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

2. 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.

3. Presenting complaint Timing and site Nature of lesion/rash 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?

4. Presenting complaint Symptoms Relieving/exacerbating factors Age
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

5. 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?

6. 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.

7. 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

8. Clinical examination Look Feel 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

9. 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?

10. Terminology

11. Macule Patch Papule Nodule Plaque

12. Vesicle Bulla Pustule Abscess

13. 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

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

15. 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

16. Weal - A transient elevated lesion i. e
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

17. 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

18. Summary History – similar to most medical conditions
Examination – Look and feel
Describe