Common Skin Diseases in the Elderly - Mahidol University · Skin types I, II (fairer skin types)*...
Transcript of Common Skin Diseases in the Elderly - Mahidol University · Skin types I, II (fairer skin types)*...
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Kumutnart Chanprapaph MD
Common Skin Diseases in the Elderly
Clinical Instructor
Division of Dermatology
Department of Internal Medicine
Ramathibodi Hospitial, Mahidol University
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“Everyman desire to live long
but none wants to be old”
Alexander Pope
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OBJECTIVES
Know and understand:
• Normal skin structures
• Normal age-related changes in skin
• Photoaging
• Recognize common skin conditions in
older adults
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Normal Structure of the Skin
Skin consists of 15–20% of the total
body weight
Epidermis
Dermis
Collagen, elastic fibers
Contains hair follicles, sebacous gland,
blood vessels, nerves
Subcutaneous layer
Connective tissue attached to muscles
Contains blood vessels, lymphatic
channels, hair follicles, and sweat glands
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Normal Function of the Skin
ProtectionRegulation of immune functionsThermoregulationVitamin synthesisSensory receptor for CNS
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Skin Changes Associated with Aging:
Epidermis
Thinning
Reduced moisture leading
to a dry, rough
appearance
Rete ridges flatten
Increased risk of skin
breakdown
Reduced melanocytes
Delay wound healing
Increased risk of infection
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Skin Changes Associated with Aging :
Dermis Decreased thickness and function
begin in 3rd decade of life
Collagen decreases in quantity
and organization causes
wrinkles
Elastin decreases in quality
causes sagging
Reduced vascularity causing paler
complexion
Capillaries thin and are easily
damaged
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Senile Purpura
Dermal epidermal separation –easily torn skin &
superficial abrasion following minor trauma
In female a sharp
decline in number of
interdigitation
occur between 40 -
60 yrs
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Skin Changes Associated with Aging:
Subcutaneous layer
Tissue thins in the face, neck, hands, and lower
legs
Hypertrophy of tissue in certain body areas
Increased body fat
Increased body fat in abdomen and thighs
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Hair Changes with Aging
Reduced number of functioning melanocytes : gray hair
Increased baldness
Hormone levels decline
Loss of hair in pubic and axillary areas
Growth of facial hair in women
Growth of nasal and ear hair in men
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Hair Loss
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Pattern Baldness
Male pattern alopecia Female pattern alopecia
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Nail Changing with Aging
• Color changes
Dull
Yellowing or grayness
• Slowed growth
Thicker nails due to decreased blood flow
• Longitudinal striations
• Longitudinal pigmented bands
Single or multiple brown or black bands
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Aging Nail
Subungual
hyperkeratosis
Onychocryptosis and
subungual
hyperkeratosis
Onychogryphosis
(exaggerated growth in
an upward and lateral
direction),subungual
hyperkeratosis
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Differential diagnosis of Aging nail
Onychomycosis Psoriasis
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Glandular Changes with Aging
• Eccrine or sweat glands
– Decreased number; decreased
ability to regulate body
temperature
• Sebaceous glands
– Increased size
– Decreased activity; increased
water evaporation causes
cracked, dry skin
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• Intrinsic: Chronology & heredity
• Extrinsic : Photoaging(UV)
smoking
wind
toxin known , unknown
How does the skin age?How does the skin age?
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.
