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Dermatology > Infectious Dermatology Part 1 > Flashcards

Infectious Dermatology Part 1 Flashcards

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1
Q

What is the etiology of impetigo?

A
  • S. aureus: MSSA and MRSA
  • Bullous impetigo: epidermolytic toxin A producing staph aureus –> scalded skin syndrome
  • Beta-hemolytic strep group A
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2
Q

Epidemiology of impetigo

A
  • Children but can occur at any age
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3
Q

Where can impetigo be located?

A
  • Minor breaks in the skin
  • Around the nose
  • Atopic dermatitis
  • Traumatic wounds
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4
Q

What is bullous impetigo?

A
  • S. aureus exfoliative toxin A –> loss of cell adhesion in superficial epidermis
  • MC in newborn and older infants
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5
Q

What age is non-bullous impetigo seen?

A

All ages

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6
Q

Clinical manifestations of non-bullous impetigo

A
  • Often asymptomatic
  • Can be painful and tender
  • Erosions with crusts
  • 1-3 cm lesions
  • Central healing often after several weeks
  • Regional lymphadenopathy
  • Arranged in scattered, discrete lesions
  • without treatment confluent
  • satellite lesions from autoinoculation
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7
Q

Clinical manifestations of bullous impetigo

A
  • Vesicles progress to bullae
  • No erythema noted
  • Vesicles/bullae filled with serous fluid, yellow –> dark brown
  • Nikolsky sign
  • 1-2 days collapse and leave erosions with crusts
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8
Q

Clinical diagnoseis of impetigo

A
  • Clinical
  • Gram stain and culture often necessary for bullous type
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9
Q

Treatment of impetigo

A
  • Warm water soaks x 15-20 minutes twice daily followed by application of mupirocin (bactroban) x 5 days
  • For widespread infection = 7 days ABX either cephalexin or erythromycin
  • MRSA = doxycycline
  • Critically ill patients with MRSA or suspected MRSA should receive vancomycin or linezolid
  • Bullous or severe = PO ABX
  • Follow up in 1 week

Azithromycin, clindamycin, or erythromycin if penicillin allergy. Widespread pets lex erythromycin and doxycycline for MRSA

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10
Q

Patient education for impetigo

A
  • Good hygiene: clipping nails (prevent scratching), proper anti-bacterial soap, frequent washing
  • Underlying condition treatment
  • Mupirocin in other areas where skin barrier has been broken
  • Wounds covered
  • Avoid contact with others (>24 hours post ABX initiation)
  • Follow up in 1 week
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11
Q

Prevention of impetigo

A
  • BPO wash
  • Check family members for signs
  • Ethanol or isopropyl gel for hands
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12
Q

What is folliculitis

A

Infection of the hair follicle with +/- pus in the ostium of the follicle

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13
Q

Causes of folliculitis

A
  • Bacteria
  • Fungi
  • Mites
  • Virus
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14
Q

Clinical manifestations of folliculitis

A
  • Infection of hair follicle
  • +/- pus in ostium
  • Non tender/slightly tender
  • Pruritic
  • Can progress and become abscess or furuncle
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15
Q

Predisposing factors to folliculitis

A
  • Shaving hair bearing areas
  • Occlusion of hair bearing areas
  • Hot tub usage
  • Topical CS
  • Systemic ABX
  • Diabetes
  • Immunosuppression
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16
Q

Microbes that can cause folliculitis

A
  • S. aureus
  • Pseudomonas aeruginosa (hot tub) usually on trunk
  • Viral (herpetic and molloscum)
  • Fungal (candida, malassezia)
  • Syphilitic

GRAM NEGATIVE –> acne patient who worsens on systemic abx with small follicular pustules

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17
Q

An acne patient worsens on systemic antibiotics with small follicular pustules. What organism is likely responsible

A

Gram negative (gram negative folliculitis)

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18
Q

Diagnosis of folliculitis

A
  • Gram stain
  • C&S
  • KOH (fungal)
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19
Q

Treatment of mild (few) folliculitis

A
  • Warm compresses
  • Wash with BPO or antibacterial soap (dial)
  • ABX if spontaneous resolution does not occur within 2-3 weeks or if symptoms worsen
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20
Q

Treatment of moderate folliculitis

A
  • Topical ABX: clindamycin or mupirocin

Clin that mu fo follicle

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21
Q

Treatment of severe folliculitis

A
  • Oral - MSSA: cephalexin
  • Oral MRSA: doxycycline or bactrim

Follicles learning severe lessons on the bact dox

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22
Q

How do you prevent folliculitis?

