DIP Episode 653 - USMLE Step 2/3 Rapid Review Series 137 (Dermatology)

All right welcome my name is divine this is episode 653 of the Divine intervention podcast and into these podcasts I'm gonna be talking about the I'm gonna be doing a step two step three rapid review. This is gonna be series 137 right again. I'll encourage you if you missed the last one I would really encourage you to listen to the last one was episode 651 it was series 136 there was a bunch of just kind of weird high-ill things I emphasized that they love to test on the exams So let's jump right into it right so and I will encourage you for this one the things I kind of plan to discuss I will encourage you to go back Have a computer in front of you, you know and just look things up like look up photos look up images of these things as I discussed them Right, but what if they give you a question about a like a flat, you know dark Smooth skin lesion in a child, right and typically it's gonna be on the palms and on the souls Typically is gonna be on the palms and on the souls if you see this I'd really hope you're saying or divine This is a junctional nevers. This is a junctional nevers. This is something they love to test on the exams This is actually the most common mole in kids, right? So look this up right again Remember lesions on the palms and souls the USM is they know that everybody that has the job description medical student has memorized You know cox ackee A with hand foot mouth disease the new memorize Rickettsiary Ketsai, right?

You know so with a Rocky Mountain spotted fever, right? And they know you know about secondary syphilis, right? But don't forget you can have lesions on the palms and souls in a person that has a Kawasaki's disease as well, right? But a junctional nevers can also be found on the palms and souls, right? Now, what if they give you a question about a farmer or a gardener, right? So a person that works outdoors, right? Although they know that most people have caught on with farmers or gardeners So these days they can give this exact same thing to like a lifeguard, right? To a lifeguard or a person that works outdoors a lot for whatever reason, right? So you can be a person that is in the military in the desert or something like that, right? So you know how they love military questions So they can give you a question about a person that is deployed, you know, has been deployed for the last couple of months in the desert or in North Africa Or in the Middle East or something like that and then they tell you that this person has this small, you know, has these a small rough, you know Erithematos, you know, papioles on the back, right? They have like a sandpaper texture or they say they have a rough texture when you see something like this I would really hope you're thinking of Actinic carotosis. I really hope you're thinking of what? Actinic aratosis. Remember they can ask you what is the most likely outcome of this person's skin lesion? You want to put a resolution, right?

Resolution is the most likely outcome. Most people that have actinic aratosis It becomes a nothing burger. It completely results. But remember, Actinic aratosis, one of the reasons we treated is that it can proceed to squirm a cell carcinoma of the skin Squirm a cell carcinoma of the skin, right? And again, how do we treat it? We're going to treat it with a topical five-floor yourself, topical five F, you, right? Sometimes on your exams, instead of using the term topical five F, you because again, they know that that is in every onky deck known to mankind. The thing that I'd rather do is they'll put like topical chemotherapy, right? Topical chemotherapy. I'm telling you this and this is a sermon I've been preaching now for the last couple of classes that have been teaching with my Testicking class and actually many of my other review courses. The USMLE is they are almost on an anti-onky crusade. Anti-onky crusade is almost like literally the words and expressions. Don't get me wrong, right? A lot of what you're studied, you're still going to see it on your exams. But every year, things are getting better and better at taking the words that you're familiar with and putting different words or putting things that are intentionally vague. It still mirrors and reflects the same thing you've learned, but just put differently just to see if they can force you to think or if you can get tripped up easily, right?

Now remember for Arctinic Aratosis, you can ask your risk factor question, right? The biggest risk factor is going to be son, exposure and again, don't forget the demographic I just voiced, right? Gardeners, Landscapes, Farmers, people that work outside, right? Okay, now what if they give you a question about a 75-year-old male and they tell you that he has a history of Parkinson's disease, right? And that for the last three months, he has noticed this discolored skin lesion, right? And then they show you an image and you see this like this plaque that kind of looks like somebody like a glutee to the person's skin, right? If you see this, I really hope you're thinking of what? Of seborrache, carotosis, seborrache, or toses. Remember, you can also be found in Parkinson's disease. Parkinson's disease has a very strong association with two seborrache problems, right? It can be a zero seborrache dermatitis, right? Because remember, Parkinson's affects the autonomic nervous system, right? So, you know, you can secret more sebum and that can create like a really good environment for bugs that can cause seborrache dermatitis. But Parkinson's is also a straight-up with seborrache carotosis, right? Typically, he's going to have this stock-on appearance, going to have this stock-on appearance, right? He's going to have this stock-on appearance. Now, what if they give you a question, right, on your exams?

