Reflecting inter national trends, changing demographics because of an ageing population has resulted in a shifting pattern of disease from acute illness to complex and multiple long-term conditions in the UK (Royal College of Nursing, 2014). These challenges have caused significant medical workforce pressures, and, as a result, over the past two decades the role of the advanced clinical practitioner (ACP) has emerged to relieve these pressures (Reynolds and Mortimore, 2021). Unless the novice ACP works within a specific specialty in which he or she already has experience, the transition to ACP roles is challenging. Senior nurses who make the transition to being novice ACPs require a broad knowledge of both medical and surgical care and an ability to work both within the acute hospital setting and primary care (Reynolds, and Mortimore, 2021). This clinical review is the first of two articles designed to support all ACPs in consulting and assessing patients with a skin condition outwith a dermatology setting.
Despite around half of the UK population experiencing a skin condition requiring medical attention at some time in their life, clinical assessment and consultation of the skin remains an area of healthcare in which many practitioners feel uncomfortable, due to a lack of training and education and the complexity of dermatological presentations (Schofield et al, 2009). Skin is the largest organ of the human body and yet is often not assessed with a degree of accuracy or confidence, which may be in part due to the large number of potential diagnoses (more than 2000) (Levell et al, 2013). However, those with less familiarity with dermatological conditions can develop their knowledge and experience so that they can offer a safe assessment and appropriate referral through a systematic and thorough history and assessment. This clinical review presents some key elements to history taking, consultation and assessment specific to reviewing a patient with a skin condition.
The importance of developing knowledge about skin conditions cannot be underestimated. Skin conditions can range from minor conditions, resolved with over-the-counter (OTC) preparations, to even life-threatening situations that can require intensive treatment. ACPs will encounter skin conditions in every specialty and therefore require a sound knowledge base of skin disorders. Assessment is vital to understand the social and psychological impact of any skin disease.
This first clinical review will specifically focus on advanced clinical assessment of the skin. It will be structured using a standardised approach to clinical assessment with a specific focus on dermatology conditions. Although there are a range of consultation models that ACPs use to support practice, it is beyond the scope of the clinical review to critique consultation models and, as such, a standardised approach has been adopted, which the reader can adapt to suit their own consultation style. This article assumes the ACP will have knowledge and understanding of normal skin health, which is required prior to being able to consult a patient with a skin complaint, and is beyond the scope of this article to address.
The consultation
As with any consultation, when obtaining a history, questions should be presented in an open and sensitive manner. This is particularly pertinent for a skin complaint as patients may not know the specific language to use or be embarrassed or concerned, which could result in key information or red flags being missed. The ACP should present themselves in a professional manner using open body language and engaging the patient to ensure that they feel they are being listened to. There are a range of tools to aid and support effective communication during a consultation, such as SOLER (Egan, 1994) (Box 1). ACPs should use both verbal and non-verbal communication skills when engaging in any consultation and tools such as SOLER support this.
Box 1.The SOLER toolSource: adapted from Egan, 1994
| S | Sit SQUARELY on to the patient |
| O | Use an OPEN posture |
| L | LEAN forward towards the patient |
| E | Maintain good, positive EYE contact |
| R | Use RELAXED body language |
The clinical environment also requires consideration before a consultation takes place, particularly due to the impact of COVID-19 and the resultant social distancing and use of masks and other personal protective equipment (PPE). These can be limiting factors to the consultation for both the patient and the ACP. The room should be well lit and quiet if possible to help those with hearing impairments. This is particularly important because tinnitus is now a more common side effect post-COVID-19 and should be a consideration in all consultations and not only in those with elderly patients. See-through masks, if available, can be a supportive aid for lip-reading patients.
Verbal communication skills have never been so important, particularly with changes in consultation practices, such as the use of telephone and online consultations during the COVID-19 pandemic (Rubinelli et al, 2020). Successful use of such technology relies on refined and well-developed communication skills. The use of photographs and webcams may be of benefit for the consultation and assessment of a patient with a skin complaint. However, ideally, skin consultations should take place in person whenever possible to allow the ACP to inspect and palpate the area (Chiang and Verbov, 2020). Non-verbal communication, particularly in a dermatology-focused consultation, also should be considered in line with infection control and social distancing guidelines. The use of touch for both patient and clinician in this context is important to begin to develop rapport and break down any concerns the patient may have due to their skin complaint. The act of shaking hands when welcoming the patient and using sympathetic touching can provide reassurance and acceptance for the patient if COVID-19 guidance allows.
