It is important to deal
with a dermatological case in a systemic way to reach an accurate
diagnosis and effective curative results.
History taking is
essentially similar to that undertaken in any general medical or surgical
concerning the time of onset and duration of the skin lesion, past and
family history and the medication used by the patient are important data
that may help in diagnosis of skin diseases.
When dealing with skin
problems in infants or children, the mother gives the history or even the
diagnosis sometimes. The physician should have great patience, questioning
systematically and persistently. It is of prime importance to ask about
all the medications that have been given to the patient whether topical or
Most patients consulting
dermatology clinics have had their skin problem treated either by a
physician, the members of the family, the pharmacist or by the advice of
friends. However, when the problem persists or becomes more complicated,
they seek for professional help.
Past history of an allergic reaction
(asthma, hay fever, urticaria, drug eruption etc.), are very important and
should be recorded in the file.
concerning the type of feeding and any particular food exacerbating the
skin lesions of the child should be taken into consideration. Newborn and
infants are not only breast-fed but other supplements may be used as
cereals, which may exacerbate their skin problem.
The role of the mother is
not to feed or just to fatten her baby. There are other ethical, moral,
and educational duties. Supervision of her child from the anatomical,
physiological and psychological point is of prime importance. The
condition of the skin, whether there is dryness, or the child sweats or
not, types of excreta coming out, for change of color, bloody or others
all should be taken into consideration and reported to the treating
physician. These physical signs may diagnose certain systemic or genetic
diseases. The physician may get valuable data from the mother, if he
follows a detailed history. He can spend few minutes in questioning and
directing the attention of the mother to such details and to be kept in
her mind. Some of data in the history save time and effort in reaching an
accurate diagnosis. The physician must not feel at all that he spent
longer time with his patient.
Certain medications or
foodstuffs taken by the mother and pass through breast milk may have an
important role in the etiology or exacerbation of dermatitis eczema
The experienced physician
will not often follow a rigid line of questioning as in the type
encountered in a typical sheet form. Complete medical history of a patient
with a skin disease should trace the development of the disease as
accurately as possible; to determine those elements in the patient‘s
present or past history which may be related to the skin problem either
psychic, personal, emotional status, hereditary and environmental.
In addition to the
inquiry concerning familial tendencies to diabetes, cardiovascular disease
and tumors, questioning concerning the familial incidences of allergic
diseases is of great importance in a wide variety of skin conditions. It
is not sufficient to simply ask the question "is there any allergy in
Hives, eczema, hay fever
and asthma should be specifically mentioned. Other common conditions in
relation to skin diseases include acne, icthyosis, xeroderma pigmentosa,
rosacea, baldness, psoriasis and some other congenital malformations.
Fig. Psoriasis ( familial, a boy& his sister)
As many other diseases,
certain skin diseases are seen much more frequently in certain age groups.
Despite the smooth and delicate appearance of a baby‘s skin, it seems to
be quite similar to the adult skin. Some organs of the newborn are less
well developed such as sebaceous glands, hair follicles and dermal
There are important
differences in the heat regulation between the infant and the adult skin.
This is due to the different area-to-body-volume ratio, the skin vascular
reactivity, and to its ability to lose heat by sweating. These very
important differences should be taken into consideration especially when
prescribing topical or other medications hence a child skin presents less
barrier to the penetration of medications and toxins than in adults.
Environment has an
important role on the pathogenesis or exacerbation of certain skin
diseases in infants and young children.
Hot humid climates
predispose to heat rash and fungal skin diseases.
Type of sports and
activities of the child, whether indoors or outdoors may have an
important role on the skin problem.
Contact with other
children in the school or in sport clubs, whether using their own
clothes or others‘ clothes are also some of the important factors.
Standard of living,
whether he lives in a flat or in a separate house with swimming pool
with surrounding gardens.
Type of pets in the
house such as cats dogs, birds and others.
Race is rarely a crucial
determining factor, however this may be of considerable importance in the
prognosis of certain skin diseases. Deep mycosis such as coccidomycosis
may cause serious prognosis in Negroes.
Certain skin diseases
such as leishmaniasis, Yaw, Pinta and Bejel are endemic in tropical areas.
Contact dermatitis occurs more in areas having specific plants, trees or
exposure to different chemicals.
An individual who spends
some time in a tropical climate, but who is not a native, is much more
likely to have some very aggravated form of common skin diseases such as
insect bites, fungal and bacterial infections than the native residents.