A
  • BPO body wash (use on regular basis if prone to folliculitis)
  • Chlorhexidine body wash
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23
Q

What is an abscess?

A
  • Acute or chronic localized inflammation
  • Collection of pus in a tissue = inflammatory response to an infectious process of foreign body
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24
Q

Where can an abscess be located

A
  • Skin and dermis, subcutaneous fat, muscle
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25
Characteristics of abscess
* Tender * Red * Hot * Indurated nodules * +/- fever or constitutional symptoms * days/weeks = pus formation
26
Diagnosis of abscess
* gram stain * C&S of exudate ## Footnote Typically MSSA or MRSA
27
Treatment of abscess
* I&D * ABX therapy
28
When would antibiotics be given for abscess?
* Single abscess >2 cm * Multiple lesions * Extensive surrounding cellulitis * Immunosuppression or other comorbidities * S/S toxicity (fever >100.5, hypotension, or sustained tachycardia) * Inadequate clinical response to I&D alone * Indwelling medical device (prosthetic joint, vascular graft, or pacemaker) * High risk for transmission of s. aureus to others (athletes, group home)
29
When would IV abx be considered for abscess?
* Toxic appearance: fever, hypotension, tachycardia * Rapid progression after 48 hr of PO ABX * Inability to tolerate orals * Close to indwelling device such as prosthetics, graft, catheter
30
When would surgery with general surgeon or plastics be considered for abscess?
* Difficult areas * Palms * Soles * Nasolabial areas * Genitalia
31
Patient education for abscess
* Do not squeeze * Prevention with antibacterial soap or BPO wash * Avoid heat and friction
32
Clinical manifestations of furuncle
* Acute * Deep seated * Red, hot, tender nodule or abscess * 1-2 cm * Fluctuant * Nodule with cavitation after drainage * From a staphylococcal folliculitis * Any hair bearing region: beard, posterior neck, occipital scalp, axillae, buttocks (multiple or solitary lesions)
33
Management of furuncle
* Warm compresses 10 minutes daily * If erythema, ABX probably necessary * PO ABX: bactrim x 7 days, clindamycin x 7 days, or doxycycline x 7-10 days Doxy clin that bact fur
34
Clinical presentation of carbuncle
* Deeper infection * Interconnecting abscesses arising in several contiguous hair follicles * Typically ill appearing: fever + constitutional symptoms * Painful/tender * MC location = nape of neck, back, and thighs
35
Diagnosis of carbuncle
* Clinical * Gram stain helpful with C&S
36
Treatment of uncomplicated carbuncle
* PO ABX * Bactrim x 7 days * Clindamycin x 7 days * Doxycycline x 7-10 days Doxy clin the back of the car
37
Treatment of complicated carbuncle
* Admission for IV abx * Vancomycin 1-2 IV daily
38
Criteria for carbuncle admission
* Toxic appearing * Rapid progression * No improvement after 24-48 hours of PO ABX
39
Review: folliculitis definition
Infection of hair follicle +/- purulence at the ostium
40
Review: abscess definition
Localized inflammation with a collection of pus enclosed within the tissue
41
Review: furuncle definition
Infected nodule evolving from folliculitis
42
Review: carbuncle definition
Deeper infections of interconnecting furuncles ## Footnote all the furuncles in a car
43
What is necrotizing fasciitis
* Rapid progression of infection and destruction of subcutaneous tissue and fascia with extensive necrosis of soft tissues and overlying skin * AKA flesh eating disease * Bacteria release enzymes/gases that degrade fascia resulting in rapid proliferation, local thrombosis, ischemia, and necrosis
44
Etiology of necrotizing fasciitis
* Polymicrobial * Beta-hemolytic GAS * Pseudomonas aeruginosa * Clostridium
45
Where can necrotizing fasciitis originate?
* Site of nonpenetrating minor trauma * Bruise, muscle, or strain * Minor trauma * Laceration * Needle puncture * Surgical incision
46
Epidemiology of necrotizing fasciitis
* MC middle age (mid 30s - mid 40s) * DM * ETOH abuse * liver disease * CKD * Malnutrition
47
Diagnosis of necrotizing fasciitis