Patient privacy and comfort are important for optimising history taking and allowing the patient to feel comfortable enough to share their ‘story’. Skin conditions can often be a source of anxiety or embarrassment for the patient and they may not have previously shared or discussed their condition with anyone else. ACPs must consider the setting of the consultation and how they can best ensure that privacy and dignity can be achieved.
Demographics
Patient demographics can provide some clues to the potential cause of the skin condition. Some key demographics for ACPs to consider are detailed below. These can usually be ascertained before the consultation, depending on the setting, and a thorough review of medical notes can help the ACP identify key areas on which to focus. Accessing information on key patient demographics is helpful if this is a new area of practice for the ACP, and prior consideration of key points can help the consultation run smoothly.
Key demographic details include age—in particular, the extremes of age can bring higher risks for particular skin conditions. Young children are more likely to contract infectious diseases such as hand, foot and mouth and impetigo. In adults the likelihood of malignancy increases with age. The sex of a patient may also offer clues to conditions that are more or less likely than others. For example, adult acne is more likely to occur in adult women than men (Tan and Bhate, 2015), while men are more likely to experience infectious skin conditions (Chen et al, 2010).
The patient's race may also be a factor in considering or excluding certain skin conditions. Patients with high levels of melanin (such as those found in African and Indian ethnic skin types) (Alaluf et al, 2002) are more likely to experience post-inflammatory hyperpigmentation, keloid scarring and dermal melanocytosis (slate grey nevi also known previously as Mongolian blue spots) (Kundu and Patterson, 2013). A patient's previous country of residence or travel may suggest a higher likelihood of some conditions. For example, leprosy and cutaneous tuberculosis, although rarely seen in the UK, have much higher levels of prevalence in other parts of the world (Public Health England, 2012; Santos et al, 2014). Additionally, as many retired people spend more time abroad, sun exposure without adequate protection can result in higher levels of skin cancer.
History taking
For ACPs, obtaining a history of a patient's presenting complaint is a key component of their clinical role. Regardless of the affected body system or presenting complaint, a full history should always be taken to ensure a thorough picture of the patient is obtained. The SOCRATES acronym and mnemonic is a useful tool when obtaining a patient history, and is traditionally used for assessing pain (Manna et al, 2015). In Table 1 the authors have adapted the SOCRATES mnemonic for a dermatology assessment.
Table 1. The SOCRATES mnemonic adapted for a dermatology consultation
| Site |
|
| Onset |
|
| Characteristics |
|
| Radiation |
|
| Associated features |
|
| Timing |
|
| Exacerbating/relieving factors |
|
| Severity |
|
The ACP should ensure that the history and examination is clearly documented. This should include a description of the patient and how they present to the ACP at the consultation. Ascertaining a patient's understanding of the disorder and how it has impacted on them and those around them is a vital part of an effective and holistic consultation. Using open questions and allowing time for patients and carers to respond in their own time and words is key for the patient to feel listened to and to believe that the ACP understands. Gaining insight into the patient's knowledge and feelings can be of benefit, too, and this can also be undertaken in a systematic fashion with use of mnemonics such as ICE (ideas, concerns, and expectation) (Matthys et al, 2009).
Once the history taking has been completed, it is good practice to summarise the history of the presenting complaint to the patient and/or carer. This is an effective way of allowing the patient to offer any relevant information that has not been gained so far. This can also be used as a mechanism to correct any information that may have been incorrectly interpreted (Lloyd and Craig, 2007). It is at this stage of the consultation that the patient can be informed of the next steps, allowing them to prepare for the further questioning and upcoming examination. This can also allow the ACP to collect their thoughts and consider how to progress their line of enquiry and consider potential differential diagnoses.
