test your knowledge with multiple-choice cases · pura. more advanced lesions are often palpable....

Copyright©

Not for Sale or

Commercial Dis

tribution

Unauthorised u

se prohibited. A

uthorised users

can download

,

display, view an

d print a single c

opy for persona

l use

The Canadian Journal of CME / July/August 2012 33

DERMCASETest your knowledge with multiple-choice cases

This month – 15 cases:

1. Large, Red Eyelid Growth p.332. Torso Rash Preceded by Patches p.343. Alarming Body Rash p.364. Papule on the Nose p.385. Weight Gain

and Cutaneous Manifestations p.406. Dry, Red, Cracked Skin on Thumb p.427. Swollen Chest Nodule p.44

8. Itchy, Swollen Lips p.469. A Swollen, Red Umbilical Stump p.4710. Abdominal Pain Followed by Rash p.4811. Enlarging Lesion on the Flank p.4912. Premature Breast Enlargement p.5013. Growth Underneath The Tongue p.5114. Bilateral, Hypopigmented Macules p.5215. Discoloured Areas on the Foot p.53

This 79-year-old man has had this developinggrowth at the corner of his eyefold over a 10-yearperiod. It has been interfering increasingly with hislateral vision, but it is otherwise asymptomatic.

What is your diagnosis?a. Solitary neurofibromab. Basal cell carcinomac. Epidermoid cystd. Amelanotic dermal nevuse. Giant angioma

AnswerSolitary neurofibroma (answer a) is a benign lesionnot associated with internal abnormalities. It occursin the superficial dermis, is unencapsulated, and iscomposed of myxomatous stroma and Schwanncells. It grows slowly and is asymptomatic, forming

soft pinkish-white papulonodules from 2 to 20 mmin size. It can easily be invaginated. When desired, itcan be easily excised.

Large, Red Eyelid Growth

Case 1

Stanley J. Wine, MD, FRCPC, is a Dermatologist in NorthYork, Ontario.

34 The Canadian Journal of CME / July/August 2012

A 30-year-old male presents with a skin rash of five-days duration, which was preceded by two patches thatwere initially mildly pruritic. He has no prior history ofskin conditions or any other health concerns.

What is your diagnosis?a. Tinea versicolor b. Numular eczemac. Guttate psoriasis d. Pityriasis rosea

AnswerPityriasis rosea (answer d) is an acutely presentingskin rash that involves the trunk in older childrenand young adults. The rash is mostly preceded by aherald patch, which is a round, sharply delineatedlesion. It is believed to be caused by human herpesvirus type 7 (HHV-7). Diagnosis is clinical; pres-ence of the herald patch prior to the rash is the hall-mark of pityriasis rosea. Pityriasis rosea is self lim-ited, resolving without intervention. Symptomatictreatment for pruritus might be needed.

Torso Rash Preceded by Patches

Case 2

Cherinet Seid, MD, LMCC, CCFP, DTM (RCPS Glas),is the Lead Physician of the North Renfrew Family HealthTeam, Deep River, Ontario, Emergency Physician at DeepRiver and District Hospital, and Assistant Professor atNorthern Ontario School of Medicine, Sudbury, Ontario.

DERMCASE


DERMCASE

This gentleman presents for an emergency appointmentwith his doctor, because he is terrified as a result ofthese rashes, which began to appear a day before.He had a severely sore throat two days prior to the

rash. He was prescribed penicillin at a walk-in clinicafter taking a throat swab.He is a very healthy gentleman, and sees his doctor

very occasionally; he is on no regular medication and isnot known to suffer from any allergies.

What is your diagnosis?a. Leukocytoclastic vasculitisb. Dermatitis herpetiformisc. Erysipelasd. Impetigo

Answer Leukocytoclastic vasculitis (answer a) — also calledhypersensitivity angiitis, allergic vasculitis — is aninflammation of dermal venules with immune complexdeposition and fibrinoid necrosis.It favours children and young adults. In older

patients, leukocytoclastic vasculitis often results from adrug reaction or reflection of systemic vasculitis.There are many possible triggers for leukocytoclas-tic vasculitis, such as infections (streptococci, tuber-culosis, hepatitis B and C), collagen diseases (lupuserythematosis, sjogren syndrome, and rheumatoidarthritis), complement defects, and serum sickness.Usually, immune complexes are formed then

deposited in the venules, where they activate comple-ments and establish inflammatory reactions that dam-age the vessel wall.