Photoaged-skin
Intrinsically aged-skin
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Age related changes in the skin
Intrinsic aging Extrinsic aging (primary UV light )
Slight epidermis thickness
Flat rete ridge
Thinning ,ridge nail
Decrease dermal collgen (1%
per year)
Loss or increase subcut fat
(site dependent)
Freckle
Solar lentigo
Wrinkling
Elastosis(yellowish skin)
Telangiectasis
Altered keratinocyte maturation(xerosis)
Senile purpura
Venous lake
Comedone
Sebaceous hyperplasia
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Sun Protection
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Common Skin Diseases in the
Aging
Common Skin Diseases in the
Aging
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1. Xerosis and Pruritis
2. Inflammatory disorders
3. Infections and Infestation
4. Autoimmune disease
5. Benign and malignant neoplasm
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Xerosis (Dry Skin) and Pruritus
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Xerosis• Dryness of the skin
• Causes: reduced water content and reduced barrier
function of aging epidermis
• Exacerbated by environmental factors
� Decreased humidity from cold weather/central heat
� Irritation by hot water, harsh soaps
• Skin findings often more on legs
• Rough itchy skin or scales; if severe, may manifest as
xerotic eczema
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Xerosis and Itching
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Xerosis and Itching
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Xerotic Eczema
Dry, erythematous,
fissured, and cracked
skin was seen on the
lower legs of this patient.
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Treatment of Xerosis
• Avoid environmental triggers
• Take tepid, not hot, showers
• Use emollients immediately after bathing eg
petrolatum
• Use moisturizing agents containing lactic acid or
α-hydroxy acids to reduce roughness
• Use mild topical corticosteroids episodically for
irritation or inflammation
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Pruritus
• Most common in elderly
• Xerosis- low humid,frequent bathing,irritant
• 10-50% -metabolic /endocrine disorder –DM,
renal failure, thyroid disease, hepatic diseases
• Malignant neoplasm-lymphoma,leukemia
• Hematologic –polycythemia vera
• Adverse drug reaction
• Scabies
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Inflammatory disorders
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A 50-year-old woman developed itching and blisters after
applying Bejin baofuling (compound camphor) cream for 5
days
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Dermatitis or eczema
• Pattern of cutaneous inflammation that
presents with erythema, vesiculation, and
pruritus in its acute phase
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Eczema
acute subacute
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Dermatitis or eczema
• The chronic phase is characterized by dryness, scaling, lichenification, fissuring, and pruritus
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Chronic eczema
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Contact Dermatitis
Skin condition created by a reaction to an
externally applied substance
Two types of contact dermatitis
Irritant Contact Dermatitis (ICD)
Allergic Contact Dermatitis (ACD)
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Irritant contact dermatitis: Paederus dermatitis
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Irritant Contact Dermatitis
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Nickel allergy
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What is the best test to confirm the
diagnosis?
A. Patch testingB. Prick skin testingC. Radioallergosorbent test (RAST)
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Patch Testing
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48 hours later
Positive patch test
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Eczema treatment
• Acute eczema Wet compression, topical
or systemic short course steroids.
• Subacute eczema Topical steroids
•
• Chronic eczema Potent topical steroids or
occlusion, keratolytic,
emollient.
Avoid contact with exogenous substances for contact
dermatitis
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• Stasis dermatitis presents with erythema, scale,
pruritus , erosions, exudate, and crust
• Usually located on the lower third of the legs,
superior to the medial malleolus
• Can occur bilaterally or unilaterally
• Edema and varicose veins is often presented
Stasis dermatitis
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Stasis dermatitis is a marker of venous insufficiency.
Normally, venous blood returns from the superficial
venous system via perforating veins into the deep
venous system.
Venous stasis occurs when the valves in the deep or
perforating veins become incompetent, causing
reflux into the superficial system
Stasis dermatitis
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Venous
hypertension
from venous
reflux and calf
muscle pump dysfunction
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Treat both the dermatitis and the underlying
venous insufficiency
Application of super-high and high potency
steroids to area of dermatitis
Elevation (to reduce edema)
Compression therapy with leg wraps
Change wraps weekly, or more often if the lesion
is very weepy
Stasis dermatitis: treatments
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Venous stasis ulcer of the medial leg. Note the characteristic features of
beefy red base, venous blush of wound edges, and varicosities.