This question that I'm about to voice, most people get it wrong, but you will not get it wrong because you're paying attention to this podcast. So, what if they give you a question on your exams and they tell you that, you know, this person is an adult, right? And this person, you know, has this, you know, and they may even show you an image. Or you see this large pigmented lesion, right? It has irregular borders, right? And it's actually in an area that is sun protected, that is sun protected, that is sun protected. Right? If you see something like that, and then you're looking at your answers and you're like, wait, I'm looking for melanoma. I can't see melanoma as an answer. You're kind of scratching your head. If you see something like this, I will strongly encourage you to pick the answer that talks about a dysplastic nervous, as strongly strongly encourage you to pick an answer that talks about what dysplastic nervous. Right? So, how is it going to be tested on your exams? It's going to be a large lesion. It's going to be pigmented, right? And it's going to have irregular borders. And typically, it will be on a sun protected area. If you see this, think of a dysplastic nervous, think of a dysplastic nervous. Right? Now, the thing is, again, typically, it's going to be a chronic problem. They're going to have had it for a long time, right? And you'll notice that it's not something that is necessarily changing recently, right? Like, you know, like melanomas, right?

Change, right? You'd probably, hopefully, know your ABCD is of melanoma. I'm going to talk about that after this, right? But you notice that it's like a chronic on-changing lesion. And, classically, they will not put melanoma as an answer choice. When you see something like this, think of a dysplastic nervous, right? And I was saying, hey, what's the ABCD of melanoma? Remember the A stands for asymmetry, right? The B stands for border irregularity. The C stands for color. It's going to have multiple colors. The D stands for diameter. It's going to be greater than 6 millimeters in diameter, right? And it's going to, the, the, the easy evolving, right? It's going to have that quality of change. It's going to be changing. It's going to be changing, right? That's pretty, pretty high up to know for your, for your exams. All right. Now, what if they give you a question about a patient and they, or they won't just make it like an epidemiology question, right? Like, what's the most common skin malignancy? Remember the most common skin malignancy of this is going to be basal cell-cursing on the, of the skin, right? And typically it's going to be above the upper lip, right? But again, our friends at the NBA knees, they know that many people have learned some of these general rules, right? Many people have learned some of these, what? General rules. So remember, it does not always have to be above the upper lip. It can literally be below the lower lip. So just be careful.

But classically, it's going to be above the upper lip. It's the most common skin malignancy, right? And it tends to have telangetages. That's a very critical thing to know. It tends to have these blood vessels, these tiny blood vessels kind of overline it. Right? So those telangetages, that's very characteristic of basal cell-cursing on. Right? Classically, scream yourself, question on the other hand, tends to be below the lip, right? It tends to be all-cerated and you have no telangetages, right? It tends to be what? Below the lip, not all-cerated. Sorry, below the lip, is all-cerated and has no telangetages. Below the lip, is all-cerated, no telangetages. Think of scream yourself, question on the skin, right? And what is the biggest risk factor for skin cancer? Just in general, what is the biggest risk factor for skin cancer? Well, the biggest risk factor is going to be UV exposure, right? And sometimes on the exams, they'll give you different kinds of UV light. And you have to pick the correct one. Pick the one that says UVB, right? Ultraviolet B, UVB exposure is the biggest risk factor for skin cancer on the USMLE exams, right? And typically, the people that get skin cancers on the USMLE is going to be Caucasians, right? It's going to be Caucasians, they can have blue eyes, right? That's going to be like the classic patients, the classic demographic that they threw in on the exams for skin cancer, right? Now, what if they give you a question about a patient, right?