Allergic rhinitis, asthma may be seen more in dusty polluted areas and in
Some skin diseases have
certain geographic distribution where the physicians of this area may be
not familial with them and most of their knowledge is from literatures,
while those living in the endemic area, such diseases may be faced and
I have seen a young
secretary lady of one of the ambassadors who was referred to me by the
family physician. This lady received a heap of medications for her leg
ulcers from local and other centers. The patient was under different
types of topical and systemic steroids for her skin lesion (cutaneous
leishmaniasis). The patient was in doubt when I told her that her problem
could be solved. She was instructed to take daily injections ( 60 mg.
Pentostam) for ten days. The patient used to take repeated photos for her
leg ulceration. On the tenth day she visited my office cheering as there
was dramatic healing of her leg ulcers.
Certain diseases have
seasonal peaks. Contact dermatitis and hay fever are invariably seen
during the season of pollens.
Many diseases including
dermatitis and superficial
fungal infections, miliaria become much worse
during seasons of high environmental temperature, especially with high
Papular urticaria is more
common in children in summer due to insect bites. Dry skin is often worse
in winter because of the low humidity of artificially heated
air-conditioned houses and exposure of the skin to long hot baths.
In patients with chronic
recurrent skin disorders, the history of climate the time and onset of the
disease, and other factors all of these are of great importance.
This is of a prime
importance especially in infants and young children. The parents should be
questioned about topical and internal medications given to their child. In
many patients with dermatitis, it will be found that the objective changes
in large part are due to the treatment that has been given to the primary
The clinical picture may
be completely distorted due to some topical medications particularly with
colored topical medications such as Gentian violet. This will not only
mask the lesion, but it may cause maceration of the infants‘ skin
especially when applied concentrated to the genital or intertriginous
A large number of
and children may be seen with striae, acniform eruption, moon face,
undescended testicles, wasted buttocks, thin and severe erythematous skin
especially on the face due to abuse or misuse of potent steroids.
Topical medications due
to the base content or the medication itself or the combination with other
medications such as neomycin, anesthetics, antihistamines and even
steroids may cause local sensitization.
Drug reactions due to
antibiotics, sedatives, tonics, vitamins, laxatives, and fixed drug
eruption induced by sulfonamides are not uncommon.
Some beverages that
contain special herbs or those in a form of herbal tea may cause severe
Examination should be
under a good light, preferably daylight or a daylight type electrical lamp
and using a magnifying lens. An assessment of a patient‘s normal skin
problems can be made at a glance, with experience, but still thorough
examination not only to the site of the lesion but to other parts of the
body should not be neglected.
The physician must get up
and do something for his patient. Besides talking to him or adding humor,
he should try to give confidence, courage and sympathy to the patient. He
can even give "hardened pessimistic cases" an optimistic look to
make his patient "cheer up", especially those who have chronic
resistant skin lesion or those with psychosomatic problems. The physician
should not be very serious and must not flip, but his light touch with the
kindly cheery smile may dispel the gloom.
Confidence of the patient
or his parents towards the physician is considered of prime importance.
The prescription alone sometimes will not do the whole job. The physician
must impose his will on his patient, and this can be done best with
graciousness, diplomacy and reason.
The physician should not
pay all his attention to diagnose and treat the skin lesion only. He has
to know that certain skin diseases are manifestations of internal
Thorough and keen
examination should not neglect signs of child abuse either by the parents,
or the housemaids, the drivers, or other employees working for the family.
Genital areas of children
should be examined for signs of local infection mainly anogenital warts,
contusions, laceration of the anogenital areas. It is not uncommon that
the physician may be faced with lacerated hymen, abrasions, contusions of
the child‘s genitalia or even vaginal or urethral discharge or other
manifestations of sexually transmitted diseases in children.
Genital contusions and mollascum contagiosum of a child
of sex abuse in a child) Genital warts (Condyloma accuminata)
of a child
and the relation of the child with his parents and other members of the
family should not be neglected during examination.
The primary skin lesions
are the original lesions that appear as a result of different stimuli
either internal or external. The different primary skin lesions seen on
Macule - a
circumscribed flat area of different color from the surrounding skin.
Macules may become raised due to edema, where it is then called
Papule - a raised
circumscribed elevation of skin.
Nodule or tubercle
- a solid elevation of the skin, larger than a papule.
Plaque - a raised
thick portion of the skin, which has well defined edges with a flat or
of the skin surface) -This is the commonest primary skin lesions, which
appears in most skin diseases. Erythema is due to dilatation of dermal
blood vessels and edema.
Blister - a skin
bleb filled with clear fluid
Vesicle - a small
Bulla - a large
Pustule - a skin
elevation filled with pus
Cyst - a cavity
filled with fluid.
Nevus - hereditary
skin disorders due to deficiency or excess of the normal constituents of
the skin and usually defined as nevi.
