CCE-CBD-028

Examiner Only Information

Questions

Q1. How would you explain Michael’s diagnosis and its significance?

• Prompt: What is solar keratosis, and why is it important to monitor?
• Prompt: How do you reassure the patient while explaining potential risks?

Q2. What further assessments or investigations would you perform?

• Prompt: When would you biopsy a lesion?
• Prompt: What signs suggest progression to SCC?

Q3. What are the treatment options for solar keratosis?

• Prompt: When is cryotherapy appropriate?
• Prompt: What are the options for widespread solar keratosis?

Q4. What preventive advice would you give to reduce further skin damage?

• Prompt: What sun protection strategies should be recommended?
• Prompt: How often should he have skin checks?

Q5. When would you consider referral to a dermatologist?

• Prompt: What clinical features warrant specialist input?
• Prompt: When is photodynamic therapy or field treatment preferred?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you explain Michael’s diagnosis and its significance?

The competent candidate should:

• Explain solar keratosis (actinic keratosis) in lay terms:
  • “These are rough, scaly patches caused by long-term sun exposure.”
  • “They are common in people with significant sun exposure, like yourself.”
• Discuss cancer risk:
  • Most solar keratoses are benign but can progress to squamous cell carcinoma (SCC).
  • Monitoring is crucial to detect changes early.
• Reassure the patient while emphasising the need for treatment:
  • “This condition is treatable, and early management can reduce the risk of progression to skin cancer.”

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Q2: What further assessments or investigations would you perform?

The competent candidate should:

• Thorough skin examination:
  • Inspect all sun-exposed areas (face, scalp, ears, neck, arms, hands).
  • Assess for suspicious features:
    • Ulceration, rapid growth, pain, bleeding, induration.
    • Poorly defined borders (possible SCC).
• Dermoscopy:
  • Helps differentiate between benign and malignant lesions.
• When to biopsy:
  • If lesion is thickened, tender, bleeding, or fails to respond to treatment.
  • Punch or shave biopsy can confirm SCC.

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Q3: What are the treatment options for solar keratosis?

The competent candidate should:

• Individualised approach based on number and severity of lesions:
  • Isolated lesions:
    • Cryotherapy (liquid nitrogen) – effective and quick.
  • Multiple lesions (‘field treatment’):
    • Topical 5-fluorouracil (Efudix) – effective but causes irritation.
    • Imiquimod cream – stimulates immune response, good for widespread lesions.
    • Photodynamic therapy – used for resistant lesions.
• Monitor response to treatment:
  • Follow-up in 3 months to assess clearance and check for recurrence.

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Q4: What preventive advice would you give to reduce further skin damage?

The competent candidate should:

• Sun protection strategies:
  • Use SPF 50+ sunscreen daily, reapply every 2 hours.
  • Wear a broad-brimmed hat, sunglasses, and protective clothing.
  • Avoid peak sun exposure (10 am – 4 pm).
• Regular skin checks:
  • Self-check every month for new or changing lesions.
  • Annual GP skin check, earlier if new lesions appear.

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Q5: When would you consider referral to a dermatologist?

The competent candidate should:

• Urgent referral if:
  • Lesion suspicious for SCC or invasive skin cancer.
  • Rapidly growing, painful, ulcerated, or recurrent lesions.
• Routine referral if:
  • Extensive or resistant solar keratosis.
  • Patient prefers specialist management (e.g., photodynamic therapy).

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SUMMARY OF A COMPETENT ANSWER

• Explains solar keratosis in an understandable way and addresses cancer risk.
• Performs a thorough skin check and uses dermoscopy for assessment.
• Provides a structured treatment plan, including cryotherapy or topical therapy.
• Educates on sun protection and regular skin checks to prevent future damage.
• Recognises when referral to dermatology is necessary.

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PITFALLS

• Failing to assess all sun-exposed areas for additional lesions.
• Not explaining the risk of progression to SCC.
• Overlooking preventive strategies like sun protection and regular skin checks.
• Delaying referral when a lesion is suspicious for malignancy.

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REFERENCES

• Cancer Council Australia on Skin Cancer Prevention
• RACGP Guidelines on Solar Keratosis Management
• DermNet NZ on Actinic Keratosis

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages the patient in an understandable discussion about solar keratosis and skin cancer risk.

2. Clinical Information Gathering and Interpretation

2.1 Performs a full skin check and identifies concerning features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates solar keratosis from SCC and determines need for biopsy.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a treatment plan based on lesion severity and patient preference.

5. Preventive and Population Health

5.2 Provides clear guidance on sun protection and skin cancer prevention.

6. Professionalism

6.3 Ensures patient-centred care and respects patient concerns.

7. General Practice Systems and Regulatory Requirements

7.2 Documents lesion findings and biopsy results appropriately.

9. Managing Uncertainty

9.1 Recognises when biopsy or specialist referral is needed.

10. Identifying and Managing the Patient with Significant Illness

10.3 Identifies high-risk lesions requiring urgent dermatology input.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD