Here’s a structured approach to taking a skin history:
- Chief Complaint:
- Begin with the patient’s main concern regarding their skin.
- Ask them to describe what prompted their visit.
- History of Present Illness:
- Onset: When did the skin problem begin? Was it sudden or gradual?
- Location: Where on the body did it start? Has it spread?
- Characteristics: What does the lesion or rash look like? Color, size, shape, and texture are important.
- Symptoms: Is there itching, pain, burning, or bleeding?
- Course: Has the condition changed over time? Getting better, worse, or staying the same?
- Aggravating/Relieving Factors: Are there factors that worsen or improve the symptoms? Consider triggers such as sunlight, skincare products, medications, foods, or environmental factors.
- Self-Treatment: Has the patient used any over-the-counter or home remedies? What was the outcome?
- Skin Care Routine: Daily skincare practices, including the use of moisturizers, soaps, and cosmetics.
- Past Medical History:
- Inquire about previous skin diseases, skin cancers, allergies, systemic diseases (e.g., diabetes, rheumatoid arthritis), and family history of skin conditions.
- Fitzpatrick skin type and tanning ability
- History of sunburns, tanning practices, solariums, and use of sunscreen.
- Medications:
- List all current and recent medications, including prescription drugs, over-the-counter medications, herbal supplements, and topical treatments.
- Some medications can cause skin reactions or photosensitivity.
- Social History:
- Occupation: Some professions may expose individuals to chemicals or irritants that can affect the skin.
- Habits: Smoking, alcohol use, and recreational drug use can have implications for skin health.
- Review of Systems:
- A broad review to identify if the skin condition is part of a systemic disease.
- Ask about recent fevers, joint pains, fatigue, or symptoms involving other organ systems.
- Family History:
- Inquire about skin diseases in family members, especially conditions with genetic predispositions like psoriasis, atopic dermatitis, or melanoma.
When taking a skin history, it’s important to be thorough and attentive to the patient’s descriptions. Visual inspection will complement the history for a comprehensive assessment. The information gathered will guide further examination, diagnostic testing, and management plans.
Always ensure the conversation is patient-centered, allowing them to express their concerns and questions fully.