Taking a history & terminology Dr Iain Henderson GP Scotstoun Hospital Practitioner, Western Infirmary Basic Dermatology Day

Diagnosis of skin disease

• In medicine in general it is said that 80% of the diagnosis comes from taking a good history, 16% from a good examination and only 4% from investigations.

Dermatology being such a visual specialty, the percentages of the first two may differ but the 96% of diagnoses from these still hold true.

Presenting complaint

Timing and site • Duration?

• Where did it start?

• Does it come and go?

Nature of lesion/rash • What did it originally look like and has it changed?

• Has it spread locally or elsewhere?

Presenting complaint

Symptoms • Does it itch? • Is it tender to touch?

• Was there preceding pain e.g. in herpes zoster (shingles)?

Relieving/exacerbating factors • Does anything make it worse e.g. heat, sunlight?

• Does anything make it better?

Age

History taking

Past medical history

• Has the patient had a skin problem before?

• Is this the same?

• Do they have a systemic disease e.g. diabetes which may have accompanying skin features e.g. necrobiosis lipoidica?

• Has there been any recent viral or bacterial illness e.g. guttate psoriasis after a streptococcal throat?

History taking

Drug history

• Have they tried any topical treatments themselves?

• Have they helped or made it worse?

• Ask about cosmetics in case they contain sensitisers causing dermatitis.

• What prescribed and over the counter oral medications have they taken? Important if one suspects a drug eruption.

Family and social history

• Ask if there is a family history of atopy. Other conditions such as psoriasis may have a genetic component.

• Do other family members or close contacts have a similar condition?

• Occupation and hobbies e.g. in contact dermatitis. Does it get better on holiday and away from work?

• Alcohol intake may be a factor e.g. psoriasis or may interact with some of the drug treatments.

• Smoking e.g. in palmar-plantar pustulosis or squamous cell carcinoma of the lip in pipe smokers.

• Travel to sunny climes and tropical regions may lead to increase sun damage to the skin and exotic infections.

• Psychological e.g. parasitosis, dermatitis artefacta

Clinical examination

Look • Good light • Magnifying glass • Whole skin/nails if necessary Feel • Surface palpation with finger tips –smooth, uneven or rough?

• Deep palpation by squeezing – soft, firm or hard?

• Scratch • Pick

Clinical examination

Describe, describe, describe!

• Site involved • Number – single or multiple?

• Distribution – symmetrical or assymmetrical?

- unilateral, localised or generalised?

- sun exposed areas?

• Arrangement e.g annular, linear, discrete, grouped, disseminated etc?

Terminology

Macule Patch Papule Nodule Plaque

Vesicle Bulla Pustule Abscess

Macule

- small flat skin discolouration

Patch

- a larger flat area of skin discolouration

Papule

- elevated skin lesion less than 0.5cm in diameter

Nodule

- elevated skin lesion more than 0.5cm in diameter

Plaque

- elevated flat topped lesion

Vesicle -

A small blister <10mm in diameter. This is filled with clear fluid and lies in the epidermis or the dermo-epidermal junction.

Bulla Pustule -

A blister >10mm in diameter.

A blister filled with a visible collection of pus. Not all pustules are signs of infection.

Abscess -

A localized collection of pus >1cm in diameter.

Lesion due to a broken surface

• Erosion - A superficial break in the skin, involving the epidermis but not the dermis therefore heals without scarring.

• Ulcer - A circumscribed area of skin loss down to and involving the dermis. It will therefore heal with scarring.

• Fissure - A linear split in the skin which can extend down into the dermis.

• Excoriation – Localised damage due to scratching with linear erosins and crusts

Weal A transient elevated lesion i.e. papule or plaque which is compressible due to dermal oedema. It is usually red or white in colour.

Cyst – A papule or nodule lined with an epithelial wall and filled with fluid, pus or keratin.

Crust – dried exudate Scale visible and palpable flakes of grouped epidermal cells

Lichenification –

Thickening of epidermis with increased skin markings due to persistent rubbing

Pedunculated –

stalk –like lesion

Papillomatous –

surface has minute round or finger –like projections

Filiform –

rough finger –like projections

Summary

• History – similar to most medical conditions • Examination – Look and feel • Describe