* Clinical If skin necrosis not obvious suspect if signs of sepsis + * Severe pain * Indurated swelling * Bullae * Cyanosis * Skin pallor * Skin hypesthesia * Crepitation * Muscle weakness * Foul smelling exudates
48
What is the progression of necrotizing fasciitis?
* Local redness * Edema * Warmth * Pain Appears 36-72 hours after onset * Involved soft tissue becomes blue in color * Vesicles and bullae appear and spread along fascial plane Progression to * extensive cutaneous soft tissue necrosis * Black eschar with surrounding irregular border of erythema * Fever and other constitutional symptoms
49
Clinical red flags for necrotizing fasciitis
* Severe, constant pain out of proportion to physical exam, or anesthesia * Erythema evolving into a dusky gray color * Malodorous, watery "dirty dishwater" discharge * Gas (crepitus or crackling sounds) in soft tissues * Edema extending beyond areas of erythema * Rapid progression despite antibiotic therapy
50
Treatment of necrotizing fasciitis
* Surgical debridement * CBC, CMP, CK, ABG, UA, serum/deep tissue culture * CT, MRI, plain film, GAS? Start broad spectrum ABX: depending on gram stain/C&S * Carbapenem * Ampicillin/sulbactam * Clindamycin * MRSA: vancomycin Necro CAMC (carbapenem, ampicillin/sulbactam, clindamycin, MRSA: vancomycin)
51
What is erysipelas?
Acute superficial infection (dermis and dermal lymphatic vessels)
52
Etiology of erysipelas
MC-group A B-hemolytic streptococcus
53
Epidemiology of erysipelas
* MC in young children and older adults
54
Clinical presentation of erysipelas
Prodrome: * fever * chills * anorexia * malaise General: +/- signs of sepsis Lesion: * painful/tender/hot * bright red * raised, edematous * indurated plaque * sharp borders
55
What is cellulitis
Acute infection of the dermis and subcutaneous tissue
56
Etiology of cellulitis
* S. aureus and group a b-hemolytic streptococcus * Cat/dog trauma: pasteurella multocida * Freshwater wound: aeromonas
57
Epidemiology of cellulitis
Middle age adults
58
Clinical presentation of cellulitis
Prodrome * Fever * Chills * Anorexia * Malaise General: +/- signs of sepsis Lesion: * Painful/tender/hot * Bright red, edematous (+/- induration) * Indistinct borders (not raised)
59
Risk factors for cellulitis
* Minor skin trauma * Body piercing * IV drug use * Tinea pedis infection * Animal bites * Peripheral vascular disease * Atopic dermatitis * Immune suppression (chronic systemic steroid use, neutropenia, immunosuppressive medications, alcohol use disorder) * Lymphatic damage (lymph node dissection, radiation therapy, vein harvest for coronary artery bypass surgery, and damage that occurs following multiple prior episodes of cellulitis)
60
Risk factors for erysipelas and cellulitis
* Compromised skin integrity: atopic dermatitis, insect bite, surgery, trauma, IV drug use * Compromised immune system: AIDS, DM, ESRD, CA, immunosuppressive therapy, drug/ETOH abuse
61
Diagnosis of erysipelas and cellulitis
* Clinical * Labs if systemic symptoms present * CBC, CMP, ESR, blood cultures * Imaging: US or MRI to rule out abscess, necrotizing fasciitis, pyomyositis, and gas forming anaerobic bacterial infection
62
Complications of erysipelas and cellulitis
* Abscess formation * Bacteremia * Endocarditis * Osteomyelitis * Metastatic infection * Sepsis * Toxic shock syndrome
63
Indications for admission/parenteral therapy for erysipelas & cellulitis
* Systemic presentation: Fever >100.5, hypotension, sustained tachycardia * Rapidly spreading lesion * Progression of clinical features after 48 h of oral abx * Unable to tolerate oral therapy * Comorbidities: immunosuppression, neutropenia, asplenia, cirrhosis, heart/renal failure * IV therapy can be switched to oral therapy once systemic s/s resolve
64
What parenteral therapy would be used for erysipelas and cellulitis?
* MRSA coverage: vancomycin (1st line), daptomycin (2nd line) * MSSA coverage: cefazolin, clindamycin, nafcillin
65
What oral therapy can be used for MRSA coverage of erysipelas & cellulitis
* Clindamycin (1st line) * AMoxicillin + one of the following: * Bactrim * Doxycycline
66
