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HISTORY

The dermatologic history includes specific details of the presenting complaint, but may also require a broader discussion of family history, occupation, general medical and other disorders, and drug treatment. In some instances, notably localized benign skin lesions, an extensive history is often not required to reach a diagnosis. However, even in these cases, there may be important patient history such as previous skin neoplasia, family history of skin lesions, drug therapy that might cause bleeding or otherwise interfere with a local anesthetic procedure, etc.

    In practice, many dermatologists use a ‘look, talk, look again' approach; an early look at the problem may be able to focus the discussion if the morphologic diagnosis is apparent. For example, in a patient with ‘hand dermatitis', a detailed occupational history is likely to be time wasted for all concerned if the initial look makes it apparent that the diagnosis is scabies. However, in less clear-cut cases, a more detailed history and re-examination of the eruption may be necessary.

    The following is a list of potentially important aspects to include in the historical record; some may not be applicable to all cases, but neither is the list exhaustive for all clinical situations.

Basic demographic details (Table 2.1)

Age

Many disorders have a predilection for certain age groups, or the features may vary in different age groups (e.g. psoriasis in children is often guttate or flexural in pattern).

Sex

Some disorders are specific to men or women, some have a different frequency between the sexes (e.g. the helical and antihelix lesions of chondrodermatitis of the ear), and some may have sex-linked inheritance.

Race and country of origin

Some disorders have racial predilection, or may appear differently depending on racial origin. Examples include the high incidence of systemic lupus erythematosus in African-Caribbeans, the strong predominance of prurigo pigmentosa in Japanese, and the skin cancer risk of red-haired individuals of Celtic origin.

Place of residence

This may be important in infectious disease outbreaks and in the practicality of some treatments (such as having to travel for phototherapy). Previous places of residence may be relevant, especially tropical countries (for the risks of skin cancer related to sun exposure and as endemic areas for infections).

Occupation

This is of particular importance in regard to occupational contact dermatitis (Ch.6), but may also have implications regarding the practicality of some treatment modalities if these are available only in normal hours of work. In some instances, a detailed account of processes and chemicals, protection methods, and previous occupations may be required. Hands are the commonly affected site in occupational dermatitis, and it is useful to record details of hand protection—gloves (Fig.2.1) barrier creams, etc.—as well as the agents to which the patient is exposed. Some dermatoses associated with specific occupations and hobbies are listed in Table 2.2; see also Fig. 2.2.

Figure. 2.1  Different glove materials. Gloves used by workers are an important part of the history: whether they are used at all, whether they provide adequate protection, or whether they might cause dermatitis (e.g. rubber glove allergy, in which the rash often finishes abruptly at the wrist or mid-forearm). Latex gloves (yellowish color, on the left), for instance, are a common cause of potentially severe reactions in health workers and occasionally in their patients. Polythene (colorless) and vinyl (white) gloves are suitable alternatives.

Table 2.2 SOME OCCUPATIONS AND HOBBIES AND THEIR DERMATOLOGIC PROBLEMS

Activity	Examples of possible dermatologic implications
Agricultural	Irritant dermatitis (e.g. disinfectants), contact allergy (e.g. rubber chemicals in gloves or footwear), hazards from animals (e.g. tinea, Fig. 2.2; atopy)
Gardening	Irritant or contact allergic dermatitis related to many plants, contact allergy to gloves
Building trade and do-it-yourself	Irritant dermatitis from cement (also causes chemical burns), plaster, solvents, preservatives, fiberglass; frictional palmar dermatitis from tools; vibration white finger related to use of some tools; contact allergic dermatitis (especially to chromate in cement, epoxy resin, formaldehyde resins, colophony in soldering flux)
Cars (trade or home)	Irritant dermatitis from solvents, paints, hand cleansers; contact allergic dermatitis from paints, resins, metals, rubber gloves; rubber chemicals in tire manufacture may cause dermatitis or rarely chemical leukoderma
Cooking (work or home)	Irritant dermatitis (detergents and hand washing, juices of meat, fruit, and vegetables); contact allergic dermatitis (or urticaria in some cases) from fruits, garlic, spices, meat, fish, gloves
Cleaning (work or home)	Irritant dermatitis from detergents; contact allergic dermatitis to fragrances or antimicrobials in detergents, polishes, etc., or to gloves
Healthcare work	Irritant dermatitis from cleaning agents and hand washing, latex allergy (urticaria or dermatitis), medicament allergies (dentists: also risk of allergy to balsam flavorings and to resins)
Hairdressing	Irritant dermatitis from shampoos, bleaches, etc.; contact allergic dermatitis from perfumes, dyes, bleaches, lanolin, antimicrobials; contact urticaria due to henna
Textiles (work or hobby)	Irritant dermatitis from solvents, bleaches, detergents and hand washing; contact allergic dermatitis from dyes, formaldehyde resins (finishes), mordants

History of the lesion or rash

Symptoms

Itch is the most common symptom, but the perceived intensity and the response to it varies considerably between individuals with objectively similar severity of eruption. Indeed, in some patients the only visible ‘rash' is actually the results of the patient scratching or picking at the skin (Fig.2.3); this can be very difficult to address, as there may be little insight into the fact that this is happening, and explaining that scratching is causing the damage may be viewed negatively. Some rashes, such as scabies (Fig.2.4), are characteristically very itchy in most patients. However, even classically itchy rashes may vary in the response they provoke: lichen planus is also very itchy, but scratch marks are rarely seen by comparison with eczema or scabies, for example. Both for diagnostic purposes and to monitor therapeutic response, it is helpful to record the patient's view of degree of itch using a semiquantitative system such as severe, moderate,or mild.

    Factors noted by the patient that aggravate or improve symptoms may provide diagnostic clues; similarly, the response, or lack of response, to previous treatments may be diagnostically useful (as discussed later).

     Some disorders are typically described as painful rather than itchy, and the quality of pain may vary. Examples include the following.

Figure. 2.2  Cattle ringworm. When an unusual site is affected ( a ) the diagnosis may be unsuspected by medical staff, even though the affected farmers usually know that their stock are infected ( b ).

Figure. 2.3Sometimes the only ‘rash' is that due to the patient scratching. Complete sparing of the area on the back that cannot be reached (the butterfly sign) is diagnostically useful, as it suggests that there is a systemic rather than a cutaneous reason for itch.

Figure. 2.4  Scabies infestation. This usually causes severe itch, and careful examination of the fingers, web spaces, and wrists is important to detect the characteristic curvilinear burrows, as shown here. Scabies is discussed in more detail in Ch. 27.

Duration, evolution, and periodicity

In the case of localized individual lesions, the duration and changes over time are usually straightforward. The timescale of changes is particularly important and needs to be considered in the clinical context. Some important examples include the following.

Figure. 2.5  Erythema nodosum. This disorder causes deep dermal and fat inflammation, presenting as poorly defined inflammatory nodules. These are typically tender, and often require treatment with oral non-steroidal antiinflammatory drugs. This patient was unusual in having chronic lesions.

     The evolution of an eruption may be characteristic, for example in pityriasis rosea, in which a solitary herald patch precedes the eruption by a couple of days, or in pyoderma gangrenosum, in which there is (usually rapidly) progressive ulceration (Fig.2.9). The site of initial involvement in a rash can also be a useful feature, for example a generalized eczema in a patient with preceding venous eczema is likely to be a secondary autosensitization eruption (see Ch.6). Similarly, many rashes have characteristic sites of involvement which may not all be apparent at the time of examination, but which may be appreciated from the history (Fig. 2.10).

    It is always worth asking the patient about perceived triggers and provocative factors (Fig.2.11), even if some are readily discounted. In particular, it is important to be aware that some infective and drug triggers may precede an eruption by several weeks. Provocative triggers and periodicity are of particular importance in eczematous processes. In some instances an answer is obvious, for example the recurrence of a photosensitivity rash every spring; in some cases, the explanation for a certain timing of episodes may become apparent after patch testing has identified a causative contact allergen. Improvement in a rash during holiday periods is often taken to imply that the cause is an occupational contact dermatitis; however, this assumption is not necessarily correct, as such improvement could also occur because the patient has not been in contact with a relevant household contact allergen, or it might represent improvement due to sunlight.

Figure. 2.6  Chondrodermatitis nodularis. This lesion occurs characteristically on the helix or antihelix of the ear on the side on which the patient sleeps. It causes a sharp pain that may wake patients from sleep. Treatment is excision of the underlying cartilage. This condition varies between the sexes, helical lesions ( a ) being most common in men and antihelix lesions ( b ) in women.

