How to take a Dermatologic full history
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Dermatologic Full History
Source: Fitzpatrick's Dermatology, Table 1-1
1. Chief Complaint & History of Present Illness (HPI)
| Element | What to Ask |
|---|---|
| Duration | When was the condition first noted? Dates of any recurrences or remissions? |
| Timing | Is it constant or intermittent? Worse at night? Worse in a particular season (e.g., winter)? |
| Evolution | How has the condition changed or progressed over time? |
| Location | Where did lesions first appear? How have they spread, if at all? |
| Symptoms | Pruritus, pain, bleeding, non-healing wounds, change in a pre-existing skin lesion, associated fever or systemic signs |
| Severity | Ask the patient to rate pain or pruritus on a 0-10 scale - useful to track severity over time |
| Ameliorating & exacerbating factors | Sun exposure, heat, cold, trauma; exposures to chemicals, medications, cosmetics, perfumes, plants, metals; relation to menses or pregnancy |
| Preceding events | Recent illness, new medications started, new topical products, new exposures |
| Treatments tried | Prescription and non-prescription remedies, home remedies, and response to each |
| Prior episodes | Any prior similar problems, prior diagnosis, results of biopsies or other studies |
2. Medical History (PMH)
- All chronic illnesses, especially those that can manifest in the skin:
- Diabetes mellitus
- Renal and hepatic disease
- HIV and other viral infections
- Polycystic ovarian syndrome (PCOS)
- Lupus erythematosus
- Thyroid disease
- Conditions associated with skin disease: asthma, atopy, allergies
- History of surgical procedures, including organ transplantation
- Immunosuppression - iatrogenic (steroids, biologics), infectious (HIV), or inherited (primary immunodeficiency)
- Obstetric history (pregnancies)
- Psychiatric disease (relevant in conditions like dermatitis artefacta, delusional infestations)
- History of blistering sunburns
- Exposure to arsenic or ionizing radiation
3. Medication History
- All prescription medications - pay special attention to recently started ones
- Non-prescription medications, vitamins, dietary supplements, herbal remedies
- Drug eruptions can mimic almost any dermatosis, so this history is essential
4. Allergy History
- Medication allergies
- Food allergies
- Environmental allergens
- Contact allergens (metals, rubber, fragrances, preservatives) - this is particularly important in dermatology
5. Social History
| Domain | Details to Explore |
|---|---|
| Occupation | Chemical exposures, hand washing frequency, outdoor work, latex gloves |
| Hobbies & leisure | Gardening, sports, crafts - potential exposures |
| Substances | Alcohol, tobacco, illicit drug use |
| Sexual history | High-risk activities for sexually transmitted infections (syphilis, HSV, HIV, molluscum, HPV) |
| Diet | Nutritional deficiencies that manifest on skin |
| Bathing habits | Frequency, soap type, water temperature |
| Pets | Zoonotic infections (ringworm, scabies, cat-scratch disease) |
| Living conditions | Alone, with family, homeless, in an institution (scabies outbreaks, etc.) |
| Travel history | Residence in or travel to endemic areas for infectious diseases (leishmaniasis, cutaneous larva migrans, etc.) |
| Cultural/religious practices | Tattooing, body piercings, use of traditional remedies |
6. Family History
- Skin disease in first-degree relatives (psoriasis, eczema, melanoma)
- Atopy triad: atopic dermatitis, asthma, allergic rhinitis/hay fever
- Skin cancer - melanoma, basal cell carcinoma, squamous cell carcinoma
7. Review of Systems (ROS)
The depth depends on the clinical scenario:
- Focused ROS - ask about symptoms that specifically accompany a known condition (e.g., joint pain, nail changes, and eye symptoms in psoriasis)
- Comprehensive ROS - use when skin signs may reflect systemic disease (e.g., palpable purpura, which requires workup for vasculitis, infection, malignancy)
- Key systems to cover: musculoskeletal, GI, renal, pulmonary, neurological, ophthalmologic, and lymph nodes
Key Dermatology-Specific Questions to Always Ask
- "Does it itch?" - Pruritus is a major differentiator (e.g., scabies, atopic dermatitis vs. psoriasis)
- "Does anyone else at home have the same problem?" - Points to contagious or contact conditions
- "What have you put on it?" - Topical product use can both treat and cause skin disease
- "Does sunlight make it better or worse?" - Helps separate photosensitive from photoprotected conditions
- "Has it changed?" - Non-healing or changing lesions raise concern for malignancy
Fitzpatrick's Dermatology, Vol. 1, Table 1-1 - History Taking in Dermatologic Diagnosis, p. 32
How to do the derma PE
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Dermatologic Physical Examination
Source: Fitzpatrick's Dermatology, Vol. 1, Tables 1-2 to 1-8
Step 1 - Setup & Conditions
Before starting, ensure ideal conditions:
- Lighting: Bright, preferably natural light - subtle but important findings are missed in poor lighting
- Undress the patient fully, gown and drape as needed; remove underwear, socks, shoes, makeup, and eyeglasses
- Room temperature should be comfortable for a lightly dressed patient
- Have a chaperone present when the physician and patient are of opposite genders
- Wash hands before and after - patients are reassured by seeing this
Recommended Tools
| Tool | Purpose |
|---|---|
| Dermatoscope / loupe / magnifying glass | Closer inspection of lesions |
| Focused bright light / penlight | Shadows to assess surface topography |
| Glass slides | Diascopy, Tzanck smear, fungal scraping, viral DFA |
| Alcohol pads | Remove surface debris or oil |
| Gauze + water | Remove makeup |
| Gloves | Worn for any contagious condition, mucous membrane exam, or procedures |
| Ruler | Measure lesion size precisely |
| No. 15 and No. 11 scalpel blades | Scraping and incising |
| KOH solution, Tzanck prep, culture media | Diagnostic tests at bedside |
| Camera | Photographic documentation |
| Wood lamp (365 nm) | Highlights pigmentary changes; accentuates epidermal (not dermal) melanin |
Step 2 - General Impression (from a distance first)
Start by observing the patient from a distance before moving in:
- Well or ill appearing?