And they tell you that, oh, this is a 10-year-old child. And this child just has like severe photosensitivity like blisters and what not when they're exposed to the sun, right? And, you know, they tell you that, oh, that, you know, whenever they have sun exposure, it's just terrible, terrible, terrible, terrible, terrible for them. When you see something like this, think of Xero-Derma pigment, right? Xero-Derma pigment, Xero-Derma pigment, Xero-Derma pigment, Xero-Derma pigment, Xero-Derma pigment, Xero-Derma pigment, right? It's an Orozomer recessive disease, right? And these people have defective DNA damage repair, defective DNA damage repair. What kind of DNA damage repair do they struggle with? Well, is the repair of 5-medine dimers? Is the repair of what? Of 5-medine dimers, right? Don't mix this up with ataxia-telegenjectasia, ataxia-telegenjectasia, they have an ATM mutation. And those people that have ataxia-telegenjectasia, the thing they struggle with is double-stranded DNA repair, double-stranded DNA repair, right? So those people struggle with X-rays, it's X-rays they struggle with, right? So please, please, please, let me really make sure that I throw this out there. People that have Xero-Derma pigment, Tossum, they struggle with UV rays. People that have ataxia-telegenjectasia struggle with X-rays, right? So UV rays are not going to be a problem for pressing with ataxia-telegenjectasia, okay? Keep that in mind, right?

People that have Xero-Derma pigment, Tossum, they struggle with UV rays. UV rays lead to the creation of thymidine dimers. Those people struggle with those things, okay? They struggle with those things, okay? So please, I'm telling you this, this is something that in the heat of an exam, a person can mess this up. Don't mess this up because you're paying attention. I'm going to repeat it again. Xero-Derma pigment, Tossum, right? It is UV rays that bug them. It's going to be X-rays that bother them. X-rays create double-stranded DNA breaks, okay? X-rays do not create thymidine dimers. It's UV rays that do. Okay, so again, I've really hit this. I really, really hope that you don't get this wrong going to test, right? If you get this wrong going to test, you should feel really bad because I basically repeated this thing like three times, like literally three times, right? Both of those diseases, they have the same amount of inheritance is a lot more recessive, right? But you've got to know those things for your exams. Now, what if they give you a question about a patient? And this patient has had a burn wound for like the last 10 years. It has not healed. And then they ask you like, what's the most likely diagnosis? I hope you have a picket and answer that says a squamous cell cancer, right? That person has a merjolins ulcer, M-A-R-G-O-L-I-N, a merjolins ulcer. They are less likely to put the term merjolins ulcer on your exams.

I'm more likely to put squamous cell carcinomone on your exams, right? Because again, merjolins seems like something that will make its way to an onky deck, right? So again, they're not going to do that. They're going to use the term squamous cell cancer, right? So if you see a person that has a skin wound that just doesn't seem to be getting better, think of a merjolins ulcer, which is again a form of a squamous cell carcinoma, right? And then if they give you a question about a patient that wants to move to an area, like an area of the country, that has a lot of sonic exposure, right? That has a lot of water where they can go by the beach. And then they ask you which of the following interventions would most strongly reduce the person's risk of skin cancer? What are some things you can do to reduce a risk of skin cancer? Well, number one, don't forget like sunscreen, right? Sunscreen that has an SPF, a sun protective factor that is 15 plus, right? That is at least 15 plus, right? And then you also want to wear protective clothing, right? Now, there's one strange thing, amazing friends at the NBM is love to do to people on the exam, right? So if they give you between sunscreen as an answer and they give you protective clothing as an answer, they are literally both answers to the same question. Which one should you pick to reduce your risk of skin cancer? Which one should you pick to reduce your risk of skin cancer?

I would really hope you're saying, oh, divine protective clothing. Protective clothing is what you should be. I know, you're like, oh, divine. Ever we have seen sunscreen? Big sunscreen on your exams and see what happens. Just try that and see what happens, right? Let's keep going. Now, what is the most important prognostic factor you may see on your test in the setting of a person that has melanoma? What is the most important prognostic factor? Well, I hope you're saying that divine, oh, I should be thinking about the thickness, right? The brislo, br e slow, br e sl o w, the brislo depth of the brislo thickness, right? So that is the most important prognostic factor, the deeper, the thicker, right? The more likely you're going to get in getting a big amount of trouble, right? You're going to have a worse prognosis that way, right? Now, let's do some matching games, right? Let's do some matching games. I think Durham is pretty good for this, right? I think Durham is pretty good for this, right? So let's do some matching games with like some skin cancers, right? So which one is a locally destructive with very little risk of metastasis? Locally destructive, very little risk of metastasis. Very good. It's going to be a bit of self-custom of the skin. Okay. Now, what is the one that can present on your exams as a small bowel obstruction? That's going to be melanoma. Very good. And then which one can arise from our jollins, ulcers or extenicatorotosis? Okay.

