An accurate diagnosis, based on a proper history and examination , must come before a rational line of treatment can be chosen; even when a firm diagnosis has been reached, each patient must be treated as an individual. For some, no treatment may even be the best treatment, especially when the disor-der is cosmetic or if the treatment would be worse than the condition itself. A patient with minimal vitiligo, for example, may be helped more by careful explanation and reassurance than by prescriptions.
If a diagnosis cannot be reached, the doctor has to decide whether a specialist opinion is needed, or whether it is best to observe the rash, perhaps treating it for a while with a bland application. In either case, the indiscriminate use of topical steroids or other medications, in the absence of a working diagnosis, often confuses the picture and may render the future diagnosis more difficult.
However, a firm diagnosis can usually be made, and a sensible course of treatment can be planned, but even then results are often better when patients understand their disease and the reasons behind their treatment. The cause and nature of their disease should be explained carefully, in language they can understand, and they must be told what can realistic-ally be expected of their treatment. False optimism or undue pessimism, by patients or doctors, leads only to an unsound relationship. Too often patients become discontented, not because they do not know the correct diagnosis but because they have not been told enough about its cause or prognosis. Even worse, they may have little idea of how to use their treatment and what to expect of it; poor compliance often fol-lows poor instruction. If the treatment is complex, instruction sheets are helpful; they reinforce the spo-ken word and answer unasked questions.
The principal steps in diagnosis and management are:
One correct diagnosis is worth a hundred therapeutic trials.
• explanation of the condition, its cause and prognosis;
• choice of treatment and instructions about it;
• discussion of expectations; and
• follow-up, if necessary.