Derma

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Dermatology Team 441

Introduction to
dermatology
(Structures & functions of the skin + the language of dermatology)

Objectives:

● Function, Structure of the skin

● Approach to dermatology patient

● Morphology of skin lesions and descriptive Terms

● Important signs and Investigations

● Topical therapy

Color index:

- Main text
- Important
- Dr’s explanation
- Golden notes
- Extra

This lecture was originally done by both 438 & 439 teams.
So great thanks to them
Function, Structure of the skin

The Skin:
● The skin is the largest organ of the body.
● Body surface area of 1.5- 2 m2
● Contributes to 1/6- 1/7 of body weight
● It consists of many cell types called “Keratinocytes”
● Specialized structures like the Basement Membrane
● It serves multiple functions that are crucial to health and survival
● Skin diseases are common
● Skin lesions maybe the presenting feature of an underlying systemic diseases
● Skin disease can have serious psychosocial effects.
● The skin is associated with RA , SLE , Dermatomyositis , Ankylosing spondylitis , Scleroderma.

Skin function:

Immune
● Barrier to harmful exogenous substance & pathogens, Langerhans cells in the skin are part of the
adaptive immune system.
● acts as a barrier from chemical, antimicrobial, heat and radiation damage.

Metabolic and endocrine


● Prevents loss of water and proteins, vitamin D production after UVB exposure.

Sensory organ
● Contains a variety of nerve endings that respond to heat, cold, touch, pressure, vibration and pain.
Hence, protects against physical injury.

Thermoregulation
● Regulates body temperature through eccrine glands “sweat glands” and dermal blood vessels.
Important component of immune system.

Other functions
● Psychological & Cosmetic Importance
● Protection: acts as a barrier from chemical, antimicrobial, heat and radiation damage.
● Sensation: it has nerve endings which respond to temperature, pressure, pain, touch & vibration.
● Storage: of fat in the hypodermis Contains 50% of fat (subcutaneous tissue).
● Synthesis: of vitamin D.
Function, Structure of the skin

A video by The Doctor Skin Structure composed of three layers:

Hypodermis
Epidermis Dermis
(Subcutaneous tissue)

1) Epidermis: ("Epi" coming from the Greek meaning "over" or "upon”)


● It is the outermost layer of the skin.
● It is stratified squamous epithelium.
● Mechanical and antimicrobial barrier.
● Protects against water loss and provides immunological protection.
● There are No blood vessels (cells receive nutrients via diffusion from
capillaries in dermis).
● The thickness is site-specific (from 0.03 mm on the
eyelids to 1.5 mm on the soles of the feet).

- The main cell types which make up the epidermis are:

1-Keratinocytes

- Major cell type of epidermis 90%.


- They found in the stratum basale and move up to stratum corneum.
- The average time for a cell to travel to the most upper layer is about 40 days. (In psoriasis the period is
shorter <2 weeks).
- Mitotically active in the basal layer

2-Melanocytes
- They are found in the stratum basale (Basal layer)
- They produce melanin.
- there are 2 types of melanin: the brownish black (eumelanin) and the reddish yellow (pheomelanin).
- Melanin packed into melanosomes and transported to basal keratinocytes.
- Skin colour is determined by the number and size of the melanosomes (not the number of
melanocytes).

3- Langerhans cells

- They are antigen-presenting immune cells.


- They have a role in the skin immunity.
- They can be found in the mid-epidermis.

4-Merkel cells

- They are small round/oval cells.


- They act as touch receptors.
- They transmit sensory information in the skin to the sensory nerves
Function, Structure of the skin
Colour/ skin’s response to UV light
● the number of melanocytes are equal
in white and dark skin.
As we go to the right (more melanosomes), the skin
becomes more resistance to burn and easily to tan

● Dark-skin: Larger melanosomes, Increase melanization, decrease melanosome degradation.


Light-skin: Smaller melanosomes, same number of melanocytes as dark-skin.

The epidermis consist of several zones:

- Dead cells with no organelles (for protection).


