Review of Specific Symptoms

The main symptoms of disease of the skin, hair, and nails are the following:

• Rash or skin lesion Changes in skin color

Itching (pruritus) Changes in hair Changes in nails

Rash or Skin Lesion

There are some important points to clarify when a patient is interviewed about a new rash or skin lesion. The specific time of onset and location of the rash or skin lesion are critical. A careful description of the first lesions and any changes is vital. The patient with a rash or skin lesion should be asked the following questions:

''Was the rash initially flat? raised? blistered?'' ''Did the rash change in character with time?'' ''Have there been new areas involved since the rash began?'' ''Does the rash itch or burn?'' ''Is the lesion tender or numb?'' ''What makes the rash better? worse?'' ''Was the rash initiated by sunlight?'' Is the rash aggravated by sunlight?'' What kind of treatment have you tried?'' ''Do you have any joint pains? fever? fatigue?'' Does anyone near you have a similar rash?'' ''Have you traveled recently?'' If so, ''To where?'' Have you had any contact with anyone who has had a similar rash?'' Is there a history of allergy?'' If so, What are your symptoms?'' Do you have any chronic disease?''

Note whether the patient has used any medications that may have changed the nature of the skin disorder.

Inquire whether the patient uses any prescription medications or over-the-counter drugs. Ask specifically about aspirin and aspirin-containing products. Patients can suddenly develop a reaction to medications that they have taken for many years. Do not ignore a long-standing prescription. Has the patient had any recent injections or taken any new medications? Does the patient use ''recreational'' drugs? Ask the patient about the use of soaps, deodorants, cosmetics, and colognes. Has the patient changed any of these items recently?

A family history of similar skin disorders should be noted. The effect of heat, cold, and sunlight on the skin problem is important. Can there be any contributing factor, such as occupation, specific food allergies, alcohol, or menses? Is there a history of gardening or household repair work? Has there been any contact with animals recently? The interviewer should also remember to inquire about psychogenic factors that may contribute to a skin disorder.

Determine the patient's occupation, if it is not already known. Ascertain avocational and recreational activities. This information is important even if the patient has been exposed to chemicals or similar agents for years. Manufacturers frequently change the basic constituents without notifying the consumer. It may also take years for a patient to become sensitized to a substance.

Changes in Skin Color

Patients may complain of a generalized change in skin color as the first manifestation of an illness. Cyanosis and jaundice are examples of this type of problem. Determine whether the patient is aware of any chronic disease that may be responsible for these changes. Localized skin color changes may be related to aging or to neoplastic changes. Certain medications can also be responsible for skin color changes. Inquire whether the patient is taking or has recently taken any medications.

Pruritus

Pruritus, or itching, may be a symptom of a generalized skin disorder or an internal illness. Ask any patient with pruritus the following questions:

''When did you first notice the itching?'' ''Did the itching begin suddenly?''

''Is the itching associated with any rash or lesion on your body?'' ''Are you taking any medications?''

''Has there been any change in the sweating or dryness of your skin?'' ''Have you been told that you have a chronic illness?'' ''Have you traveled recently?'' If so, ''To where?''

Diffuse pruritus is observed in biliary cirrhosis and in cancer, especially lymphoma. Pruritus in association with a diffuse rash may be dermatitis herpetiformis. Determine whether the pruritus has been associated with a change in perspiration or dryness of the skin, because either of these conditions may be the cause of the pruritus.

Changes in Hair

Inquire whether there has been a loss of hair or an increase in hair. Ascertain any changes in distribution or texture. If there have been changes, ask the following questions:

When did you first notice the changes?'' Did the change occur suddenly?'' Is the hair loss symmetric?''

Has the change been associated with itching? fever? recent stress?'' ' 'Are you aware of any exposure to any toxins? commercial hair compounds?'' Have you changed your diet?'' What medications are you taking?''

Changes in diet and medications are frequently responsible for changes in hair patterns. Hypothyroidism is frequently associated with loss of the lateral third of the eyebrows. Vascular disease in the legs often causes hair loss on the legs. Alternatively, ovarian and adrenal tumors can cause an increase in body hair.

Changes in Nails

Changes in nails may include splitting, discoloration, ridging, thickening, or separation from the nail bed. Ask the patient the following questions:

When did you first notice the nail changes?''

Have you had any acute illness recently?''

Do you have any chronic illness?''

Have you been taking any medications?''

Have you been exposed to chemicals at work or at home?''

Fungal disease causes thickening of the nail. Clues to systemic disease may be found by close examination of the proximal nail fold, the lunula, the nail bed, the nail plate, and the hyponychium. Acute illnesses are associated with lines and ridges in the nail bed and nail. Medications and chemicals are notorious for causing nail changes.

General Suggestions

All patients should be asked whether there have been any changes in moles, birthmarks, or spots on the body. Determine any color changes, irregular growth, pain, scaling, or bleeding. Any recent growth of a flat, pigmented lesion is relevant information.

All patients should be asked whether there are any red, scaly, or crusted areas of skin that do not heal. Has the patient ever had skin cancer? If the patient has had skin cancer, further questioning regarding the body location, treatment, and description is appropriate.

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