The hallmark of leukocytoclastic vasculitis is pur-pura. More advanced lesions are often palpable. Otherlesions may be urticarial, pustular, or necrotic. Thelower legs are 100% involved by the rash, arms 15%,mucosa 15%, external ears 10%, and conjunctivae 5%.

Alarming Body Rash

Case 3

Therapy Includes the following:

• If acute onset, treat the trigger

• Often no therapy is needed; bed rest and compression stockings help

• Prednisone 60 mg q.d. for three to five days

• If recurrent, dapsone 0.5 to 2.0 mg/Kg q.d. or colchicine 0.5 to 1 mg q.d.

Therapy for Leukocytoclastic Vasculitis

Hayder Kubba, MBChB, LMCC, CCFP, FRCS(UK),DFFP, DPD, graduated from the University of Baghdad,where he initially trained as a Trauma Surgeon. Hemoved to Britain, where he received his FRCS andworked as an ER Physician before specializing in FamilyMedicine. He is currently a Family Practitioner inMississauga, Ontario.


DERMCASE

A 44-year-old female presents with a stable papule onher nose of several years duration. She has no personalor family history of skin cancers.

What is your diagnosis?a. Basal cell carcinoma b. Verruca vulgarisc. Compound nevus d. Spider angiomae. Angiofibroma

AnswerAn angiofibroma (answer e) is a common, benignpapule, most commonly seen on or around the nose.Most lesions are asymptomatic, although minor traumacan induce bleeding in some cases. There is no genderor racial predilection, and most patients presentbetween 25- and 45-years-of-age.Most angiofibromas are small (1 to 5 mm), firm,

dome-shaped papules with a shiny appearance. Theyare skin-coloured to reddish. They typically present asone lesion, although two to three papules are occasion-ally observed.

Angiofibromas may be biopsied or excised to con-firm the diagnosis (a basal cell carcinoma is in the dif-ferential diagnosis). Treatment options include electro-surgery, laser, shave excision, or curettage; cosmeticoutcome is usually excellent.

Papule on the Nose

Case 4

Benjamin Barankin, MD, FRCPC, is a Dermatologistpracticing in North York, Ontario.


DERMCASE

A 59-year-old Caucasian man presents to the emer-gency department with a three-day history of non-tender abdominal distention and weight gain. Hispast medical history includes hypertension, dyslipi-demia, and a prior diagnosis of hepatitis C virusinfection fifteen-years previous. The patient deniesconsuming excessive alcohol. Physical examinationreveals numerous tattoos, proximal muscle wasting,multiple spider nevi on his upper trunk, bulgingflanks with shifting dullness, as well as the cuta-neous manifestations shown in Figure 1.

What is your diagnosis?a. Diabetes Mellitusb. Thyrotoxicosisc. Cirrhosisd. Rheumatoid Arthritise. Lymphoma

AnswerCirrhosis (answer c) results from progressive fibrosisof the liver. With time, these changes irreversibly alterhepatocellular architecture, ultimately leading to hepat-ic failure and a significantly shortened life expectancy.In North America, the most common causes of cirrho-sis are alcohol and hepatitis C virus infection. Thispatient exhibited some of the classic cutaneous mani-festations (or stigmata) of advanced cirrhosis. Theseincluded palmar erythema (arrowheads, Figure 1) andDupuytren’s contracture (arrow, Figure 1). Palmar ery-thema results from an exaggeration of normal palmarmottling and is thought to be caused by alterations in

the metabolism of sex hormones. It is seen on thethenar and hypothenar eminences, with central palmarsparing. Dupuytren’s contractures are due to shorteningand thickening of the palmar fascia, which slowly flex-es the affected digit. While accumulation of free radi-cals may play a role, the precise underlying pathophys-iology is unknown. Neither of these cutaneous mani-festations are specific for cirrhosis; however, their co-occurrence along with findings on history and physicalexamination support the diagnosis.

Weight Gain and Cutaneous Manifestations

Case 5

Brent M. McGrath, MD, MSc, PhD, is an AssociateChief Resident from the Department of Medicine atDalhousie University in Halifax, Nova Scotia. He worksat the Saint John Regional Hospital in Saint John, New,Brunswick.