Systemic enquiry
The systemic enquiry allows for a brief overview of the other body systems, whether or not they are relevant to the presenting complaint. This process ensures that symptoms not previously mentioned are noted and may uncover clues to the presenting complaint. This includes the following body systems and points to include in the assessment:
- Cardiovascular system—chest pain, palpitations, oedema, etc Respiratory system—shortness of breath, wheeze, cough, dyspnoea, etc
- Gastrointestinal/genitourinary system—nausea, vomiting, diarrhoea, urinary symptoms, abdominal pain, menstruation-related issues, etc.
- Central nervous system—headache, visual/auditory disturbances, fevers, fits/faints/’funny turns', etc.
Past medical history
This is a vital step in the history taking as skin conditions are often associated with underlying conditions such as diabetes, atherosclerotic disease, sarcoidosis and heart failure. Asking whether any conditions are well-controlled, their impact on the patient and their lifestyle, as well as any associated appointments/surgery/investigations/procedures that have occurred or are awaited are also important as part of the skin consultation. Determining any allergies is an important step; the trigger and nature of reactions should be documented. This is an important consideration for a dermatology assessment as allergies can present as skin irritation.
Medication review
Skin conditions may be triggered or worsened by medications including OTC, prescribed, herbal, illegal and homeopathic medications. Common medications that may trigger a skin reaction are allopurinol (to treat or prevent gout), antibiotics, ibuprofen (an analgesic) and phenytoin (an anticonvulsant) (Cho et al, 2017). It is therefore essential that the ACP obtains a full and thorough drug history, including previous drug allergies, however mild. Checking that electronic records align with the information provided allows for any nuances to be clarified or omissions to be questioned with the patient at this time.
Recreational drug use should be explored as there is an increased risk of conditions such as necrotising fasciitis associated with intravenous drug use. Skin complaints can also be linked to infections such as hepatitis B, HIV and hepatitis C, which are all of higher prevalence in intravenous drug users. This information should be gathered in a non-judgemental manner to ensure that a therapeutic patient-professional relationship is maintained.
Family history
Some skin conditions such as melanoma, eczema, psoriasis and ichthyoses are all associated with familial trends. These are internal factors. These should not be confused with external causes of skin conditions, where those living in the same conditions present with the same skin condition secondary to environmental causes. Contagious diseases (such as scabies), transmitted through living arrangements, are also external factors (see Table 2).
Table 2. Factors that impact on skin health
| External factors | Internal factors |
|---|---|
| Sun/ultraviolet exposure | Medications |
| Allergies | Genetics |
| Chemicals | Diet |
| Environmental/pollution | Smoking |
| Temperature—extreme cold | Disease |
| Smoking | Stress |
| Exercise | Hydration |
| Occupation |
Social history
A patient's social history may also be key to the diagnosis of their skin condition. Travel history is an important factor to consider during a consultation of the skin. History of sunlight exposure, as well as environmental or geographical risks, should be obtained.
Activities undertaken while travelling, alongside hobbies and pastimes undertaken at home may offer insight into the presenting complaint. Open water swimming is becoming more popular but, alongside the obvious health benefits, it may have a negative impact on skin health. Such a condition is ‘swimmer's itch’ (cercarial dermatitis) (Baldassarre et al, 2017). Other outdoor hobbies may be of risk to the skin, particularly if pursued without the use of an appropriate sunscreen or other protection. Conditions such as cutaneous larva migrans and reactions to insect bites may present in patients who are returning from travelling; it is important, therefore, to obtain not only a succinct travel history, but a detailed account of activities undertaken while abroad.
A thorough smoking and alcohol history is important as many skin conditions, such as psoriasis, can be triggered or worsened by these activities. The patient's occupation and past occupations may be relevant and should be investigated. Occupational hazards such as wearing PPE and using chemicals are potential causes of some common presentations.
Finally, the patient's living arrangements should be investigated. Who lives with them? Are there any pets? The location of the home may play a part in helping to include or exclude a potential diagnosis. Any recent changes in time spent at home or in different environments should be ascertained.
Examination
Before the physical examination, it is useful to recap the information provided. This gives the patient a second opportunity to offer further pertinent history and to clarify any salient points. This pause also allows the practitioner to give a short explanation of the examination process. As many consultations are now online or by telephone, it may not be possible to conduct a physical examination at this stage. However, a thorough and structured history may assist the ACP in deciding if they require the patient to attend for a physical examination.
