation.? boggy swelling with pustulation. Often, the pus discharges from
multiple orifices. Hair from such a swelling is easily and painlessly
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pluckable
? WHICH BEDSIDE TEST WOULD
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YOU DO?
? Potassium hydroxide (KOH)
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scraping AND MOUNTING? Technique
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? Mount specimen on glass slide,adding 10% KOH (to dissolve the
keratin).
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? Keep for half an hour;
? nail clippings require longer (2 h)
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and warming (not boiling).? Fungus is easily detected using the
low power objective lens (10 ?)
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with the iris diaphragm closed and
the condenser positioned down.
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? Scenario: tinea capitis outbreakin a school
? What investigation should you
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do?
? Wood's light examination- green
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fluorescence? General measures
? Keeping area dry.
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? Avoiding use of syntheticclothes.
? In recurrent infection,
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prophylactic use of anti-fungal
talc
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? Systemic therapy isrecommended in the following
situations:
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? Extensive dermatophytic
infections.
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? Tinea unguium.? Tinea capitis
P. VERSICOLOR
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? Perifollicular, hypopigmented (or ? KOH mount
hyperpigmented), macules
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surmounted with branny scales. ? shows characteristic `spaghettiand meat ball' appearance.
? Upper trunk, neck, upper arms.
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? Topical agents? Systemic agents
? Imidazoles:Ketoconazole, 2%
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? Needed in extensive lesions or
applied daily for 4 weeks.
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when recurrences are frequent:? Selenium sulfide: 2.5% lotion in a ? Ketoconazole, 200 mg daily for
detergent base, used weekly for
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three consecutive days.
4 weeks.
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? Fluconazole, 400 mg single dose.? Itraconazole, 200 mg daily for 7
days.
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CANDIDAL INTERTRIGOCandidal paronychia
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Candidal balanoposthitis? frayed lesion in the groin with
satellite pustules.
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? Oral candidiasis:
? KOH mount shows budding yeasts
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and pseudo- hyphae.
? Culture
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? Rule out diabetes in patients withrecurrent infection.
? Rule out immunocompromised
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states in
recurrent/extensive/atypical
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disease.? General measures
? Topical agents
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? Predisposing factors should be
? Candidal intertrigo:Topical azoles
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sought and eliminated.(clotrimazole, miconazole, and
? Intertriginous areas should be kept
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ketoconazole) are effective.
dry by adequate wiping after a
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? Candidal paronychia: Topical azolebath.
lotions
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? In paronychia, prolonged
? Oral candidiasis: Lotions and oral
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immersion in water is best avoided.suspensions of azoles. Or nystatin.
? Genital candidiasis : Imidazole
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pessaries for vaginal infection.
Topical azoles for balanoposthitis.
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? Systemic therapy recommended ? Recurrent oral candidiasis: In
in the following situations:
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immunocompromised patients? Candidal vulvovaginitis: Single
(e.g., HIV infection), fluconazole,
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dose fluconazole (150 mg) or
150 mg weekly dose.
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itraconazole (400 mg).? Chronic mucocutaneous
? Weekly doses of fluconazole
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candidiasis: Requires prolonged
(150 mg) for recurrent problem.
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therapyMYCETOMA
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MYCETOMA? Begin as subcutaneous nodules,
? which slowly evolve into abscesses and draining sinuses
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? Over period of time, the surrounding tissue becomes hard due to
fibrosis.
? Investigations
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? Establish the diagnosis of mycetoma.? Identify the causative organism ( actinomycetes vs eumycetes).
? Find the extent of local spread
? Examination of pus and granules
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? Histology? Culture
? X-ray of the affected part
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? Treatment depends on whether? Eumycetoma
the mycetoma is actinomycotic or
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eumycotic.
? Ketoconazole
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? Actinomycetoma Responds to a 6? ? Itraconazole.9 months course of combination of ? Amphotericin B in resistant cases
chemotherapeutic agents like:
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Streptomycin + dapsone or co-
trimoxazole.
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? Surgical intervention:? Co-trimoxazole + amikacin.
? Deep debridement and even
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? Tetracyclines + streptomycin +
amputation may need to be done
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rifampicin.in case of recalcitrant lesions
? Penicil ins + gentamycin + co-
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trimoxazole
? ulcerated nodules are arranged
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in a linear fashion along thelymphatic drainage.
? single infiltrated plaque
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? Sporotrichosis
? Treatment:
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? Causative agent-
? Saturated solution of potassium
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? Sporothrix schenckii.iodide. Or itraconazole.
? cauliflower-like hypertrophic
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plaque
? Characteristically, surface is
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studded with black dots? Chromoblastomycosis
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? Trauma prone sites.? Treatment:
? Several fungi can cause
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? Itraconazole, flucytosinchromoblastomycosis
? painless subcutaneous swelling
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with smooth edge which can be
raised by inserting a finger under
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it? Subcutaneous phycomycosis
? Potassium iodide
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? GOOD DAY !!!!