Mallory S. Toner, BSc, and Marcella D. Cronkhite, BN,BSc, are Medical Students in the Faculty of Medicine atDalhousie University, Halifax, Nova Scotia.

Figure 1: Classic Cutaneous Manifestations of Advanced Cirrhosis


DERMCASE

A two-year-old boy visits the clinic with his mother,because he developed dry, red, cracked skin over his leftthumb.

What is your diagnosis?a. Scabiesb. Contact dermatitisc. Impetigod. Thumb-sucking

AnswerThumb-sucking (answer d) for many younger chil-dren can be a way to relieve the feeling of hunger.About 70 to 90% of infants suck their thumb, butmost of them gradually stop on their own betweenthe ages of three and six. A thumb-sucking childusually places the thumb in the mouth above thetongue, pressing forward against the upper frontteeth or gums, and backward against the lower frontteeth or gums. Thumb-sucking in children youngerthan four is not usually problematic. Prolonged fin-ger sucking can create crowded, crooked teeth, orbite problems. The child may also develop speechproblems or problems with swallowing properly.Protrusion and displacement of front teeth are com-mon results of thumb sucking. This can affect thechild’s appearance and cause further emotional

problems. Prolonged finger sucking can also causeminor physical problems like chapped skin, callus-es, and fingernail infections. Problem thumb-suck-ing is most often resolved with home treatments,such as offering rewards and praise when the childis not thumb-sucking. If home treatments do notwork, other treatments may be necessary. Thesetreatments include behavioural therapy, thumbdevices, and oral devices, such as palate changeswith the teeth pushed forward.

Dry, Red, Cracked Skin on Thumb

Case 6

Jerzy K. Pawlak, MD, MSc, PhD, is a GeneralPractitioner in Winnipeg, Manitoba.


DERMCASE

A 13-month-old infant presents with a swollen noduleover the left upper chest. It has been there for the pasttwo weeks. The mother recalls a dimple that has beenpresent in the area since birth.

What is your diagnosis?a. Branchial cleft sinus and cyst b. Accessory nipple c. Wattled. Thyroglossal duct cyst e. Atypical mycobacterial infection

AnswerBranchial cleft sinuses and cysts (answer a) areepithelial cysts formed along the course of the firstand second branchial clefts as a result of improperclosure during embryonic development. They aregenerally located along the lower third of the lateralaspect of the neck. Lesions may be unilateral orbilateral, and they may open onto the cutaneous sur-face or may drain into the pharynx. Lesions are pre-sent at birth as cystic swellings. They are benign,but occasionally may become infected and painful,as is the case above. If they become symptomatic,they may be surgically corrected. It is doubtful that this lesion is a thyroglossal

cyst/sinus, as these tend to occur near the midline ofthe neck. These lesions represent persistence of theembryonic structure associated with normal thyroiddescent, and move when swallowing.This is unlikely to be a wattle, otherwise known

as a congenital cartilaginous rest of the neck. This isa rare developmental abnormality that tends to fre-quently occur as small, fleshy appendages, ratherthan the cystic structure we see in this case. Wattlesare generally located on the anterior neck or near thelower half of the sternocleidomastoid muscle.

It is implausible that the nodule is a supernumer-ary nipple (polythelia), as they tend to occur along,or slightly medial to, the embryologic milk line.They also tend to manifest more commonly assmall, brown or pink, concave, umbilicated, or ele-vated papules. They are most common on the chestor upper abdomen and are occasionally seen in othersites including the face, neck, shoulder, back, geni-tals, and thighs. Atypical mycobacterial infections tend to occur

in immunocompromised individuals or in animmunocompetent host following skin trauma.These present most commonly as cervical lym-phadenitis in healthy children.

Swollen Chest Nodule

Case 7

Tram Nguyen is a third year Pediatric Resident at McMasterUniversity, Hamilton, Ontario.

Joseph M. Lam is a Clinical Assistant Professor ofPediatrics and Associate Member of the Department ofDermatology and Skin Sciences at the University ofBritish Columbia. He practices in Vancouver, BritishColumbia.


DERMCASE

A seven-year-old boy presents with itchy, swollen lipsan hour after ingesting some chocolate. There is noassociated dyspnea or dysphagia.

