Assessment of the patient

As well as assessing the clinical changes, the effect of a skin condition on the patient's life and their attitude to it must always be taken into account. For example, severe pustular psoriasis of the hands can be devastating for a self employed electrician and total hair loss from the scalp very distressing for a 16 year old girl.

Fear that a skin condition may be due to cancer or infection is often present and reassurance should always be given whether asked for or not. If there is the possibility of a serious underlying cause that requires further investigation, it is part of good management to answer any questions the patient has and provide an explanation that he or she can understand. It is easy to forget this aspect of medical practice at times.

The significance of occupational factors must be taken into account. In some cases, such as an allergy to hair dyes in a hairdresser, it may be impossible for the patient to continue their job. In other situations the allergy can be easily avoided.

Patients understandably ask whether psoriasis can be cured and often want to know the cause. The cause is unknown and the best answer is that the tendency to develop psoriasis is part of a person's constitution and some factor triggers the development of the clinical lesions. Known factors include physical or emotional stress, local trauma to the skin (Koebner's phenomenon), infection (in guttate psoriasis), drugs (P blockers, lithium, and antimalarial drugs).

To illustrate the use of these basic concepts in the diagnosis of lesions in practice two common skin diseases are considered— psoriasis, which affects 1-2% of the population, and eczema,, an even more common complaint. Both are rashes with distinctive epidermal changes. The difficulty arises with the unusual lesion: Is it a rarity or a variation of a common disease? What should make us consider further investigation? Is it safe to wait and see if it resolves or persists? The usual clinical presentations of psoriasis and eczema are also used as a basis for comparison with variations of the usual pattern and other skin conditions.

A relevant history should be taken in relation to occupational and environmental factors

• Where? Site of initial lesion(s) and subsequent distribution

• How long? Has condition been continuous or intermittent?

• Prognosis—Is it getting better or worse?

• Previous episodes—How long ago? Were they similar? Have there been other skin conditions?

• Who else? Are other members of the family affected? Or colleagues at work or school?

• Other features—Is there itching, burning, scaling, or blisters? Any association with drugs or other illnesses?

• Treatment—By prescription or over the counter? Have prescribed treatments actually been used?

The following points are helpful when examining skin lesions

Distribution

• This may give the essential clue, so a full examination is necessary. For example, there are many possible causes for dry thickened skin on the palms, and finding typical psoriasis on the elbows, knees, and soles may give the diagnosis

Morphology

• Are the lesions dermal or epidermal? Macular (flat) or forming papules? Indurated or forming plaques? With a well defined edge? Forming crusts, scabs, or vesicles?

Pattern

• This is the overall clinical picture of both morphology and distribution. For example, an indeterminate rash may be revealed as pityriasis rosea when the "herald patch" is found

Inheritance (genetic)_|

Infection

Environment

Disease process

Change in environment

Change in environment

Treatment

Response of organism (immunological, physiological)

Response of organism (immunological, physiological)

Factors possibly affecting development of skin disease such as psoriasis Further reading

Braun-Falco O, Plewig G, Wolff HH, Winkelmann RK. Dermatology.

Berlin: Springer-Verlag, 1991 Champion RH, Burton JL, Ebling FJ. Textbook of dermatology. 6th ed.

Oxford: Blackwell Scientific, 1998 Fitzpatrick TB, Freedberg IM, Eisen AZ, Austen KF, Wolff K.

Dermatology in general medicine. 4th ed. New York: McGraw-Hill, 1993 Sams WM, Lynch PJ, eds. Principles and practice of dermatology, 2nd ed. New York: Churchill Livingstone, 1996

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