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

1. Taking a history& terminology Dr Iain HendersonGP ScotstounHospital 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 • 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 • 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 • 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. MaculePatchPapuleNodulePlaque

12. VesicleBullaPustuleAbscess

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. Macule - flat circumscribed area of altered skin colour

15. Patch – a larger flat area of skin discolouration

18. Papule - small circumscribed elevation

24. Nodule - solid circumscribed elevation which mainly lies beneath the skin surface

25. Plaque – flat topped palpable lesion

26. 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.

27. Vesicle - a small (<5mm) fluid containing lesion

28. Bulla – a larger fluid containing lesion

29. Pustule – collection of pus

32. 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

33. Excoriation – shallow abrasion caused by scratching

34. Ulcer – excavation due to tissue (epidermis) loss

36. Scar - a permanent lesion caused by repair by replacement with connective tissue

37. 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 exudateScale - visible and palpable flakes of grouped epidermal cells

38. Weal - slightly raised smooth pink lesion

41. Scale – thickened loose fragments of stratum corneum

43. Crust – dried exudate

45. Lichenification – Thickening of epidermis with increased skin markings due to persistent rubbingPedunculated – stalk–like lesionPapillomatous – surface has minute round or finger –like projectionsFiliform – rough finger–like projections

46. Lichenification – thickened epidermis with accentuation of skin markings

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