What is your diagnosis?a. Dermatomyositis b. Angioedemac. Urticaria d. Cellulitis

AnswerAngioedema (answer b) is characterized by diffuse,subcutaneous tissue swelling with normal or erythe-matous skin. The lesion may be intensely pruritic oritchy. There may also be a burning or stinging sen-sation at the affected site. Angioedema usuallyaffects the face, but it may also involve the handsand feet, and rarely the genitalia. There may beassociated dyspnea or dysphagia. The release of his-tamine, leukotrienes, and bradykinin from theaffected cells causes vasodilatation and increasedvascular permeability with resuling edema.Angioedema is most commonly caused by a

type 1 anaphylactic, an immunoglobulin E-mediat-ed response, or immediate hypersensitivity reactionto a food, drug, insect venom, preservative, latexproduct, or aeroallergen. Angioedema may alsodevelop consequent to a type II cytotoxic reaction(transfusion reaction) or a type III antigen-antibodycomplex reaction (serum sickness). A subset ofangioedema (vibratory angioedema and exercise-induced angioedema) results from hypersensitivityto a mechanical or physical factor. Hereditary

angioedema is an autosomal dominant disordercaused by the absence or dysfunction of the C1inhibitor.Angioedema is usually self-limited, but known

triggers should be avoided. Pruritus can be relievedwith antihistamines. Intramuscular epinephrine(1:1,000), 0.01ml/kg (maximum dose, 0.3 ml), usu-ally provides rapid relief of acute, severe angioede-ma. A short course of systemic corticosteroidshould be considered for severe episodes ofangioedema.

Itchy, Swollen Lips

Case 8

Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel),FRCPCH, is a Clinical Professor of Pediatrics at theUniversity of Calgary, Calgary, Alberta.

Alex H.C. Wong, MD, CCFP, is a Clinical AssistantProfessor of Family Practice at the University of Calgary,Calgary, Alberta.

DERMCASE

A 29-year-old male is seen in the ER with a painful,swollen, red umbilical stump. It developed progressive-ly over one week. He has no fever and no history oftrauma or piercing. He has not had any prior similarpresentations.

What is your diagnosis?a. Umblical hernia b. Phlebitis c. Umblical granuloma d. Omphalitis with abscess

AnswerOmphalitis with abscess (answer d) is the diagnosis.Omphalitis, an infection of the umbilical stump, is wellknown in new borns, but is rather rare in adults.Folliculitis can be an underlying cause here. If this

condition recurs, the possibility of infection of the rem-nants of the allantois or omphalomesenteric (vitline)duct should be considered. Imaging with ultrasound orCT scan will be necessary in such cases.Treatment involves antibiotic use to cover both gram

positives and negatives, as etiologic agents of omphali-tis tend to be polymicrobial. Incision and drainage isrequired when there is an abscess. Specific antibioticscan then be chosen depending on the culture and sensi-tivity result.

Early treatment is necessary to prevent furtherspread of the infection into the fascia and abdominalmuscles. Recurrent cases due to remnants of the allan-tois or veteline duct would require further surgicalremoval of these remnants.

A Swollen, Red Umbilical Stump

Case 9

Cherinet Seid, MD, LMCC, CCFP, DTM (RCPS Glas),is the Lead Physician of the North Renfrew Family HealthTeam, Deep River, Ontario, Emergency Physician at DeepRiver and District Hospital, and Assistant Professor atNorthern Ontario School of Medicine, Sudbury, Ontario.


DERMCASE

A six-year-old girl presents with abdominal pain, bilat-eral knee pain, smoky urine, and a rash. She had a sorethroat two-weeks-ago.

What is your diagnosis?a. Henoch-Schönlein purpura b. Idiopathic thrombocytopenic purpurac. Poststreptococcal glomerulonephritis d. Systemic lupus erythematosus

AnswerHenoch-Schönlein purpura (HSP) (answer a) is anIgA-mediated, systemic small-vessel vasculitis witha predilection for the skin, gastrointestinal tract,joints, and kidneys. Approximately 75% of casesoccur in children between 2- and 11-years-of-age,with a peak at 4- to 7-years-old. The hallmark is apressure or gravity-dependent purpuric or petechialrash. Abdominal pain, arthritis, and nephritis arecommon. Between 60 and 75% of patients withHSP have a history of upper respiratory tract infec-tion. Streptococcus is the most common infectingorganism.Most cases are self-limited. The average duration

of the disease is four-weeks. Recurrences are report-ed in up to 33% of patients. Therapy consists of gen-eral and supportive measures as well as treatment of

the sequelae of the vasculitis. Prednisone should beconsidered for patients with severe gastrointestinalor joint involvement. Early prednisone treatmentdoes not prevent renal disease, although it is effec-tive in treating renal involvement and reduces theodds of developing persistent renal disease.