Secondary skin lesions
are modifications or changes of the primary lesions due to infection,
trauma or due to other factors. The different secondary skin lesions are :
Scales - a flake
of flat horny cells loosened from the horny layer. Fine desquamation of
the skin is an ordinary physiological in normal individuals due to the
wear and tear. When the formation of epidermal cells are rapid or there is
disturbance of normal skin keratinization pathological scaling will
result. Skin scaling may be localized or generalized called as exfoliative
Crust - dried
serum seen in ruptured vesicles, pustules or bulla.
mechanical abrasion of the skin usually caused by the fingernails in
attempt to relive itching.
Fissure - a crack
or split in the epidermis.
Erosion - an area
of partial loss of epithelium of skin or mucous membrane.
Ulcer - an area of
total loss of epithelium of skin or mucous membrane.
Atrophy - loss of
thickness of the epidermis or dermis or other tissue.
thickness of both prickle cell layer and horny layer with exaggeration of
normal skin marks.
diffuse or circumscribed induration of the subcutaneous tissues.
Fibrosis - the
formation of excessive fibrous tissue.
Abscess - a
localized collection of pus in a cavity formed by disintegration or
necrosis of tissue.
Cellulitis - an
inflammation of cellular tissue, particularly purulent inflammation of the
deep dermis and subcutaneous tissue.
Pyoderma - any
purulent skin disease.
localized or generalized loss of hair due to local or systemic factors.
Alopecia may be primary or secondary to a local skin disease such as
fungal or bacterial infections.
Burrow - a small
tunnel in the skin that houses a metazoal parasite, such as the scabies
Comedo (nes) - a
plug of keratin and sebum in a dilated pilosebaceous orifices.
Hematoma - a
localized tumor-like collection of blood.
(bruise) - a macular area of hemorrhage more than 2 cm in diameter.
Petechiae - a
punctate hemorrhage spots approximately 1-2 mm in diameter.
Stains or pigments
- local hyperpigmentation of the skin following certain skin diseases.
Exfoliation - the
splitting off of the epidermal keratin in scales or sheets.
Hemosedroses - in
Fistula - an
abnormal passage from a deep structure to the skin surface or between two
structures. It is often lined with squamous epithelium.
Keratoderma - a
localized hyperplasia and thickening of the stratum corneum.
Striae - linear
lesions due to stretch of the skin, either physiological or pathological.
Callus - a horny
thickening of the skin.
Milium - a tiny
white cyst containing lamellated keratin.
Vegetation - a
growth of pathological tissue consisting of multiple closely set papillary
Papilloma - a
nipple-like mass projecting from the surface of the skin.
Aphtha - a small
ulcer of the mucosa.
The Koebner‘s or
isomorphic phenomenon - is the formation of skin changes such as that of
the primary skin disease by non-specific trauma as in psoriasis.
OF DIAGNOSIS IN DERMATOLOGY
The skin is the exposed
covering and the outer coat lining of the body surface. Skin lesions
whether primary or secondary appear frankly to the naked eye. The
experienced physician can immediately diagnose some skin diseases on the
spot without hesitation.
The patient who spent his
time and money to have the opportunity to reach the physician to treat his
skin problem should have appropriate and appreciated care. From the
psychological point of view he may be disappointed when he finds that his
problem was solved within a few minutes especially when that was done in a
rush and a non-convincing way. Just a few minutes after sitting in front
of his physician, the patient will be provided with a piece of paper
containing the medications. He may be given the impression that the
physician has finished his job and he has to leave his seat for another
patient. Some patients may have doubt that his skin problem was not
handled in the proper way especially those who have chronic skin diseases
and have consulted different clinics.
We were faced with
patients saying that "these were the most expensive minutes in our
life, we paid a lot of money for these few minutes".
It is true that some skin
diseases can be diagnosed on sight with a high degree of confidence but
even in such cases, detailed history is indispensable for an effectively
In spite of all of that,
it is true from the physician point of view that he can diagnose most skin
diseases in this way but certain skin diseases need more care and more
investigations to reach a thorough and convincing diagnosis.
Auerbach AD. Diagnosis of diseases of DNA synthesis and repair that affect the skin using cultured amniotic fluid cells. Semin Dermatol 1984; 3: 172-84.
Auerbach AD. Diagnosis of diseases of DNA synthesis and repair that affect the skin using cultured amniotic fluid cells. Semin Dermatol 1984; 3: 172-84.
Ahlstedt S, Eriksson N, Lindgren S et al. Specific IgE determination by RAST compared with skin and provocation tests in allergy diagnosis with birch pollen. Timothy pollen and dog epithelium allergens. Clin Allergy 1974; 4: 131-140.
Boyd AS, Neldner KH. The isomorphic reponse of Koebner. Int J Dermatol 1990; 29: 401-10.
Committee on Provocative Food Testing. Identification of food allergens. Ann Allergy 1973; 31: 375-92.