It's going to say okay answer. Very good. Right? Which one can arise after a person has got in a transplanted organ right on the binonaminosuppression? Very good. It's going to say okay answer. Right? Again, don't forget melanomas. I don't know for whatever reason, almost no resource covers this specific factoid, which is actually very, very high up to know for you exams. Friends at the end, MBM Es can give you a question about a person that has a skin lesion, right? And it melanoma literally metastasis to the bowel and causes a small bowel obstruction. Right? Whenever you see a person that has like a hysterov like intense on exposure and he shows you like a skin lesion and the person has been constipated for a really long period of time. Think of metastatic melanoma. It has literally metastasis to the person's small bowel. Right? Obviously when you have that kind of metastasis, like that's a awful, awful, awful prognosis. Right? This is another matching game. This is another matching game. But let's do it with melanomas. Right? Let's use this matching game. I kind of like these matching games. Let's use these matching games to kind of hit some of these melanomas. So first things first, what is the most common kind of melanoma? What is the most common kind of melanoma? It's going to be superficial spreading. Okay. Now which melanoma has the best prognosis? Which one has the best prognosis? It's going to be lentigo maligna. Lintigo maligna. Lintigo. L-E-N-T-I-G-O.

Maligna is a separate word M-A-L-I-G-N-A. Don't let that maligna word make you feel like, oh, this is bad. No, it actually has the best prognosis of all the melanomas. Okay. Now for all the melanomas, which one is UV exposure not a risk factor? For which one is UV exposure not a risk factor? UV exposure is not a risk factor. I hope you're picking the one that talks about acral lentichinus. Acral lentichinus. Acral lentichinus. Okay. Next one. Which one is pretty common in people of color? Right? And you may even find them the sole of the foot on the sole of the foot. I hope you're also saying acral lentichinus. Acral lentichinus. Okay. Now which one has the worst prognosis and is the second most common? Remember I said the most common is superficial spreading. Which one has the worst prognosis and is actually the second most common? It's going to be nodula. It's going to be nodula. Now which one has a long horizontal growth phase? It's going to be superficial spreading. And this one has a rapid initial vertical growth phase. It's going to be nodula. Right. So let's talk about these growth phases. Right. I really, I'm telling you this. Some of these rapid reviews that I put out right is just like always some rapid review. It's like one out of the other 137 divine has made. I'm telling you this. These rapid review series. They're no things to ignore. These things are like super, super, super high. You'll think that can make you a lot of really amazing points on your exams.

Right. The thing is if you're a person that is like shooting for like, hey, I want to get like in the 270s. Right. It can just be questions like these where it's like there's no test taking strategy that can save you. You've not seen it in any resource. You just randomly remember divine. Spending like two minutes talking about like some random factor and that's why you got it right. Right. So again, that's the thing right like every question counts. Right. But let's talk about these things. Right. So the thing is melanomas. Right. They have this phenomenon of growth phases. Right. You can have a horizontal growth phase. We can have a vertical growth phase. Right. Now let me ask you this. Which growth phase you think is really bad. Well, it's actually going to be the vertical. Right. A vertical growth phase means that oh, that thing is going deeper and is beginning to a metastasize. Right. But if it has a horizontal growth phase, it means that the thing is just going horizontally. It's not going deeper because remember the official layer. So you have like your mucosa or something goes from what not. Right. As you begin to go deeper, you begin to get to the blood vessel layer of your of your skin. And once you get to that blood vessel layer, right. Things cancels can enter the bloodstream and begin to metastasize. They can begin to get to lymphatic and begin to metastasize. So if your person has skin cancer, you want one that has a very, very long horizontal growth phase.

Right. It means that oh, it may be locally destructive, but it's not going to cause many problems because it's not going down vertical. Remember, I said that's the biggest determinant of prognosis in a person that has melanoma is the brislo depth is the brislo depth. Right. So the thing is superficial spreading melanoma has a very, very long very, very long horizontal growth phase. So it doesn't metastasize very easily. Right. That's why it has a pretty decent prognosis. Although remember the prognosis is not as good as lintigo maligna. Right. But what did I see was the second most common skin can second most common melanoma and had the worst prognosis of all. I said nodula, right. nodula has a very rapid initial vertical growth phase. A rapid initial vertical growth phase. Right. So again, keep these things at the back of your mind. Right. This can be a very easy way for them to test metastatic potential on your exams. Very easy way for them to test prognosis on your exams. That's why I'm emphasizing this. The USM is these days they really, really love prognosis prognosis prognosis prognosis. They love these things on the exams. Right. So please make sure you bank these things in your brain. Make sure you bank these things in your brain. Right. And just some other, I guess maybe like random things I just want to throw in here. Since where I guess we're kind of talking about Derm. Right. Since we're kind of talking about Derm. Right. Metanomans, right.