Abdominal Pain Followed by Rash

Case 10


Andrew S. Wong, MD, CCFP, is a Resident in theDepartment of Family Medicine at the University of Calgary,Calgary, Alberta.

This 50-year-old man has had a slowly enlarging lesionon his flank for three years. It is asymptomatic.

What is your diagnosis?a. Eczemab. Seborrheic keratosis c. Basal cell carcinomad. Psoriasise. Bowen’s disease

AnswerBowen's disease (answer e), otherwise known asintraepithelial squamous cell carcinoma, is mostoften located on chronically sun exposed skin, but itcan occur elsewhere. Most grow slowly over timeand seldomly progress to squamous cell cancer.Lesions are usually solitary with a well defined bor-der. Depending on the degree of colour, erythema,and scale, any of the choices above need to be con-sidered. Indeed, a biopsy is often required to arriveat the correct diagnosis. Most commonly, suchlesions are excised or curetted and cauterized.

At times, due to the infirmity of the patient orlocation and size of the tumour, medical treatmentusing topical imiquimod or fluorouracil has beenused.

Enlarging Lesion on the Flank

Case 11

Stanley J. Wine, MD, FRCPC, is a Dermatologist in NorthYork, Ontario.

DERMCASE


DERMCASE

A two-year-old girl presents with enlargement of thebreasts, most notable on the right. There is no dischargefrom the nipples. Her health is otherwise unremarkable.

What is your diagnosis?a. Neurofibromas of the chest wall b. Premature thelarche c. Neonatal hyperplasia of the breastsd. Gynecomastia

AnswerPremature thelarche (answer b) denotes isolated breastdevelopment before the age of eight-years in girls whodo not manifest any other signs of pubertal develop-ment. The condition is especially prevalent during thefirst two years of life. Premature thelarche may resultfrom an “overactivation” of the hypothalamic-pituitaryaxis in early childhood, secondary to altered sensitivityto steroids of the hypothalamic receptors controllingsexual maturation, increased circulating free estradiol,increased sensitivity of breast tissue to estrogens, andincreased production of adrenal androgens from thezona reticularis. The increased adrenal androgens mayserve as precursors to the peripheral conversion toestrogens. Premature thelarche may also result from amutation in the GNAS gene. The enlargement mayinvolve only one breast or both breasts, with one

notably larger than the other. Breast size may fluctuatecyclically. Breast enlargement is not usually excessive,and no significant changes of the nipples or areolaedevelop. Children with premature thelarche are of nor-mal height and weight. Growth and osseous maturationare normal. Menarche occurs at the normal time andthe pattern of adolescent sexual development and func-tion is normal. Laboratory tests are seldom indicated.The condition is benign, and no therapy is necessary.

Premature Breast Enlargement

Case 12


A 63-year-old male presents with a painless growthon the dorsum of the tongue. He states that henoticed it only a few weeks ago. It has been yearssince he quit smoking. He has no constitutionalsymptoms, and he has no associated lymphadenopa-thy.

What is your diagnosis?a. Squamous cell carcinomab. Papilloma c. Hemangiomad. Mucocele

AnswerHemangioma (answer c), biopsy proven, is thediagnosis. Hemangiomas are mostly diagnosed inearly life as a result of congenital malformations.When they occur in adults, they tend to result fromrepetitive trauma to the blood vessels. Tonguehemangiomas comprise the most common heman-giomas of the head and neck. The lesion shown herewas excised in office under local anaesthesia fol-lowed by suturing with no complication.

Growth Underneath The Tongue

Case 13

Cherinet Seid, MD, LMCC, CCFP, DTM(RCPS Glas),is the Lead Physician of the North Renfrew Family HealthTeam, Deep River, Ontario, Emergency Physician at DeepRiver and District Hospital, and Assistant Professor atNorthern Ontario School of Medicine, Sudbury, Ontario.