A physical examination of the presenting complaint should be systematic and thorough. Crucially, the practitioner should have a good knowledge of a normal skin presentation to allow them to identify the abnormal. Ideally, the examination should take place in a well-lit, warm, and comfortable setting where patient privacy can be maintained. It may be appropriate, if available, to offer a chaperone for the examination and patient comfort and dignity should be preserved at all times. It may be beneficial to obtain a torch or lamp to aid visual inspection and a dermascope can provide magnification of areas requiring closer examination and palpation (Chiang and Verbov, 2020).
A general inspection should be the first step of this process. The ACP should start by noting the patient's general appearance and any immediately obvious skin concerns. Any obvious discomfort or abnormalities displayed by the patient should be noted. To examine the presenting skin complaint a basic ABCDEF approach can be adapted to offer the ACP a structure to the examination and ensure a comprehensive assessment (National Cancer Institute, 2021):
- A: asymmetry—is the lesion/complaint symmetrical or asymmetrical?
- B: borders—are these smooth? Irregular? Well-defined? Ragged?
- C: colour—is the skin complaint a consistent colour or variable? Is it very pronounced or faint?
- D—diameter—measure the size of the presenting skin complaint or, in the instances of widespread rashes, the total body surface area (TBSA) that it covers. Useful tools for this include the Mersey Burns App (Barnes et al, 2015) and the Wallace Rule of Nines (Wallace, 1951), both of which were developed for assessment of burns TBSA
- E: evolving or changing—does the condition show stages of change or development? Does the patient have pictures of it from onset or if it previously appeared differently?
- F: funny—does it look different to everything else? This is known as an ‘ugly duckling’ sign (Daniel Jensen and Elewski, 2015).
As well as a visual inspection of the presenting skin condition, it is useful to touch and feel the area. Look for heat, note the texture, any swelling, or other abnormality. An assessment of lymph nodes may also be useful.
Finally, a complete skin check, including hands and feet (including between fingers and toes and nails), flexural and extensor areas, hair and scalp, and mucous membranes. Any abnormalities should be noted.
This set of observations will guide diagnosis.
Communication and potential referral
Following the examination, the ACP will need to describe and record the findings and communicate this accurately using appropriate terms. Medical or dermatological terminology rather than colloquial terms, should be used to ensure the correct explanation is given. It may also be pertinent to involve medical photography to document the skin complaint for future review, comparison and dissemination (Ratner et al, 1999).
Conclusion
Assessing anyone with a skin complaint, requires consideration of the sensitivity of the complaint. Diagnosis, investigation and treatment is a key role for ACPs, and a thorough and holistic skin assessment is paramount. For an ACP, developing confidence in skin assessment will ensure that a patient is appropriately assessed and referred as appropriate. For any practitioner, identifying their limitations and seeking experienced support is encouraged and crucial for safe patient care.
As the number of ACP roles continues to increase and ACPs work more autonomously, their level of knowledge has also increased. However, despite skin problems being a common presenting complaint, it is an area that many ACPs feel less confident to assess. Therefore this clinical review has provided an overview of the key considerations that should be included in the consultation and clinical assessment of the skin. The next article in this two-part series will explore the next steps for a novice ACP, considering some differential diagnoses and mimickers, common investigations and treatment options for a patient presenting with a skin complaint. Decision-making is crucial for ACPs when caring and supporting a patient with a skin condition.
KEY POINTS
- Despite skin conditions being a common presenting complaint, this is an area that novice advanced clinical practitioners often feel less confident to assess
- A thorough and systematic history is an imperative part of any patient consultation, including that of the skin
- It is important to consider all internal and external factors that may impact on a skin condition
- A sound knowledge and understanding of normal skin health is required before being able to consult with a patient with a skin condition
CPD reflective questions
- What is your current knowledge and understanding of normal skin health and would this support you to consult a patient with a skin complaint?
- Think about key points to remember when approaching a patient who has presented with a skin complaint
- Consider how to support a patient and family who comes under your care and how you would support them within the consultation process when assessing a skin condition
- Think about what local services or departments are available for referral or specialist advice in your area