Just quick general management. Right. Again, they don't go very deep on management here. Right. But if it's a small lesion on your exams, you can just do some kind of excisional biopsy. Right. If it's a cosmetic, if you know, you're kind of worried about like cosmetic issues with resectin delusion, or it's a large lesion, at peak, the answer that talks about an incisional biopsy. Right. So for small lesions, excisional for large lesions or lesions where like it's going to be an an error of cosmetic consequence. You want to do an incisional biopsy, an incisional biopsy. Right. I would encourage you to almost never pick punch biopsy for melanomas, punch biopsy, melanoma questions, not not a good mix. Right. And one answer is you definitely not pick with melanomas is a shave biopsy. A shave biopsy picking a shave biopsy as your answer for melanoma is like consulting the ethics committee for an ethics question. That's not going to end well for you on your exams. Right. Now, one of the things that you may also see, right, because again, they know that many people have memorized like the brislo depth for prognosis in melanoma. One of the things that's also pretty high yield to measure actually in the work of melanomas is the LDH, the lactate dehydrogen is the lactate dehydrogen is. It's actually a prognostic indicator. Right. In fact, that may actually be an indicator of liver metastasis. The reasoning behind that is well, well, well beyond the scope of the USM in exams.

I'm not going to talk about it, but don't forget that measuring the LDH, the lactate dehydrogen is is also a very good prognostic indicator and it may be an indicator of a potential liver metastasis in a person that has a melanoma. Right. And then again, remember, we've talked about how many of the skin cancers like the diesel cell, cross enoma, the scum cell cancer, or you can treat them with topical chemotherapy. You can do like topical five if you right, five floor yourself, right, you can use a make way mod, I am I cue you I M O D, right, in make way mod, in make way mod, right, in make way mod, right. Some skin cancers like bisels cell, scum cell, you can do a electro desiccation and curatage, right. These are all words you may see on your exams. But remember, for melanoma, you pretty much always do surgery, you pretty much always do surgery, you pretty much always do surgery, right. And I will encourage you for melanoma is usually not a smart idea to pick moles surgery M O H S, right, is usually not a good idea to pick moles surgery for melanoma, you exams. I don't know for whatever reason, our friends at the MBM is they don't like that being the correct answer for melanoma, right. And then sometimes, right, although this pops up not very frequently, but every few years, you're going to see this pop up, right. But remember, for bisels cell carcinoma, what are the surgical margins you want, right, you want like three to five millimeter margins, right.

And for scum cell carcinoma, what kind of margins do you want? You want like five to 10 millimeter margins, five to 10 millimeter surgical margins, maybe like divine. How do I remember which is which well, just remember that the larger number, the larger margin goes with a bigger letter, right. The larger margin goes with a bigger letter, the larger margin goes with a bigger letter. And then, you know, don't forget, right, another skin thing, right, don't forget your neck fast, right. Remember, you know, diabetic, who are the classical, I get necrotizing fasciitis, right, diabetes, IV drug users, right, you may see Bula, you may see Crepidus, you may see hyponitramia, right, the legions tend to be violations, you may see gas bubbles on imaging, right. When you see this thing over neck fascia, remember neck fascia needs to be a polymicrobial infection, right, tends to be a polymicrobial infection, okay, tends to be a polymicrobial infection. Don't forget your SGLT2 inhibitors that can cause a neck fascia of the perineum, right, which we call foneescan green, right. And again, remember, if your culture, a strebobus or clostridium septicum, where you need to go ahead and do a colonoscopy, right, to screen those both for colorectal cancer, right, a lot of colorectal cancer. And sometimes when a person has neck fascia, right, if there's a lot of muscle involvement, if there's a lot of muscle death, you actually need to consider a mutation in those people, right, in those people.