- Body habitus: obese, cachectic, or normal weight
- Skin color: degree of pigmentation, pallor (anemia), jaundice
- Skin temperature: warm, cool, or clammy
- Skin surface characteristics: xerosis (dryness), seborrhea (excessive oiliness), turgor, hyper- or hypohidrosis, texture
- Degree of photoaging: lentigines, actinic purpura, rhytides (wrinkles)
Step 3 - Systematic Head-to-Toe Skin Examination
Work in a consistent, systematic sequence so no area is overlooked:
- Scalp and hair - alopecia, scaling, erythema, nits
- Face - including periorbital, perioral, ears, nose
- Oral mucosa - lips, buccal mucosa, tongue, gingiva, palate (erosions, ulcers, white plaques, pigmentation)
- Neck and cervical lymph nodes
- Chest and axillae - include intertriginous folds
- Back and flanks
- Upper extremities - extensor and flexor surfaces, wrists, interdigital spaces
- Nails (hands and feet) - pitting, onycholysis, subungual changes, color
- Abdomen and groin / inguinal folds
- Genitalia and perianal area - use gloves
- Lower extremities - thighs, popliteal fossa, shins, ankles
- Feet and toes - soles, web spaces
After completing the exam, document all findings descriptively or on a body map. For lesions suspicious for malignancy, use photography and triangulation from anatomic landmarks so the site can be definitively re-identified for treatment.
Step 4 - Describe Each Lesion Using the Morphologic Framework
The morphologic description is the core skill of dermatology. Think of it as building a sentence: Primary lesion (noun) + secondary changes + color + shape + configuration + distribution (adjectives).
A. Primary Morphology
Flat (Non-palpable) Lesions
| Lesion | Size | Description |
|---|---|---|
| Macule | < 1 cm | Flat area of color change, not palpable |
| Patch | ≥ 1 cm | Same as macule but larger |
Raised / Palpable Solid Lesions
| Lesion | Size | Description |
|---|---|---|
| Papule | < 1 cm | Elevated or depressed solid lesion; describe topography: dome-shaped, flat-topped, umbilicated, filiform, pedunculated |
| Plaque | ≥ 1 cm | Solid plateau-like elevation or depression |
| Nodule | > 1 cm | Domed/spherical palpable lesion; describe depth (epidermal, dermal, subcutaneous) and texture (firm, fluctuant, boggy) |
Fluid-filled Lesions
| Lesion | Size | Description |
|---|---|---|
| Vesicle | < 1 cm | Fluid-filled papule |
| Bulla | ≥ 1 cm | Large fluid-filled blister |
| Pustule | Any | Pus-filled (neutrophils) - may be follicular or non-follicular |
Other Primary Lesions
- Wheal (urtica) - transient edematous papule/plaque from dermal edema; characteristic of urticaria
- Cyst - enclosed cavity with a lining, containing fluid, semi-solid, or solid material
- Erosion - superficial loss of epidermis only (heals without scarring)
- Ulcer - full-thickness loss extending into dermis or deeper (heals with scarring)
B. Secondary Morphology (Epidermal Changes)
These develop from evolution of the primary lesion or from external modification (scratching, infection, treatment):
| Secondary Change | Description |
|---|---|
| Scale | Accumulation of stratum corneum cells; indicates epidermal involvement |
| Crust | Dried serum, blood, or pus on surface |
| Lichenification | Thickened skin with accentuated skin markings from chronic rubbing/scratching |
| Excoriation | Linear or punctate erosion from scratching |
| Fissure | Linear crack through epidermis into dermis; common on palms/soles |
| Atrophy | Thinning of epidermis (shiny, translucent) or dermis (depression, loss of normal texture) |
| Scar | Fibrous replacement after dermal damage |
| Keloid | Hypertrophic scar extending beyond original wound margins |
C. Color
Color is often the most diagnostically important additional feature. Key correlations:
| Color | Common Cause |
|---|---|
| Brown | Epidermal melanin (tan to brown-black); dermal melanin appears blue-gray (Tyndall effect) |
| Red / erythema | Vascular dilation; blanches on diascopy |
| Purpura / petechiae | Extravasated RBCs; does NOT blanch on diascopy |
| White | Loss of melanin (vitiligo), fibrosis, or vasoconstriction |
| Yellow | Lipid, carotene, or bilirubin deposition |
| Blue-gray | Dermal melanin (Tyndall effect), drug deposition (amiodarone, minocycline) |
| Black | Concentrated melanin, necrosis, or exogenous pigment |
Diascopy (pressing a glass slide firmly over the lesion): blanching = vascular; non-blanching = purpura/hemorrhage.