What oral therapy can be used for MSSA coverage in erysipelas and cellulitis?
* Cephalexin * Nafcillin * Clindamycin
67
What antibiotics should be used for erysipelas and cellulitis due to a dog/cat bite?
Augmentin (caused by pasteurella multocida
68
What antibiotics would be used for erysipelas/cellulitis due to a human bite?
Augmentin (caused by eikenella, group A streptococcus)
69
What antibiotics would be used for erysipelas/cellulitis due to exposure to fresh water? Salt water?
* Fresh water: ciprofloxacin (cover aeromonas) * Salt water: doxycycline (cover vibrio vulnificus)
70
What is lymphagnitis?
Acute inflammatory process involving the subcutaneous lymphatic channels
71
Etiology of lymphangitis
Acute: * GAS * S. aureus * Herpes simplex virus Chronic: * Mycobacterium marinum
72
What can lead to lymphangitis?
* break in skin * Wound * Paronychia * Primary herpes simplex
73
Symptoms of lymphangitis
* Pain +/- erythema proximal to break in skin * Red linear streaks and palpable lymphatic cord
74
Diagnosis of lymphangitis
* Clinical * Resolves with correct diagnosis and treatment * Culture wound if open and actively weeping * Labs only if systemic: CBC, CMP, blood cultures
75
Treatment of lymphangitis
* Oral ABX dependent on sensitivity * Dicloxacillin or 1st generation cephalosporin * MRSA: clindamycin or bactrim * Follow up in 24-48 hours * Admit if toxic appearing or no improvement after 24-48 hours The diclox named ceph has Lymphangitis so you have to clin that bacteria up
76
What is cutaneous candidiasis?
* superficial fungal infection of the skin * MC: candida albicans * MC neonates and adults >65 years old
77
Common areas involved in cutaneous candidiasis
* Genitocrural * Gluteal * Interdigital * Inframammary * Axilla * Under pannus
78
Risk factors for cutaneous candidiasis
* Obesity * DM * Local occlusion/moisture * Steroid/abx use * Hyperhidrosis * Incontinence
79
Presentation of cutaneous candidiasis
* Pruritic * Tender/painful * Macerated * Erythematous * Satellite lesions typically present
80
Diagnosis of cutaneous candidiasis
* Clinical * KOH prep
81
Treatment of mild to moderate cutaneous candidiasis
* Topical antifungals 2-3 weeks, continue x 2 weeks after clearance * Ketoconazole * Econazole * Clotrimazole * Miconazole
82
Treatment of severe cutaneous candidiasis
* Oral antifungals: fluconazole
83
Patient education for cutaneous candidiasis
Prevention is key * Keep areas dry * Powders * Hair dryer * Avoid occlusive clothing
84
What is balanitis
* Inflammation of the glans penis, can be triggered by numerous factors * Affects uncircumcised men with poor hygiene
85
Common infectious triggers of balanitis
* Candida * Trichomonas vaginalis * Gonorrhoeae * Streptococcus
86
Diagnosis of balanitis
* Culture * KOH * Tzank smear * RPR-syphilis * Patch test * depending on history
87
Treatment of balanitis
* Improved personal hygiene * Use of low to medium potency topical steroid until improved
88
What is dermatophyte infection
* Fungal infection that infects nonviable keratinized cutaneous structures * Includes: stratum corneum, nails, hair (can surviva in human scales for 12 months)
89
What are the 3 genera of dermatophytes?
* Trichophyton (MC): hair and nail * Microsporum * Epidermophyton
90
What is the most common area of dermatophyte infection by age?
* Scalp MC in children * Intertriginous areas in young and older adults
91
How are dermatophytes transmitted?
* Person to person (MC) * Animals * Soil (least common)
92
Pathophysiology of dermatophytes
* Dermatophytes produce enzymes that break down keratin allowing fungi to invade epidermis, nail, and hair shaft
93
Areas affected by dermatophytes
* Feet (tinea pedis) * Groin (tinea cruris) * Trunk/extremities (tinea corporis) * Hands (tinea manuum) * Face (tinea facialis) * Hair (tinea capitis) * Facial hair (tinea barbae) * Nails (onychomycosis)
94
Classifications of dermatophytes
* Person to person = anthropophilic * Animal to human = zoophilic * Environmental = geophilic
95
Predisposing factors to dermatophytes