Figure. 2.7  Urticaria. The margin of lesions was marked with ink (solid line) when initially examined ( a ), and again after 30 min (dotted line in b ), showing asymmetric expansion of the lesions. Small unmarked weals at the upper part of the figure have become more prominent, being little more than erythematous patches at baseline. (From Lawrence CM, Cox NH. Physical Signs in Dermatology, 2nd edn. London: Mosby, 2002.)

Figure. 2.8  Erythema annulare centrifugum. An accurate history is useful, as this annular inflammatory dermatosis slowly migrates and enlarges over a period of weeks (see also Ch.11).

Response to treatment(s)

     Many patients will have tried treatments bought over the counter, prescribed for a previous problem, or borrowed from friends before they see a primary care physician. Many will also have used agents prescribed by a referring physician before they see a dermatologist. It is important to document the response (or lack of response) to these treatments, mainly because they may give clues about the diagnosis or may have altered the features of the disorder, but also because credibility is lost if the secondary care physician prescribes an agent that has been tried and failed. As examples, a supposed localized fungal infection that has failed to respond to a few weeks of antifungal therapy is almost certainly not fungal, while a true fungal infection treated for the same few weeks with a topical corticosteroid may be virtually unrecognizable. Bear in mind that previous treatments, especially herbal medicines or treatments bought over the counter, may not be volunteered unless the patient is directly questioned.

     Careful questions about the original shapes and patterns of the eruption or lesion, as described in Chapter 1, may be required.

Figure. 2.9 Pyoderma gangrenosum. This form of inflammatory ulceration usually has a rapid rate of progression and significant discomfort, which distinguish it from most commoner causes of ulceration of the skin (see also Ch. 14). Infections, in particular, must be excluded. Note the peripheral pustules, a feature of active disease.

Figure. 2.10 Mycosis fungoides. This starts on covered areas of the body, such as the buttocks, lower trunk, or thighs, and in most cases gradually worsens over months (see also Ch. 33).

Figure. 2.11  Koebner reaction in lichen planus, producing linear lesions at a site of scratching. Patients may volunteer that they have noticed lesions at sites of injury in other disorders as well, such as psoriasis (see list of disorders producing a Koebner reaction, Table 1.4).

Figure. 2.12  ( a , b ) Pretibial myxedema is a good example of a dermatologic condition that occurs in conjunction with systemic disease (see also Ch. 12). Lesions occur on the shins, and close examination reveals a peau d'orange appearance of the skin.

Previous episodes

In the case of localized lesions, previous similar lesions may suggest the diagnosis and lead to earlier intervention. For example, patients with three or more previous basal carcinomas have a very high risk of a further new basal carcinoma within 5 years, and any new lesion should be treated with suspicion.

    In the case of rashes, previous episodes may be useful or even critical for diagnosis of a cause. For example, recurrent poststreptococcal episodes of guttate psoriasis are not unusual, so the diagnosis can often be suspected once an earlier event has been diagnosed. In the case of occupational hand dermatitis, knowledge of previous proven hypersensitivity may be of huge value in diagnosis and avoidance.

Figure. 2.13  Clubbing of the fingers usually indicates a systemic disease and results in swelling of the soft tissues under the nail.

Figure. 2.14 In purpuric disorders, the fact that lesions are palpable is of great importance, as it implies that the cause is a vasculitic process (i.e. that there is an inflammatory component rather than simple leakage of erythrocytes, as might occur in thrombocytopenia, extravasation secondary to vascular fragility, etc.). This photograph has used side-lighting to demonstrate this.

Figure. 2.15  The importance of a general history of recent illnesses is often clear in patients with a viral exanthema, in whom the rash may occur several days after the malaise or sore throat has settled, especially if the main feature is desquamation, as in this case.

Previous skin disorders

These may be of importance, particularly in the diagnosis of eczemas. For example, irritant hand dermatitis is not uncommon in adult patients with a history of childhood atopy, even though the patient may not recognize this as being the same process as the eczema behind their knees as a youngster. On the other hand, it is important not to be misled by a history of a previous skin problem, especially if the diagnosis is unsubstantiated; to use the same example, the fact that a patient has previous atopic dermatitis does not preclude a subsequent contact allergic dermatitis.