Wood lamp: accentuates epidermal but NOT dermal melanin - useful to distinguish the two.
D. Shape of Individual Lesions
- Round / oval
- Annular (ring-shaped) - tinea, granuloma annulare, secondary syphilis
- Nummular (coin-shaped)
- Target / iris - erythema multiforme
- Linear - contact dermatitis (external agent), lichen striatus, Koebner phenomenon
- Serpiginous (snake-like) - cutaneous larva migrans
- Polygonal - lichen planus
- Irregular - melanoma, basal cell carcinoma
E. Configuration (Arrangement of Multiple Lesions)
- Grouped / herpetiform - herpes simplex/zoster
- Linear - contact dermatitis, Koebner response
- Dermatomal - herpes zoster
- Reticulated (net-like) - livedo reticularis
- Satellite lesions - candidiasis
- Confluent - widespread eruptions
F. Distribution
This is often the most powerful single clue to diagnosis:
| Pattern | Example Conditions |
|---|---|
| Sun-exposed areas (face, dorsal hands, V-neck, forearms) | Lupus, polymorphous light eruption, photoallergic/phototoxic drug reaction |
| Flexural (antecubital, popliteal, neck folds) | Atopic dermatitis |
| Extensor surfaces (elbows, knees) | Psoriasis |
| Intertriginous (groin, axillae, under breasts) | Candidiasis, inverse psoriasis, intertrigo |
| Acral (hands, feet) | Hand-foot-mouth disease, secondary syphilis |
| Follicular | Folliculitis, keratosis pilaris |
| Dermatomal | Herpes zoster |
| Symmetric | Systemic/endogenous conditions (drug eruption, atopic dermatitis) |
| Asymmetric / localized | External/exogenous cause (contact dermatitis, infection) |
Step 5 - Reaction Pattern Recognition
After describing primary morphology + secondary changes, assign a reaction pattern - this is the diagnostic category that generates your differential diagnosis:
| Reaction Pattern | Key Feature | Common Diagnoses |
|---|---|---|
| Papulosquamous | Papules/plaques with scale | Psoriasis, lichen planus, tinea, pityriasis rosea, secondary syphilis, mycosis fungoides |
| Eczematous | Spongiotic papules/vesicles, crusting, lichenification | Atopic, contact (irritant/allergic), nummular, stasis dermatitis |
| Vesiculobullous | Fluid-filled blisters | Pemphigus, pemphigoid, herpes, dermatitis herpetiformis, porphyria |
| Pustular | Pus-filled lesions | Folliculitis, acne, pustular psoriasis, IgA pemphigus |
| Nodular | Deep palpable nodules | Lymphoma, panniculitis, sarcoidosis, melanoma, BCC |
| Vascular | Erythema, purpura, urticaria | Vasculitis, urticaria, viral exanthem, drug reaction |
Step 6 - Adjunctive General Examination
Depending on the suspected diagnosis, complement the skin exam with:
- Vital signs (fever in systemic infections, drug reactions)
- Lymph node examination - especially in infection and suspected malignancy
- Abdominal examination for hepatosplenomegaly (lymphoma, sarcoidosis, viral illnesses)
- Peripheral pulses (ischemic ulcers, Raynaud)
- Nail and hair examination - nails show pitting/onycholysis in psoriasis; diffuse hair loss in telogen effluvium, lupus, thyroid disease
- Mucous membrane examination - erosions in pemphigus, Behcet, Stevens-Johnson syndrome
Fitzpatrick's Dermatology, Vol. 1, pp. 31-44 - Tables 1-2 through 1-8
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