* Atopy, ichthyosis * Collagen vascular disease: RA, SLE, temporal arteritis, scleroderma * Steroid use (oral/topical) * Sweating, local occlusion * Occupational exposure
96
Diagnosis of dermatophytes
* Skin and nail for KOH and direct microscopy * Woods lamp with microsporum blue green fluorescence * Fungal culture * Dermatopathology via skin biopsy
97
How is a KOH prep done?
* Skin: use blade to scrap skin cells from area * Nail: use dull scalpel to remove excess keratin from nail * Hair: remove hair at root * 2 drops of 10% KOH on glass slide and let sit for 15 minutes * Inspect under low and high power: hyphae and spores will be present
98
How is fungal culture performed?
* Skin: specimen obtained with brush * Hair: specimen remove 5-10 hairs with forcep/hemostat at one time, use brush to obtain scales and inoculate fungal medium * Nail: use fingernail clipper or sharp curette to obtain keratinous debris from under nail * Place specimen inside fungi culture medium ## Footnote Limitations: requires days - wks to return definitive diagnosis; benefits: differentiates between fungal spp
99
Treatment of dermatophyte infection
Topical antifungals * Imidazoles: clotrimazole, miconazole, ketoconazole Allylamines: Naftfine, terbinafine Systemic antifungals * CBC, Cr, LFTs * Imidazoles: itraconazole, ketoconazole, fluconazole * Allylamine: terbinafine
100
Benefits and limitations of dermatopathology via skin biopsy for dermatophytes
* Benefits: most sensitive form of diagnosis * Limitations: skin biopsy sample required, more invasive testing
101
Epidemiology of tinea capitis
* MC in children * MC in african americans
102
What are the parts of tinea capitis
* Ectothrix outside of hair shaft: grey patch that is scaly, circular with hairs broken off, very brittle * Endothrix within hair shaft: black dot, kerion, favus
103
Presentation of non-inflammatory tinea capitis
* Scaling * Pruritis * Alopecia * Adenopathy
104
Presentation of inflammatory tinea capitis
* Pain * Tenderness * Alopecia
105
Why does tinea capitis have a black dot at the endothrix?
* Broken off hairs near the scalp --> swollen hair shafts * Diffuse and poorly circumscribed * Caused by T. tonsurans. or T. violaceum
106
What is a kerion?
* In tinea capitis * Inflammatory mass where remaining hairs are loose * Boggy, purulent, inflamed nodules, and plques * Painful --> drains pus from multiple openings * Hairs do not break off but fall out or pulled without pain * Crusting and matting of surrounding hairs * Caused by T. verrucosum, t. mentagrophytes, heals with scaring alopecia
107
What is a favus?
* Tinea capitis * Perifollicular erythema and matting of hair * Thick/yellow crusts * Odor * Doesn't clear spontaneously * Results in scarring alopecia
108
Diagnosis of tinea capitis
* Woods lamp: T. tonsurans doesn't fluoresce * Direct microscopy * Fungal culture: usually growth seen in 10-14 days * Bacterial culture: to rule out bacterial with staph (can have superimposed infections)
109
Treatment of tinea capitis
* If left untreated permanent hair loss! * PO antifungals: terbinafine, griseofulvin * Antifungal shampoos: ketoconazole 2% shampoo
110
Prevention of tinea capitis
* Wash clothing, bedding, and towels * Wash furniture if in contact * Avoid used pillow cases * Avoid head to head contact * Disinfect combs and other hair products | `
111
What is tinea cruris?
* "Jock itch" * Tinea of inguinal folds and thighs * MC in males, coexists with tinea pedis typically * Subacute or chronic dermatophytosis of upper thigh and adjacent inguinal and pubic regions
112
Clinical presentation of tinea cruris
* Large scaling, well demarcated dull red/tan/brown plaques * Central clearing * Papules and pustules @ margins * Treated = lack scale * Post-inflammatory hyperpigmentation in darker skinned persons * Scrotum and penis rarely involved
113
Diagnosis of tinea cruris
Clinical diagnosis
114
Treatment of tinea cruris
Topical antifungal x +/- 3 weeks: * Ketoconazole *Econazole: zeasorb AF powder PO antifungals if failure of topicals: * Griseofulvin
115
Management/prevention of tinea cruris