- (the cells in this layer have No nuclei =(corneocytes)).
Stratum - (cornified layer horny cell layer): the outermost layer of the epidermis.
Corneum - Its 25-cell layer. The cells have a thick envelope that helps it resist external chemicals.
- In psoriasis you see a nuclei in the stratum corneum, because the keratinocytes is dividing
rapidly. (Parakeratosis)

Stratum - It is only found on the palms and soles below the Stratum Corneum.
lucidum

- Flat cells containing keratohyalin granules which is responsible for the colour of the cells,
making it the darkest layer.
- Diamond shaped granular cell layer & Cytoplasm is filled with Keratohyalin granules..
Stratum
- The thickness of this layer is proportional to that of the stratum corneum (thicker in palms
granulosum
and soles (10 cell layers) than in the face (1-3 cell layers) because the stratum corneum is
thicker there.
- Has a waterproof properties

- polyhedral cells with larger nucleus attached by desmosomes.


- spinous cell layer as they are connected to each other by desmosomes and gap junctions
which appear as spines.
Stratum
- Desmosome is a complex modification of the cell membrane. When there is a problem
spinosum
with desmosomes, the patient develops “blistering diseases” > the connection between
keratinocytes is no longer there due to autoimmune antibodies or other causes.
- Langerhans cells are found in this layer.

- columnar dividing cells : (Keratinocytes, Melanocytes, MC, LC)


- basal cell layer which Rests on the basement membrane.
- Divides continuously and moves upwards.
Stratum
- melanocytes : They synthesize melanin (which is responsible for skin color and protection
Basale
against UV light) stored in melanosomes “pigment granules”.
- Melanosomes: Transferred to adjacent keratinocytes by means of dendrites thus forming
the epidermal melanin unit includes melanosomes, melanocytes and keratinocytes.

Dermoepidermal junction (BMZ)

- It is the meeting point of the dermis and epidermis.


- Provide adhesion and transport of cells and molecules between them.
- It is the site of attack injury in blistering diseases.
Basement
- Formed by: Plasma membrane of basal cells and hemidesmosomes, Thin clear amorphous
membrane
space (lamina lucida), An electron dense area (lamina densa) and Anchoring fibrils that
anchors the epidermis to dermis.
- Thickened in certain skin diseases like discoid lupus erythematosus.
Function, Structure of the skin
Dermis

● Provides nutrition and support to the epidermis and interacts with it during wound repair.
● Gives the skin its strength, elasticity, and softness.
● It contains nerve endings so if you feel pain after stepping on a pin it means that the pin
reached the dermis.
● The range is between 1 and 4 mm in thickness (depending on age and body site). So it’s
thicker than epidermis
● It is divided into two layers:
○ Papillary dermis (Upper layer).
○ Reticular dermis (Lower layer).
● Consists of:
1. Collagen fibers 70-80%:
○ Provides strength to the skin.
○ Thin & loose fibers in papillary dermis.
○ Thick & dense fibers in the reticular
dermis.
2. Elastic fibers 1-3% :
Dermis ○ Provides elasticity.
○ Protects against trauma and shearing forces.
3. Ground substance:
○ E.g. proteoglycans and glycoproteins.
-Functions includes water absorption, shock-absorption and lubrication
between collagen and elastic fibers.

4. Blood vessels (provides Nourishment to the overlying epidermis), sweat glands


and hair follicles.
5. Cellular component:
○ e.g. fibroblasts (produce collagen), mast cells, plasma cells and histiocytes.

Hypodermis (Subcutaneous fat)

- It lies below the dermis.


- It binds the skin to underlying bone and muscle.
Hypodermis - It supply the dermis with blood vessels and nerves.
- The main cell type is adipocytes (fat cells), used mainly for fat storage.

Skin appendages (Skin-associated structures that serve a particular function)

- They open directly on the skin surface.


- They are not connected to the hair follicle.
- They regulate body temperature.
- Abundant in palms and soles.
Eccrine - They present everywhere except:
sweat - Vermilion (lip) border.
glands - Nail beds.
- Labia minora & glans.
- Under parasympathetic cholinergic stimuli.
Function, Structure of the skin
Skin appendages cont’

- They are larger than eccrine glands. open to the hair follicle
- They release region-specific secretions that bacteria act on.
Apocrine - They are mainly found in the axilla and genital skin.
sweat - Under adrenergic stimuli.
glands - Modified sweat glands that present in the: External ear canal, Eyelids (moll’s glands) and
Areola.
- Under adrenergic stimuli.

- They secrete sebum (Oil) to lubricate the hair and skin.