Family history

This is usually asked in relation to other family members who appear to have the same disorder, and may be relevant for:

In some instances, the family history may not be positive for the presenting disorder but for associated diseases, for example in the following.

Medical history and medications

A general medical history may be important in determining causes of some skin disorders, as several multiorgan diseases are first manifest in the skin (Figs 2.12 - 2.15); dermatology has interfaces with all other medical specialties (Chs 11 - 14). Recent events, which may be viewed as minor and not volunteered by patients, include sore throats (a typical trigger of guttate psoriasis) and influenza-like symptoms (which may precede a viral exanthem or urticaria).

    Medications (over the counter and prescribed, topical and systemic, and including ‘natural' herbal preparations) may cause skin eruptions, some patterns being linked strongly to a small number of specific agents, and the dermatologic history should document medications in the period prior to occurrence of an eruption. Questions to ask if patients are suspected of having a drug eruption are given in Ch.18.

    Knowledge of current medication may also be important to avoid interactions, particularly with increasing use of potentially toxic systemic therapy in dermatology. Previous systemic drug hypersensitivity and external contact allergies may be important when planning therapy. Aspirin is particularly relevant as a potential cause of bleeding in patients having skin surgery, but its use is often not documented or volunteered by patients. Foods may also be important, especially for episodic urticaria.

Hobbies

These are less likely to be relevant than the occupation as a cause of dermatitis, but a number of chemicals are encountered in common hobbies. These include epoxy resins (adhesives), rubber chemicals (footwear, gloves, and handles of sports equipment), and plant substances (gardening) (Table 2.2 and Ch. 6).

Figure. 2.16  The matchbox sign. A collection of carpet fluff and small fragments of wood and skin produced by a patient with delusions of parasitosis. (From Lawrence CM, Cox NH. Physical Signs in Dermatology, 2nd edn. London: Mosby, 2002.)

Figure. 2.17 Pitted keratolysis. This condition is essentially site-specific, affecting the sole of the foot (rarely, a similar appearance may occur on the hands).

Figure. 2.18 Herpes simplex folliculitis is confined to areas where there are adequate follicles. ( a ) View to show distribution in the beard area. ( b ) Close-up shows typical morphology of herpetic vesicles and follicular distribution.

Effects of the condition

There has been recent interest in the effects of skin problems on lifestyle, relationships, costs to the patient, and costs to the community from workdays lost. Various quality of life questionnaires have been developed, which are particularly applied for health economics research. In routine practice, it is helpful to know at least the patient's main concerns. These issues apply particularly to chronic skin eruptions, especially those with severe itch, with visible rash, or requiring complicated time-consuming treatments; however, many patients with discrete lesions also have concerns and in particular often want reassurance that skin malignancy is not a consideration.

     Sometimes patients may be hugely affected by a problem that appears clinically trivial to the observer (in some instances, to the point of this being psychologically abnormal and requiring expert help). Such issues require careful documentation.

Social factors

Several social factors may influence treatment modalities. Work commitments may make it difficult to use messy treatments, or to attend an outpatient treatment facility if this cannot offer out-of-hours appointments. Factors such as having several young children may determine the feasibility, and alcohol intake the desirability, of hospital admission.

    Excessive alcohol intake, apart from being a risk for behavioral difficulties with inpatients, appears to worsen several inflammatory skin disorders (if nothing else, it leads to poor treatment compliance), and sufficient alcohol to cause abnormal liver function may contraindicate use of systemic agents such as methotrexate.

    Cigarette smoking has a close association with palmoplantar pustulosis (see Ch.7, Fig.7.14) and is useful support for this diagnosis. About 90% of patients are smokers at the onset of the condition; unfortunately, resolution of the pustules does not follow cessation of smoking. In patients treated with antimalarial drugs for collagen vascular disorders, smoking significantly reduces the benefit that can be achieved.

    Depending on the healthcare system in which the practitioner works, financial considerations for the patient (such as extent of insurance cover), or for the healthcare system (such as agreements on cosmetic procedures), may also be an important part of the history.

White/Cox: Diseases of the Skin, 2ed.(c) 2006, Elsevier Inc. All rights reserved.