But again, remember, how do you handle neck fascia, right, the breed bend, the breed bend, the breed bend and antibiotics, brospectrum antibiotics, right, brospectrum antibiotics, antibiotics, okay. And now there's this kind of strange thing our friends at the MVM is love to do with cellulitis, right, because many of you can probably recognize cellulitis pretty easily. But I've noticed one strange thing that you love to do these days is they can ask you what layer of the skin is involved. You're like, wait, what? What layer of the skin is involved? If you notice for cellulitis, don't forget that it is the deep dermis and subcutaneous tissue that is involved in cellulitis, okay. It's what it's the deep dermis and subcutaneous tissue that is involved, the deep dermis and subcutaneous tissue, all right. And then the last thing I'm just going to talk about, these are rapid reviews series, I don't want this to go too long, right. But what if you see us blackest crying apostle worker, what are you thinking about? What are the rest of the work I'm going to do with this? Why do you need this sign? It's going to be anthrax, right. It's going to be anthrax, it's going to be anthrax, all right. So I think I'm going to go ahead and stop here. Again, I'm telling you this is going to score you so many easy points on your exams, right. Things that people will get wrong, you don't have to get them wrong, give you a bit of attention here. Now, do you love the way I teach?

Then you're going to love my classes. I have a battery of classes that kind of start in today actually, right. So I have a 25 hour basic science review. It's for people taking step one or people taking step two, step three that have poor, poor foundations, right. This class will benefit you tremendously. It's a case based review, right. It's not like a review where it's just like, oh, what's the definition of this? No, no, no, no, no, right. I use cases, I use clinical scenarios to purchase the points, right. So you're learning it in the context of an MBA exam. And then after this week, the 25 hour basic science review, starting next week, I have a CCS cases class for step three specifically, right. And then after that, I have a test taking strategies class for step one to three to two and a half hour class, I have a bio stats class for step one to three to four hour class. I have a social sciences quality improvement, a hospital medicine ethics review is a five hour class for step one to step three super, super, super comprehensive class. It's actually one of my most popular classes. Many people take it and find it to be extremely helpful for their exams, right. And then after that, I have the last many reviews specifically for step two and step three to three hour class that shows you not just concepts that are commonly test testable on the exams, but also just methods and approaches that the USM is used to test concepts.

And then after that, I have a 20 hour step to step three review that is again, specifically for step two and step three. And then in the month of June, first weeks in the month of June, this is the only time this is going to take place this year, have the 50 hour step to step three review, right. It's an epic, epic, epic, amazing, amazing, amazingly wonderful class. Many people have taken this class, I've just found it extremely helpful. And then I also offer one on one to learn for all the USM, million complex exams and medical school exams. And then have these podcasts on Apple Google and Spotify, so check those out. I also have a You Tube channel that I post all the videos that I make, right. And some podcasts that I make as well, I throw those on there. And then many of you listen to this podcast, not a Christ follower. Right. So I do have another website called a divine intervention life lessons. I post like one or two podcasts, we're from a biblical perspective. I do address a life lesson. There's actually an Apple podcast associated with that called the divine intervention life lessons podcast. And then I also help with your applications, more interviews, personal statements, recommendation letters and things of that nature. I help with editing those things, right. Editing those things and making them very polished to what admissions committees and residency selection committees are looking for. So thank you for listening to me today.

I will see you got really in episode 654, but have a wonderful day. God bless you and bye for now. Thank you.

Palms and soles.

Actinic keratosis.

Basal cell carcinoma (BCC).

Telangiectasias (tiny blood vessels over the lesion).

Lentigo maligna.

Breslow depth (thickness).

Deep dermis and subcutaneous tissue.

Xeroderma pigmentosum (XDP).

X-rays (Ionizing radiation).

Basal cell carcinoma.

BCC: 3–5 mm; SCC: 5–10 mm (Larger number $\rightarrow$ larger margin).

Superficial spreading melanoma.

Biggest risk factor is UVB (Ultraviolet B) exposure.

Marjolin's ulcer.

Xeroderma pigmentosum (XDP).

X-rays (Ionizing radiation).

Basal cell carcinoma.

BCC: 3–5 mm; SCC: 5–10 mm (Larger number $\rightarrow$ larger margin).

Superficial spreading melanoma.

Biggest risk factor is UVB (Ultraviolet B) exposure.

Marjolin's ulcer.