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Distention of
capillary from
venous
insufficiency
leakage of
fibrinogens
fibrin cuffs
around
capillaries
deprive O2
ulceration
Venous Ulcers
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Venous insufficiency: risks
Heredity
Age (older)
Female
Pregnancy
Chronic venous disease is extremely common and is
associated with a reduced quality of life secondary
to pain, decreased physical function, and mobility
Obesity
Prolonged standing
Greater height
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Patient education is crucial in successful treatment
Avoid topical antibiotics in order to prevent
development of contact dermatitis
Cleanse the wound with saline.
Avoid products like betadine and hydrogen peroxide
to prevent skin breakdown
Venous insufficiency: treatment
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Avoid frequent manipulation of the wound.
Dressings can be changed as infrequently eg.weekly
Once healed, avoid development of ulcers with
regular use of compression stockings
Patients with venous ulcers that do not demonstrate
response to treatment (reduction in size) after 6
weeks should be referred to dermatology
Venous insufficiency: treatment
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Infections and Infestations
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Infections and Infestations
Viral Infection
• Herpes zoster
infection
Fungal Infection
• Dermatophyte
Infestation
• Scabies
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Varicella infection (Chickenpox)
Herpes zoster �Shingles, zoster
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Zoster
Prodrome
•Pain
•Paresthesia
•Itching
•Tingling
•Burning
Rash
Erythematous macules & papules
vesicles
Several days
•Dermatome innervation
pustules
Dry & form crusts
12-24 hrs
3rd day
7-10 days
Persist 2-3 wks
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Rose-colored
Macules & papules
vesicles
pustules
crusts
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Herpes zoster (shingles)
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Herpes zoster
(shingles)
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Herpes zoster (shingles)
Caused by latent varicella zoster virus (VZV)
Clue to diagnosis
• Dermatomal eruption on one side of the face,
body, extremity
• Group of vesicles on an erythematous base
• Most often on the trunk but can be anywhere
• Preceded by pain or burning
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Treatments
Antiviral therapy
Anti-inflammatory therapy
Post Herpetic Neuralgia caused by inflammation of sensory ganglion
Glucocorticoid (during acute phase)
reduce acute pain
prevent PHN
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Immunocompetent adult
• Acyclovir 800 mg po 5 times per day for 7 days
• Valacyclovir 1 g po every 8 hr for 7 days
• Famcyclovir 1 g po every 8 hr for 7 days
Immunocompromized (severe)
• Acyclovir 10 mg/kg IV for 7-10 days
Herpes zoster (shingles): Antiviral
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Tinea corporis60 years old man present with two months history of
itching rash on his back
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10%KOH
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Branching septate hyphae
10%KOH preparation
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Dermatophytosis
A clinical condition caused by dermatophyte
infection of keratinized tissue
(e.g., skin, hair, nail)
Dermatophytes
-Trichophyton sp.
-Microsporum sp.
-Epidermophyton sp.
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Pathogenesis
Incubation period in humans is 1-2 weeks
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Transmission
Direct contact
• Anthropophilic : person to person
• Zoophilic : animal to human
• Geophilic : environment eg soil
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Tinea coporis
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Tinea capitis
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Tinea pedis
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Treatment
• Topical antifungal agents : NON extensive skin
infection
• Systemic antifungal agents : extensive skin
infection, infection of HAIR and NAIL
• Azoles: ketoconazole, fluconazole, itraconazole
• Allylamines: terbinafine
• Others: griseofulvin
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Dermatophytosis
treatment
Tinea ungium Tinea capitis
Systemic antifungal agents
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Topical antifungal agents for
dermatophytosis
• Azoles: clotrimazole, ketoconazole
• Allylamines: terbinafine
• Others: ciclopirox olamine, tolnaftate
Apply at least 3 cm beyond advancing margin
for at least 4 weeks
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Infestation
Scabies
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Sarcoptes scabiei var. homonis
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Ova of Sarcoptes scabiei mite
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Stratum granulosum
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Scabies Infestation
• Intractable pruritus at night
• Web space, flexor area (wrist,
axilla), periumbilical, sacral,
buttock, penis and scrotum
• Pathognomonic lesion - burrow
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Crusted scabies
Crust scabies
Advanced age
Debility
Down’s syndrome
Immunosuppression
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Scabies infestation: treatment
Two approaches;
• The patient and the environment must both
be treated.
