Clinical examination has been, is, and will remain the essence of medicine concerning the diagnosis of diseases and consequently the correct choice of treatment. In modern times, despite the plethora of specialized tests, both microbiological and imaging, clinical examination remains paramount in dermatology.
In recent years, the abundance of social media platforms and the ease of sending photos have led to a mistaken perception that diagnosis can easily be made with a simple photo sent for evaluation by the doctor remotely. However, many times the photo is not focused and therefore not helpful at all, which can lead to wrong decisions.
Indeed, there are instances where a diagnosis can be made in seconds even by reviewing an image, but this practice once can lead to a wrong diagnosis and decision, highlighting the seriousness and necessity of clinical examination and obtaining a comprehensive medical history.
In fact, many times the diagnosis stems from taking the appropriate history, asking open-ended and closed questions, and then simply confirming it with clinical examination. Additionally, we must learn what led the patient to us, what concerns them deeply. Often, a patient may have an inflammatory condition but fears it's cancer. Or they may worry if something is contagious or transmittable. All these questions must be answered in the context of comprehensive service provision. But what is the significance of clinical examination in Dermatology?
Taking the correct history leads the doctor to a differential diagnosis, i.e., to a mental list of possible diagnoses. Based on these possible diagnoses, the doctor examines the patient systematically. It's crucial to determine how long the rash has been present and when exactly the specific lesion appeared, as well as how it has changed. The examination must be conducted with appropriate lighting, often involving palpation to assess tenderness and inflammation. We compare the temperature of the area with the rest of the patient's skin. We may press and assess the presence of vascular elements and their depth. We check for scales and how easily they peel off. By lifting the skin, we can assess the depth and consistency of the lesion, for example, if it has hypertrophic tissue and is firm. There are times, of course, when the clinical diagnosis differs from the initial clinical suspicions, making the concentration of the doctor on clinical examination even more crucial, as well as having an open mind and a receptive approach in their office!
In recent years, the use of dermoscopy has become invaluable, if not indispensable. This handheld tool uses polarized and non-polarized light and a x10 magnification to allow for a more detailed examination of a suspicious lesion or rash. There is vast literature with patterns that we should look for during this examination, which refer to specific diagnoses. Its use is now absolutely necessary in assessing moles for malignancy and will determine if there is sufficient clinical suspicion to proceed with the removal of a potential cancer or not.
Finally, to complete the aspect of clinical examination and our contact with the patient, we must also mention the necessity, sometimes, of performing a biopsy. There are many cases where patients come with a lesion or rash that has been present for over a month, without a clear diagnosis, while they have tried various therapies unsuccessfully. In Dermatology, the ease with which a small biopsy can be taken without pain and within the timeframe of the clinical examination, without requiring a separate appointment, allows for the most accurate diagnosis possible, as well as rapid confirmation of our suspicions at the cellular level. This is crucial for the search for a rare condition, for the identification of a common condition that requires years of therapeutic intervention, but also for the confirmation of malignancy.
Of course, all these cannot be achieved by sending a low-quality or mediocre photo without history, which will be hastily and cursorily evaluated by the doctor among their patients and among their other duties.
