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
Macule - flat circumscribed area of altered skin colour
Patch – a larger flat area of skin discolouration
Papule - small circumscribed elevation
Nodule - solid circumscribed elevation which mainly
lies beneath the skin surface
Plaque – flat topped palpable 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 - 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.
Vesicle - a small (<5mm) fluid containing lesion
Bulla – a larger fluid containing lesion
Pustule – collection of pus
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
Excoriation – shallow abrasion caused by scratching
Ulcer – excavation due to tissue (epidermis) loss
Scar - a permanent lesion caused by repair by
replacement with connective tissue
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
Weal - slightly raised smooth pink lesion
Scale – thickened loose fragments of stratum corneum
Crust – dried exudate
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
Lichenification – thickened epidermis with
accentuation of skin markings
Summary
• History – similar to most medical
conditions
• Examination – Look and feel
• Describe