logo History taking in dermatology

Introduction to dermatology

History taking in dermatology

Objectives

To develop skills in history-taking.

Key points

Important characteristics of a dermatological history include:

  • Site or sites affected by the dermatosis.
  • Its time course.
  • Symptoms and functional problems.
  • Exacerbating and relieving factors.
  • Other health concerns and medications.

Introduction

Although sometimes a “spot diagnosis” can be made by a brief inspection of a skin lesion or rash, in most cases accurate diagnosis requires careful history taking, just as in other medical conditions. In many patients more than one skin problem may be present, Management of the disorder may depend upon age, occupation, current or past medical conditions and medications, for example.

Note the patient’s age, sex and occupation: some skin diseases are more likely in childhood or old age, others may relate to hormonal or environmental influences.

The patient or caregiver should be asked to give their own account of the skin problem and then asked specific questions to complete the history.

A dermatological history should be comprehensive but with practice can generally be extracted from the patient or caregiver within a few minutes. Patients with chronic skin diseases such as atopic eczema, hand dermatitis, extensive psoriasis, urticaria and diffuse hair loss, may require a prolonged consultation.

Presenting complaint

Find out which sites are affected by the skin condition and related symptoms.

History of presenting complaint

Sometimes several skin conditions appear very similar but can be distinguished by a different time-course or pattern of behaviour. Management may depend on correct diagnosis and the response to previous treatment (prescribed and un-prescribed).

Consider:

Review of systems

As for other health problems, run through a general review of systems to identify respiratory, gastrointestinal, neurological, rheumatic, urological, gynaecological or sexual health problems. These may be relevant for diagnosis or management of the skin disease.

Past medical history

It may be helpful to use a checklist to identify diseases that commonly influence diagnosis or management of skin disease.

Most important are:

Family history

Inflammatory skin diseases are often familial, especially atopic eczema and psoriasis. Sun damage and skin cancer relates to skin phototype (how easily sun exposed skin burns and tans) and other genetic factors,

A familial tendency to autoimmune conditions such as thyroid disease predisposes to vitiligo, alopecia areata, lichen sclerosis and connective tissue diseases including lupus erythematosus,

Medications

It is important to list all medications used regularly or occasionally for skin diseases and other conditions. For what were they prescribed and when? Do they have observed side effects?

Include:

Allergies

Many patients erroneously attribute their skin disease to allergy without objective evidence for this. If they attribute it to a specific drug or food, ask them to describe its effect and the effect of avoiding it, and why they think it is related to their skin problem. In fact, only a small percentage of those with acute or chronic dermatitis or acute urticaria have identifiable true allergy, and it is less likely in other conditions.

Distinguish immunological reactions to drugs from expected side effects, interactions and other adverse events. For example, “allergy to antibiotics” may indicate life-threatening anaphylaxis, an annoying rash, gastrointestinal upset, candidal infection or unrelated event.

In patients with dermatitis, ask about contact reactions to jewellery (nickel hypersensitivity), rubber, fragrances, plants, cosmetics and applied creams (prescribed or other). Distinguish immediate stinging (nearly always an irritant effect) from delayed but more persistent reactions (which may be irritant or allergic).

Bee-sting reactions may include delayed local swelling or acute anaphylaxis.

Social history

A careful social history may identify possible environmental causes of the skin disease. How do the skin disease and its treatment affect this individual?