- They Present in the scalp, forehead, face, upper chest in hairy areas but NOT in
the palms and soles. (hands can be sweaty but never oily).
Sebaceous - Under adrenergic hormonal control (enlarges during puberty)
glands - Attached to hair follicles or open freely.
- Sebaceous glands in the areola are called Montgomery tubercles, in the eyelid they are
called meibomian glands.
- Ectopic Sebaceous glands in the mucous membrane are called Fordyce spots.

- We have up to 5 million hairs over the surface of the skin.


- Most of this is vellus hair (fine short hair).
- Terminal hair (longer and thicker hair) typically found on the
scalp, axillae and the pubic area.
- Pilosebaceous unit: formed by the hair follicles with it’s attached
sebaceous gland.
Hair follicle - Avg number of hairs on the scalp is 100,000 (100 lost each day)
- Hair growth is dynamic process within three phases:
1. Anagen (active growing hair) 2-6 years (85% of hair).
2. Catagen (rest phase of the hair) 2-4 weeks (2% of hair).
3. Telogen (shedding of the hair) 3 months (15% of hair).
Mnemonic: Rule of Three: 3 years, 3 weeks, 3 months
- Hair follicle has the hair shaft, hair bulb and the bulge.

Consist of:
○ Nail plate (Formed of hard keratin)
○ Nail bed, (under the plate)
○ Matrix (The lunula is the visible part of the matrix),
○ Proximal and lateral nail folds (Proximal nail fold
morphology can be altered in connective tissue
disease)
Nails ○ Hyponychium.

- Fingernails grow 3mm/month.


- Complete replacement in 6 months
- Toenails grow 1mm/month.
- Complete replacement in 18 months
- Can be affected in systemic and skin diseases.
(e.g: Lichen planus). This image is super important

How do you approach a patient with skin lesions?

History Examination Investigations


EXTRA!! Approach to dermatology patient.
History:
● Introduce yourself, Confirm identity of the patient, Take permission

● Step 1: Start with basics: Name, age, sex ..etc.,


- Let the patient talk uninterruptedly in the beginning
● Step 2 : History of skin lesion: When? (Onset), Where? (site of onset), Extension of lesions, Evolution,
Associated symptoms, Aggravating factors, Treatment and if does it help.

● Past medical history:


○ many common systemic diseases display skin manifestations.

● Family history:
○ Does anyone in the family have a similar problem?,
○ Does anyone in the family have a disorder of the skin?
○ N.B. Some skin conditions:
e.g. (neurofibromatosis, have a strong genetic basis).

● Drug history: very important to ask about


○ Over-the-counter, new, old, Herbal medications.
○ any known drug allergies.

● Psychological history:
○ People with severe, chronic skin disease may suffer from anxiety, depression and social isolation
(e.g: patients with psoriasis).
○ The psychological problem may be the cause of the skin disease, e.g dermatitis artefacta.

● Social history:
○ Occupation (e.g. occupational dermatitis) and hobbies.
○ History of contact with other affected individuals.
○ Recent travel (abroad): it is important to be aware of endemic diseases in other parts of the world.
○ Sun exposure: tanning.. etc.
○ Smoking habits: some conditions are related directly to smoking such as psoriasis, hidradenitis
suppurativa and palmoplantar pustulosis.

● Systemic review
Examination:
● Wash your hands, Introduce yourself, Confirm identity of the patient, Take permission (consent and explain
examination), Privacy, Exposure.
● Use good light, Don't forget to examine: Hair, Nails and Mucous membrane. Look for the patient as a whole,
even if he came with a local lesion!
● General appearance of patient: is he/she well? scratching or displaying other signs of distress.
● Inspection:
Is it symmetrical or asymmetrical?, Does it involve particular sites? (e.g. extensor or flexor, sun-exposed or
covered), Do lesions adopt any particular pattern? (e.g. diffuse, linear, grouped or scattered).

