What is the approach to taking a thorough history in dermatology for a patient with a skin condition?

History Taking in Dermatology

Structured Clinical History Framework

A systematic dermatological history must capture atopic background, temporal patterns, product exposures, occupational factors, and environmental triggers to identify causative agents and distinguish between disease mechanisms. 1

Essential Personal and Family Background

• Ask specifically about childhood atopic dermatitis, asthma, hay fever, and family history of atopy to distinguish endogenous/atopic dermatitis from contact dermatitis 1, 2
• Document any previous allergic reactions to medications or products, including the specific type of reaction 1
• Record prior medical problems, particularly recurrent herpetic infections and respiratory infections 1
• Obtain complete immunization history, especially in children, as vaccinations may have been inappropriately omitted 3

Symptom Characterization

• Document the primary symptoms: itching (or scratching behavior in children), burning, pain, redness, crusting, weeping, or pustules 3, 1
• Determine temporal patterns: when symptoms are worse (morning worsening suggests blepharitis; evening worsening suggests aqueous deficient dry eye) 3
• Establish duration of symptoms and whether presentation is unilateral or bilateral 3
• Ask about history of itchiness in skin creases (elbow folds, neck, or cheeks in children under 4 years) 3

Distribution and Progression Patterns

• Determine where symptoms initially began and how they subsequently spread, as progression patterns provide crucial diagnostic clues 2
• Document whether lesions affect flexural areas, face, trunk, or extremities 3, 1
• Ask about general dry skin in the past year 3
• Note if onset occurred in the first two years of life (for pediatric cases) 3

Temporal and Environmental Relationships

• Ask whether symptoms improve during weekends, holidays, or when away from specific environments, and whether they recur upon return, as this temporal relationship strongly suggests occupational or environmental triggers 2
• Identify exacerbating conditions: smoke, allergens, wind, contact lenses, low humidity, retinoids, diet, alcohol consumption, eye makeup 3
• Determine time of day when symptoms worsen 3

Product and Substance Exposures

• Question the relationship to specific products: cosmetics, personal-care products, topical medications, clothing, bandages, or protective equipment like gloves 2
• Obtain detailed history of all wash products contacting the skin, as most contain harsh emulsifiers/surfactants that damage the skin barrier, particularly in predisposed individuals 2
• Document use of emollients and their frequency of application 3

Occupational History

• Take detailed occupational history including specific tasks performed, products handled at work, and review of health and safety data sheets, as occupational dermatitis accounts for approximately 70% of occupational skin disease 2
• Consider occupational exposures that might transfer to other body areas via hands 2

Dietary and Lifestyle Factors

• Take comprehensive dietary history, as parents of children with atopic eczema often experiment with dietary restriction 3
• Document diet and alcohol consumption patterns 3

Medication History

• Record current and previous systemic and topical medications, including antihistamines, drugs with anticholinergic effects, or past isotretinoin use that might affect the ocular surface 3
• Document any immunosuppressive therapy 3

Associated Systemic Conditions

• Ask about symptoms and signs related to systemic diseases: rosacea, atopy, psoriasis, graft-versus-host disease 3
• Inquire about dermatologic diseases such as rosacea, atopic dermatitis, herpes zoster ophthalmicus 3
• Screen for immunodeficiency states (recurrent systemic or ear infections, petechiae) 3

Surgical and Trauma History

• Document previous intraocular and eyelid surgery, cosmetic blepharoplasty 3
• Record local trauma history: mechanical, thermal, chemical, and radiation injury 3
• Ask about history of hordeola and/or chalazia (common in posterior blepharitis) 3

Infection Exposure

• Determine recent exposure to infected individuals (e.g., pediculosis palpebrarum) 3
• Look for signs suggesting secondary bacterial infection: crusting, weeping, pustules, increased erythema beyond baseline 4

Critical Pitfalls to Avoid

• Do not rely solely on morphology and distribution to predict the cause, as clinical features are unreliable in distinguishing atopic/endogenous dermatitis from irritant or allergic contact dermatitis, even in children 2
• Do not overlook occupational exposures that might transfer to other body areas via hands, as this can prevent healing despite apparent allergen avoidance 2
• Do not miss signs of eczema herpeticum, which requires immediate antiviral therapy—this is a medical emergency 4
• Do not underestimate pustules in neonates, which always require investigation to exclude infectious disease 1
• Do not dismiss deterioration in previously stable eczema, as this commonly indicates secondary bacterial infection or development of contact dermatitis 3, 4