DERMCASE


DERMCASE

A 12-year-old boy presents with bilateral, hypopig-mented macules over the cheeks. His symptomshave been present over the summer months.

What is your diagnosis?a. Vitiligob. Tinea versicolor c. Nevus anemicus d. Pityriasis albad. Nevus depigmentosus

AnswerPityriasis alba (answer d) is a disorder characterized bypost-inflammatory hypopigmentation, often in atopicindividuals, and it is most frequently seen in individu-als with darker skin. Histologic evaluation shows nor-mal numbers of melanocytes, but they are often degen-erated or dysfunctional. Most cases of pityriasis albabecome apparent after sun exposure, which enhancesthe contrast between areas with intact pigmentaryresponse to ultraviolet light and areas of pityriasis alba.Treatment usually involves moisturizing and sun pro-tection. Repigmentation can take several months toyears. Vitiligo is an acquired pigmentary disorder of the

skin and mucous membranes in which some, or all, ofthe melanocytes in the affected skin are selectivelydestroyed. It is characterized by well-delineated depig-mented macules and patches. On Wood’s lamp exami-nation, vitiligo lesions commonly show chalky-whiteaccentuation. Tinea versicolor is a common, superficial fungal

disorder of the skin characterized by multiple scalinghypo- or hyperpigmented oval macules, patches, or thinplaques. They generally occur in sebum-rich areas ofthe upper trunk and proximal arms and less commonlyover the face or neck. Most cases present in adoles-cents. Similar to pityriasis alba, sun exposure can leadto accentuation of affected areas.

Nevus anemicus is a congenital vascular anomalythat presents clinically as a hypopigmented macule orpatch. The underlying cause is hypersensitivity to cate-cholamines, leading to localized vasoconstriction, andit can be distinguished from other hypomelanoses bydiascopy (applying pressure with a glass slide to thelesion and adjacent unaffected skin). With diascopy,nevus anemicus lesions become indistinguishable fromthe surrounding skin, which is now blanched from thepressure of the slide. Loss of melanin does not occur inthe lesion, and, thus, there is no enhancement onWood’s lamp examination. Rubbing of the affected areafails to cause vasodilation or erythema, unlike nevusdepigmentosus. Nevus depigmentosus is an uncommon skin condi-

tion characterized by nonprogressive hypopigmentedlesions presenting at birth or soon after. It most com-monly affects the trunk and can be segmental. Unlikenevus anemicus, it has an erythema response to friction.

Bilateral, Hypopigmented Macules

Case 14

Jack Chang is a final year Medical Student at the Universityof British Columbia, Vancouver, British Columbia.

Joseph M. Lam is a Clinical Assistant Professor ofPaediatrics and Associate Member of the Departmentof Dermatology and Skin Sciences at the University ofBritish Columbia. He practices in Vancouver, BritishColumbia.

DERMCASE

A 19 year-old male has slowly enlarging, asympto-matic, discoloured areas on the bottom of his foot.

What is your diagnosis?a. Tinea pedis b. Foreign body granulomasc. Cornsd. Pitted keratolysise. Plantar warts

AnswerPlantar warts (answer e) generally occur as a result ofthe human papillomavirus (HPV) types 1, 2, or 4. Theyare transferred through direct contact, often in publicshowers, pools, and gyms. This virus can spread to sur-rounding areas, but it is not thought to be capable ofspreading to areas beyond those in proximity to the out-break, such as the genitalia. Warts can occur at any age,though children and adolescents are most commonlyaffected.Plantar warts are typically self-limited but some-

times can last for several years. Unfortunately, there isno simple foolproof treatment for warts, hence, variousmodalities, can and often need to be tried. Over thecounter salicylic acid preparations or compounded acidmixtures are a great starting point; these are bestapplied after scraping down the wart with a pumicestone. Cryotherapy using liquid nitrogen on a regular

basis is often a useful destructive method, and occa-sionally cantharidin is also used. For stubborn or resis-tant warts, excision or electrosurgery can be tried, ascan CO2 or pulsed dye laser therapy, immunotherapywith diphencyprone or candida antigen, or even intrale-sional bleomycin.

Discoloured Areas on the Foot

Case 15

Benjamin Barankin, MD, FRCPC, is a Dermatologistpracticing in North York, Ontario.

test your knowledge with multiple-choice cases · pura. more advanced lesions are often palpable....

Documents