• Environmental care includes washing all
clothing and linens in hot water, sealing items
which may not be washed in bags for two
weeks, and vacuuming.
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Autoimmune Diseases
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A 70 year-old woman with 2 month history of itchy rash at neck arms
and legs. Recent onset of generalized blistering. NO MUCOSAL
INVOLVEMENT
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Bullous Pemphigoid
Majority are older than 60
Tense blistering on normal
or erythematous skin
Marked pruritus
Common: lower abdomen,
thighs , flexor, anywhere
Mucous Membrane: 10-35%
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SUBEPIDERMAL BULLAE
*EOSINOPHILS, *NEUTROPHILS,
*LYMPHOCYTES
BULLOUS PEMPHIGOID
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DIRECT IF:
LINEAR BMZ DEPOSITS OF C3 & IGG
INDIRECT IF:
CIRCULATING IGG ANTI-BMZ ANTIBODIES
DETECTED ON NHS.
MAPPING TO THE ROOF
THE SPLIT SKIN : S p l i t
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Treatment
Localized
BP
Topical steroid
Topical tacolimus
PrednisoloneExtensive
BP +Azathioprine
MTX
Cyclophosphamide
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Skin Tumors
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Benign Tumors
• Benign tumors are characteristics of aging
• Acrochordon (skin tag)• Cherry angiomas• Seborrhic keratosis• Lentigines
Begin to appear in middle age & numerous in
nearly every adult > 65 yrs
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Skin Tag
Asymptomatic skin-colored lesions
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Seborrheic keratosis
• Number increase with aging, independent sun expose
• Biomarker of intrinsic aging
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Lentigines
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Cherry Angiomas
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Malignant Tumors
• Basal Cell Carcinoma (BCC)• Squamous Cell Carcinoma (SCC)
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Basal Cell Carcinoma
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Most common skin cancer
Etiology
Ultraviolet radiation induces DNA damage
PTCH (tumor suppressor gene) mutation
Spontaneous/acquired mutations from UV-induced DNA
damage
Basal Cell Carcinoma
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Skin types I, II (fairer skin types)*
History of intense or prolonged ultraviolet light
exposure
History of ionizing radiation exposure or arsenic
ingestion
Immune suppression (transplant patients, systemic
immunosuppressive medications)
Genetic conditions that increase skin cancer risk
Basal Cell Carcinoma: risk factors
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There are several surgical and non-surgical
treatment options.
The best option is selected after
consideration of clinical and histologic
features.
To select the optimum therapy, refer to a
dermatologist
Basal Cell Carcinoma: treatments
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Basal Cell Carcinoma: treatments
Surgical Treatment Options:
Curette and Desiccation
Cryosurgery
Excision with standard 3-4mm margins
Mohs micrographic surgery
Non-Surgical Treatment Options:
Imiquimod cream
5% fluorouracil cream
Photodynamic therapy
Radiation
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Squamous Cell Carcinoma
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Most commonly occurs among people with
white/fair skin
Commonly located on the head, neck, forearms,
and dorsal hands (sun-exposed areas)
SCC has increased associated mortality compared
to basal cell carcinoma, mostly due to a higher rate
of metastasis
Squamous Cell Carcinoma
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Squamous Cell Carcinoma
Cumulative UV exposure
Causeing genetic alterations
SCC arising in non sun- exposed
areas may be related to chemical
carcinogen exposure (e.g. arsenic)
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Surgical Treatment Options
Surgical excision
Mohs micrographic surgery
Curette and Desiccation (reserved for in situ SCC
Non-surgical Treatment Options
Radiation therapy for poor surgical candidates
5-Fluorouracil cream, imiquimod cream,
photodynamic therapy
Squaous Cell Carcinoma: treatments
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