As a dermatologist, I often myself the brunt of jokes from colleagues who have specialised in other areas of Medicine. IN the medical professional, dermatologists are 2nd only to plastic surgeons when it comes to jokes about their patients and profession. We are widely seen as having patients that we can treat, at great expensive to the patient, and that treatment is generally about managing conditions that are permanent such as psoriasis, eczema, allergies etc,

I’m too thick skinned(metaphorically – my skin is fine) to be worried about these comments and can think of many examples where a patient has come to me with a seemingly minor condition which I have been able to diagnose as a symptom of something major.

Example 1 – its not just a rash
I had a patient come in with a leg rash after returning from a trip to India. He was thinking it was something to do with the dirty living conditions he had experienced or some strange tropical condition. He mentioned that over the years he had suffered from many strange conditions none of which had been treated particularly successfully. Weight fluctuation, unexplained fever, vision blurriness, aching joints. Each had been treated by specialists. Endocrinologists, opthamologists, orthopaedic surgeons etc, Treatment had ranged from temporarily effective to totally ineffective, but as he travelled a lot there had never been a long term follow up of each condition… or his conditions altogether.

Instead of just examining the leg rash I gave my patient a thorough physical exam and noticed his neck was swollen. Only slightly, but enough for me to guess he had Graves Disease, an auto immune disease that fit all the symptoms. He’d come in for a rash, but after describing and a history of separate physical ailments, I was able to a diagnosis of a serious but treatable condition that finally put all his symptoms together.

As a medical professional I see myself as investigator first a dermatologist second. Too often the medical world has become one of providing a treatment for a physical symptom, without spending enough time investigating cause.

Example 2 – Don’t just look at symptoms. Ask questions.
I had a patient, a 14 year old boy who would attend my office with his mother almost every other month. Recurring folliculitis which only appeared on one leg, his right leg, and only from the top of his thigh to his knee. I treated it, it went away, and it recurred. I had no answer. Then…. No visit for 3 months. I thought perhaps finally it had been cured till I checked my schedule for one fine Monday morning to see he was once again coming to see me.

On examination, his folliculitis was worse than ever, again, only on the right leg. “I thought we’d finally beaten it.” His mum said. ” We went camping in the outback for 3 weeks and it just cleared up. But as soon as we got home…. It started again within days. I am beginning to think we have a sick house.”

In my mind I heard a penny drop and I asked my patient’s mother to give me a moment alone with her son…. and then gently and tactfully told him of my suspicions…. Which were that whilst he sat on the throne, he picked his nose and then scratched his legs. He only picked his nose with his right hand, but scratched his legs with both hands thus the condition only affected his right leg. The problem had cleared up whilst camping and using bush toilets… as they were not places to sit for any length of time doing anything other than necessary business.

He was a bit embarrassed but confirmed that he had a problem with his sinuses that simply blowing seemed unable to address. So I had a quick look up his nose and immediately saw the problem. Nasal polyps. My teenage client with the skin problem on one leg had nasal polyps. The irritation from them caused him to pick his nose. He did it privately in the toilet, always with his right hand, and without washing his hand properly would then scratch his legs. Staph Bacteria from his nose would then infect his leg hair follicles causing the folliculitis.

I explained he did not need another script for antibiotics; he just needed to refrain from scratching his legs after picking his nose. I gave him a referral to an ear nose and throat specialist to get treatment for his nasal polyps.

What’s my Point?
Symptoms are often important indicators of another problem. Too often modern medicine is focused on treating and alleviating symptoms rather than looking for the underlying cause(s).

It important to dig a little deeper than just skin deep.

Name and address supplied but withheld by request.