● Describe skin lesion as follow:


○ Distribution, Configuration, Size, Border and shape, Color, Morphology ( Primary lesion and
Secondary changes).
● Distribution: refers to how the skin lesions are scattered or spread out.
○ Skin lesions may be isolated ( solitary/ single) or multiple.
○ The localization of multiple lesions in certain regions aids in making a diagnosis, as skin diseases tend to
have characteristic distribution.
○ Aids in understanding the extent of the eruption and its pattern.
EXTRA!! Approach to dermatology patient.
Distribution Types
Distribution: how the skin lesions are scattered or spread out:

All over the body. Such as knees, elbows, shins. (Vasculitic


Generalized Extensor lesions on the limbs ddx: henoch-schonlein
purpura)

Restricted to one area of skin Affecting the distal extremities such as


Localized Acral
only. ears, fingers, toes, nose e.g. acral vitiligo.

both sides are the same or Such as sacrum, buttocks, ankles, heels.
Symmetrical Pressure areas
similar.

affecting one side of the body Affecting sun-exposed areas such as face,
Photo
Unilateral only. neck and back of hands. Ex: subacute
-sensitive
lupus, nonmelanoma skin cancer

Arising in a wound or scar. The The areas generally affected by seborrheic


Koebner phenomenon refers to dermatitis, with a tendency to oily skin
Koebnerised the tendency of several skin Seborrhoeic (seborrhoea). Scalp, behind ears,
conditions to affect areas eyebrows, nasolabial folds, sternum and
subjected to injury interscapular

Body folds (also known as Corresponding with nerve root


intertriginous) such as groin, distribution. Ex: Herpes zoster
Flexural Dermatomal
neck, behind ears, popliteal and
antecubital fossa.

Examination (cont’):
● Configuration: shape or outline of the skin lesion
- Anullar
- Nummular “Discoid”
- Grouped
- Reticular
- Linear
- Target.

● Colour: What colour is the affected skin?


● Shape, Size.
● Border: Is the border well-demarcated or not?
● Palpation: Tenderness,temperature,
consistency, mobility and depth.
Descriptive Terms and morphology of Skin lesions

Descriptive Terms: Description

Photodistribution - Lesions occurring over sun exposed skin.


- Protected areas remain free of lesions.

Linear - Forms a line.

- Occurring within the distribution of nerve.


Dermatomal
- Most common example: Herpes zoster
(Shingles)

Annular - Ring like (pale in the centre).

- Lesions grouped in a manner


Herpetiform
similar to herpes simplex lesions.

Reticular - Net like.

Discoid: - coin like lesions e.g. discoid lupus.


- Not pale in the center (unlike annular )

Guttate - Drop Like ‘’en gouttes’’ ‫ﻣﺛل اﻟﻣطر‬

- Round lesions with concentric border and


Targetoid a dark center.
- Iris like. Seen in erythema multiforme.

- Round depression in the center


Umbilication
E.g: Molluscum contagiosum.

Skin lesions: are divided into:


Primary skin lesions Secondary skin lesions

basic lesion
VS Develop during evolution of skin
disease or created by scratching
or infection
Descriptive Terms and morphology of Skin lesions
Primary
Description
skin lesion

- Flat lesion. If you close your eyes, your won’t know it’s
there
- Change in skin colour.
Macula
- less than 1 cm in size.
- It Lacks surface elevation or depression.
(not palpable) e.g. freckle.

- Flat lesion.
- Change in skin colour. Pale or dark doesn’t matter
Patch - More than 1 Cm .
- it Lacks surface elevation or depression.
e.g Vitiligo, melasma.

- Raised lesion.
- solid lesion.
- less than 1 cm in size.
Papula - Examine for color and surface changes eg. Umbilicated (mulloscum
contagiosum), Keratotic (like warts), Papillomatous,
Flat topped (lichen planus)

- Raised lesion.
- Contains pus.
- less than 1 cm in size.
Pustule
- Just like a papule but it contains pus.
- it is filled with neutrophils, and may be white, or yellow.
- Not all pustules are infected

- Raised lesion.
- lacks a deep component.
- more than 1 cm in size.
- Confluence (group) of papules leads to the development
Plaque
of larger, usually flat-topped, circumscribed, plateau-like
elevations known as Plaques e.g. Plaque psoriasis.
- Opposite of Papules in term of of size
- Opposite of Patches in term of elevation

- Raised lesion.
- with deep component.
Nodule
- more than 1 cm in size.
- e.g. hidradenitis.

- Raised lesion.
- Contains clear fluid.
- less than 1 cm in size.
Vesicle
- e.g. Dermatitis Herpetiformis.
- Vesicle is a smaller bulla.
Descriptive Terms and morphology of Skin lesions
Primary skin
Description
lesion

- Raised lesion.
- Contains clear fluid.
Bulla - more than 1 cm in size.
- bulla is A large vesicle.
- e.g. Bullous Pemphigoid.

- Raised lesion (swelling).