* Wear shower shoes while bathing * Put on socks before pants * Antifungal/drying powders * Benzoyl peroxide wash * Alcohol based sanitizer gels * Avoid tight fitted clothing/use cotton underwear
116
What is tinea corporis?
* Ring worm * Fungal/dermatophyte infection involving anywhere on the body * Wrestlers infection
117
diagnosis of tinea corporis
* Clinical * Biospy if unsure
118
Findings of tinea corporis
* Asymptomatic * Pruritis depending on area * Sharply marginated plaques * Vesicles and papules * Central clearing
119
Treatment of tinea corporis
* Topical antifungals * Oral antifungals: terbinafine; need CBC, Cr, LFT's
120
What is tinea pedis?
* MC dermatophyte infection: athlete's foot
121
Presentation of tinea pedis
* Erythema * Scaling * Maceration * +/- bullae formation (if tinea cruris diagnosed check feet) * MC age 20-50 y/o
122
Risk factors for tinea pedis
* Hot * Humid climate * Occlusive footwear * Hyperhidrosis
123
Subtypes of tinea pedis
* Interdigital * Moccasin * Inflammatory * Ulcerative
124
Presentation of interdigital type of tinea pedis
* Dry scaling * Maceration * Fissuing: hyperhidrosis common; MC site between 4th and 5th toe
125
Presentation of moccasin type of tinea pedis
* Well demarcated * Scaling with erythema * Papules at margin * Fine white scale * Hyperkeratosis: MC on soles or lateral border of feet; MC bilateral
126
Presentation of inflammatory type of tinea pedis
* Vesicles or bullae with clear fluid * Pus usually indicates secondary bacterial infection * After rupture erosions like ragged ringlike border * ID reaction can occur * MC on sole, instep, and web spaces
127
Presentation of ulcerative type of tinea pedis
* Extension of interdigital tinea pedis onto the plantar and lateral foot * May have secondary bacterial infection --> S. aureus
128
Treatment of tinea pedis
Topical antifungal * BID x 2-4 weeks * Ketoconazole & Econazole BID Oral antifungal: best for hyperkeratotic * Terbinafine; Blood work prior (Cr, LFT's CBC) and monitor
129
Prevention of tinea pedis
* Wash with BPO daily * Use antifungal powder * Shower shoes in communal showers * Alcohol based sanitizers
130
What is tinea versicolor?
* Pityriasis versicolor * Not part of group caused by dermatophyte * MC adolescents * Overgrowth of malassezia furfur * Seen often in patients with oily skin * Not contagious
131
Risk factors for tinea versicolor
* Climate * Sweating * Immunodeficiency * Products * Steroid use * Oily skin
132
Presentation of tinea versicolor
* Some itching, possibly psychological * Macules +/- scale * Patches +/- scale * Plaques +/- scale\ * Hypo/hyperpigmentation * Erythema
133
Diagnosis of tinea versicolor
* KOH shows hyphae and budding yeast (spaghetti and meatballs) * Woods light
134
Treatment of tinea versicolor
* Selenium sulfide or zinc pyrithione * Topical antifungals --> ketoconazole * PO therapy not recommended unless failure of topicals
135
A 8 year old boy is brought in for evaluation of a chronic rash on his trunk. Examination reveals multiple erythematous, scaling plques and papules with raised borders and some central clearing. What is the best next step in management?
Examine scrapings in a 20% KOH solution by direct microscopy
136
A 26 year old female presents with a rash consisting of hypopigmented macules and papules with fine scales located on the lower back and abdomen. Which of the following laboratory findings is consistent with the most likely diagnosis?
Large blunt hyphae with budding spores ## Footnote tinea versicolor
137
138
A 19 year old male college student presents with an asymptomatic rash extending over his upper trunk, shoulders, and neck. The hypopigmented annular lesions vary in size from 4 to 5 cm in diameter to larger, confluent areas. There is no visible scale associated with the lesions What organism is the most likely cause of his symptoms?
Malassezia furfur ## Footnote tinea versicolor
139
What is the best description of erysipelas?
Localized painful, distinctly demarcated, raised erythema and edema often with streaking and prominent lymphatic involvement

Dermatology (12 decks)

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