- Transient firm, edematous plaque that is evanescent (transient/short lived)
and pruritic.
- Happens in diseases such as urticaria or atopic dermatitis (in atopic
Wheal
dermatitis they can be white not pink). Can also be with
dermatographism
- pale center and a pink margin (flare of border).
- Well circumscribed,

Cyst - Nodule that contains fluid or semisolid material.

Burrow
- Linear tunnel in the epidermis induced by scabies mite.

Secondary Skin
Description
lesion

- Epidermal thickening (stratum corneum).


Scale - Flakes off easily
- e.g. psoriasis, fungal infection

- Dried serum, blood or pus.


- Yellow to brown
- Previous primary lesion usually a vesicle,
Crust
bulla, or pustule. e.g. impetigo.
- A collection of cellular debris.
- Doesn’t flakes off easily

- A partial loss of part/all epidermis.


Erosion - Heals without scarring.
- Like excoriations but they’re not linear

Ulcer - A full thickness focal loss of epidermis and dermis


- heals with scarring.
Descriptive Terms and morphology of Skin lesions
Secondary Skin
Description
lesion

- Thinning of the skin


Atrophy - It might be due to the long-standing
Use of Topical corticosteroids.

- Increased skin markings secondary to chronic scratching (ex:


Lichenification - atopic dermatitis.. Anyone that scratches chronically will have
more melanin deposition in the skin. If they stop scratching,
the darkening of the skin will get better)

Excoriation - Linear erosion induced by scratching.


- Heals without scarring

Fissure - Vertical loss of epidermis and dermis with sharply defined


walls; “cracks in skin”

- A collection of new connective tissue.


Scar - May be hypertrophic (raised) or atrophic (depressed)
- Implies dermoepidermal damage.

Important Signs
Description
In Dermatology

Koebner's - Trauma to the skin reproduce certain diseases like:


phenomenon psoriasis, vitiligo and lichen planus.

- Firm stroking of the skin produce erythema


and wheal.
Dermographism - Seen in physical urticaria.
- In patients with atopy, stroking produces
white dermatographism rather than red.

- Removal of scale on top of a red papule produces


bleeding points (pinpoint bleeding)
Auspitz sign
- Seen in psoriasis (in psoriasis the blood vessels
are closer to the surface)
Important signs and investigation
Important Signs
Description
In Dermatology

- Rubbing of apparently normal skin induces blistering


of the skin.
Nikolsky sign - Seen in pemphigus vulgaris and toxic epidermal
necrolysis (TEN). In diseases that are associated
IMPORTANT
with separation of the skin such as autoimmune blistering
disorders (ex: pemphigus vulgaris) or Steven Johnson
syndrome or TEN

Investigations:

Wood’s lamp
● Produces long wave UVL (360 nm).
● Useful in:
○ Vitiligo (Milky white).
○ Erythrasma (coral red).
○ Tinea Versicolor (orange).
○ Pseudomonas (green).
○ Tinea Capitis - (yellow green) fluorescence in M.canis, M. audouini

KOH preparation

● For diagnosing fungal infections.


● Method:
1. Cleanse skin with alcohol Swab.
2. Scrape skin with edge of microscope slide onto a second microscope slide.
3. Put on a drop of 10% KOH
4. Apply a cover slip and warm gently.
5. Examine with microscope objective lens.

Direct immunofluorescence (DIF)


● autoimmune diseases e.g. Bullous pemphigoid. (it’s used for blistering disorders)

Prick test
‫ﯾﺗم ﺣﻘن اﻟﻣﺎدة ﺗﺣت اﻟﺟﻠد‬
● food allergy, drug allergy
● Method:
○ Put a drop of allergen containing solution.
○ A nonbleeding prick is made through the drop.
○ After 15-20 minutes the antigen is washed, and the reaction is recorded.
● A positive test shows urticarial reaction, erythema, wheels at site of prick.
● Detects immediate-type IgE mediated reaction (type 1 hypersensitivity)
● Emergency therapeutic measures should be available in case of anaphylaxis.
Important signs and investigation

Investigations cont:

Patch test
● allergic contact dermatitis.
● Method:
○ Select the most probable substances causing dermatitis.
○ Apply the test material over the back.
○ Read after 48 & 72 hr (type 4 hypersensitivity) and look for
(erythema, edema, vesiculation).
● Positive patch test showing erythema and edema.
● In severe positive reaction vesicles may be seen.

Tzanck smear

● Important in diagnosing:
Herpes simplex or VZV (multinucleated giant cells).

● Pemphigus Vulgaris (acantholytic cells; which are floating cells in blistering disorders due to antibodies
against desmosomes)
● Method:
○ Select a fresh vesicle.
○ De-roof and scrape base of the vesicle.
○ Smear onto a slide.
○ Fix with 95% alcohol.
○ Stain with Giemsa stain.
○ Examine under microscope.

Skin biopsy
Very important
● To diagnose or R\O some skin diseases.
○ Shave biopsy: we shave a thin layer from the lesion.
○ Punch biopsy: we use an instrument called “punch”
to remove a circular section through all layers of the lesion.
○ Excisional biopsy: we use a scalpel to take off the entire lesion.
○ Method:
■ Clean skin with alcohol.
■ Infiltrate with 1-2 % xylocaine with adrenaline.
■ Rotate 2-6 mm diameter punch into the lesions.
■ Lift specimen and cut at base of lesion.
■ Fix in 10% formalin
■ For Immunofluorescence put in normal saline.
■ Suture if 5 mm punch is used.
Topical therapy

Topical therapy:
● Applied directly to the skin
● Advantage: less side effects and toxicity.
● Disadvantage: can be time-consuming to apply, messy or uncomfortable!

● Common types of topical formulations:


○ Solution: Water or alcoholic lotion containing a dissolved powder.
○ Lotion: thicker than a solution and more likely to contain oil as well as water or alcohol. 70% water
○ Cream: thicker than a lotion, a 50/50 emulsion of oil and water.
○ Ointment: nearly water-free (80% oil), Greasy, sticky, emollient,protective and occlusive.

● Tropical steroids:
○ They act as anti-inflammatory, anti-mitotic, and immunosuppressive agent.
○ Many topical steroids available, from mild (Hydrocortisone) to very potent (Clobetasol).
○ Successful treatment depends on an accurate diagnosis and consideration of the steroid's delivery
vehicle, potency, frequency of application, duration of treatment and side effects.

● Common types of topical steroids: (depending on; diagnosis, location, age)


○ Ointments: the most potent/most occlusive (ex: for dry/ thick hyperkeratotic lesions).
○ Creams: less potent than ointment but cosmetically more appealing, non-occlusive.
○ Lotions: less occlusive (ex: work well in hairy regions).
○ Gels: like lotions, less occlusive and greasy; (ex: work well in hairy regions; more beneficial
for the scalp.

● Topical steroid Side effects:


○ Atrophy and striae.
○ Telangiectasia and purpura.
○ Masking the initial lesion.
○ Perioral dermatitis and rosacea or acne.
○ Systemic absorption.
○ Tachyphylaxis (sudden loss of response).
Quiz!
1- What is a patch?

A) Solid elevated less than 1 cm C) Flat circumscribed less than 1 cm


B) Solid elevated less more than D) Flat circumscribed more than 1 cm

2- A reticular lesion is similar to which of the following?

A) coin like lesion C) line like lesion


B) drop like lesion D) Net like lesion

3- Which one of following is a secondary lesion?

A) Plaque C) Wheal
B) Papule D) Ulcer

4- What makes the difference between whites and dark skin?

A) Number if melanocytes. C) Sizes of melanosomes.


B) Sizes of melanocytes. D) Number of melanosomes.

5- Which layer of the following composed of cells with no Nucleus?

A) Granular layer. C) Spinous layer.


B) Basal layer. D) Cornified layer.

6- Woods lamp is helpful in diagnosing which one of the following?

A) Lichen planus. C) Vitiligo.


B) Tinea capitis D) Psoriasis.

7- Flat discoloration of the skin more than 0.5 cm:

A) Patch C) Papule
B) Plaque D) Macule

Answers:
1:D, 2:D, 3:D, 4:C, 5:D, 6:C, 7:A
Thanks!!

438 Team leader: 439 Team leader:


Mohsen Almutairi Mohammed Albabtain

438 Done by: 439 Done by:


Abdulelah Alrasheed Mohammed Alquhidan
Abdulaziz aljarbou

438 Academic leader 439 Academic leader


Saud Bin Queid Hamad Almousa

This lecture was updated by: 441 Academic Leader Bassam Al Hubaysh

Dermatology Team 441

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