CASE INFORMATION

Case ID: DERM-2025-007
Case Name: Sarah Mitchell
Age: 42 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S99 (Skin disease, other)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and communicates effectively 1.2 Elicits history and patient concerns 1.5 Provides clear education about the diagnosis and management plan
2. Clinical Information Gathering and Interpretation	2.1 Obtains a thorough history including triggers and symptom progression 2.3 Performs a focused dermatological examination 2.4 Identifies red flags for serious skin conditions
3. Diagnosis, Decision-Making and Reasoning	3.2 Differentiates between inflammatory, infectious, and neoplastic skin conditions 3.4 Identifies when further investigations (e.g., biopsy, blood tests) are required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based management for chronic skin conditions 4.3 Prescribes appropriate pharmacological and non-pharmacological treatments 4.6 Addresses lifestyle modifications and preventive strategies
5. Preventive and Population Health	5.1 Discusses skin care strategies and lifestyle modifications
6. Professionalism	6.2 Demonstrates patient-centred care and shared decision-making
7. General Practice Systems and Regulatory Requirements	7.1 Completes appropriate documentation and referrals if required
8. Procedural Skills	8.1 Demonstrates appropriate technique for skin biopsy if indicated
9. Managing Uncertainty	9.1 Recognises when referral to dermatology is warranted
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and manages complications of chronic skin disease

CASE FEATURES

Middle-aged female presenting with a persistent, pruritic rash over her flexural areas (elbows, knees, neck, and hands).
Symptoms intermittent over the last 6 months but worsening in the past 3 weeks.
No response to over-the-counter corticosteroid creams and antihistamines.
History of asthma and allergic rhinitis, raising suspicion of atopic dermatitis.
Concerned about cosmetic appearance, impact on work, and long-term treatment options.
Requires assessment for triggers, appropriate treatment plan, and discussion about chronic skin management.

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Mitchell
Age: 42 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Salbutamol inhaler PRN for asthma
Loratadine 10 mg daily for allergic rhinitis

Past History

Asthma diagnosed in childhood, well controlled
Allergic rhinitis

Social History

Works as a teacher, concerned about rash appearance and itching during work.
Two children, reports frequent handwashing at home.
No recent travel history or known contact with infectious skin conditions.

Family History

Mother has eczema and father has psoriasis.

Smoking

Non-smoker

Alcohol

Occasional drinker, 1-2 drinks per week

Vaccination and Preventative Activities

Up to date with influenza and tetanus vaccines

SCENARIO

Sarah, a 42-year-old teacher, presents with a 6-month history of recurrent, intensely pruritic rash affecting the flexural surfaces of her elbows, knees, neck, and hands. She reports intermittent flare-ups, with the most recent episode worsening over the past 3 weeks.

She has tried over-the-counter hydrocortisone cream and oral antihistamines, with minimal improvement. The itching is worse at night, disrupting her sleep. She is concerned about the cosmetic impact and long-term management.

EXAMINATION FINDINGS

General Appearance: Well, but scratching flexural areas.
Skin Examination:

Erythematous, excoriated, lichenified plaques over elbows, knees, neck, and hands.
No active weeping, secondary infection, or vesicles.
No nail pitting or scalp involvement (reduces suspicion for psoriasis).

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What key aspects of history would you explore further to assess Sarah’s skin condition?

Prompt: Ask about triggers (e.g., stress, allergens, irritants, climate, soaps, fabrics).
Prompt: Explore personal and family history of atopy (asthma, eczema, allergic rhinitis).

Q2. What are the most likely diagnoses, and what features support your conclusion?

Prompt: Discuss why atopic dermatitis (eczema) is the most likely diagnosis.
Prompt: Explain why psoriasis, contact dermatitis, and fungal infection are less likely.

Q3. What is the initial management plan for Sarah?

Prompt: Discuss topical corticosteroids, emollients, and avoidance of irritants.
Prompt: Address itch relief, lifestyle modifications, and follow-up needs.

Q4. What are the key complications to monitor, and how would you prevent them?

Prompt: Explain the risks of skin infections, chronic lichenification, and steroid side effects.
Prompt: Identify when to escalate treatment (e.g., dermatology referral, immunosuppressants).

Q5. How would you counsel Sarah about long-term management and prognosis?

Prompt: Provide clear education on chronic disease management and treatment adherence.
Prompt: Discuss triggers, lifestyle adjustments, and psychological impact of visible skin disease.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What key aspects of history would you explore further to assess Sarah’s skin condition?

A detailed history is crucial to differentiate between chronic dermatological conditions and determine appropriate management.

1. Symptom Onset and Progression

When did the rash first appear?
Has it worsened or improved over time?
Any previous episodes of similar skin issues?

2. Triggers and Aggravating Factors

Irritants: Soaps, detergents, fabrics, perfumes, occupational exposures.
Allergens: Dust mites, pollen, pet dander, foods.
Climate and environment: Cold weather, humidity, excessive sweating.
Psychological stress: Exacerbation with emotional distress.

3. Personal and Family Atopic History

Any history of eczema, asthma, or allergic rhinitis?
Family members with similar conditions?

4. Treatment History and Response

What treatments have been tried? (e.g., corticosteroids, antihistamines, emollients)
Did symptoms improve with any particular treatment?
Any previous need for systemic therapy or dermatology referral?

5. Impact on Daily Life

Effect on sleep due to nocturnal itching?
Impact on work as a teacher (cosmetic concerns, stress)?

6. Red Flags for Alternative Diagnoses

Any systemic symptoms (fever, weight loss, joint pain)?
Rapidly spreading rash or unresponsive lesions?

A structured history guides diagnosis, identifies triggers, and informs a personalised management plan.

Q2: What are the most likely diagnoses, and what features support your conclusion?

1. Atopic Dermatitis (Eczema) – Most Likely

Chronic, pruritic, flexural distribution.
Personal history of asthma and allergic rhinitis (atopic triad).
Lichenification due to chronic scratching.

2. Differential Diagnoses

Contact Dermatitis: If rash improves with removal of suspected irritant/allergen.
Psoriasis: If silvery scales, nail pitting, or scalp involvement were present.
Fungal Infection (Tinea): If annular lesions with central clearing.
Cutaneous Lupus: If photosensitivity and systemic symptoms.

Given Sarah’s history, distribution of lesions, and atopic background, atopic dermatitis is the most likely diagnosis.

Q3: What is the initial management plan for Sarah?

1. Topical Therapy

First-line: Moderate-potency corticosteroids (e.g., mometasone 0.1% ointment)
Daily emollients to restore skin barrier and reduce flare-ups.

2. Itch Control

Oral antihistamines (e.g., cetirizine 10 mg daily) if nocturnal itching affects sleep.
Wet dressings for severe flares.

3. Lifestyle and Trigger Management

Avoid hot showers, harsh soaps, wool clothing.
Identify potential food/environmental allergens if suspected.

4. Education and Follow-Up

Explain chronic nature of eczema and need for ongoing management.
Review in 2 weeks to assess response and adjust treatment if needed.

This multifaceted approach addresses symptoms, triggers, and prevention.

Q4: What are the key complications to monitor, and how would you prevent them?

1. Skin Infections

Risk: Secondary bacterial (Staphylococcus) or viral (eczema herpeticum) infections.
Prevention: Avoid scratching, use antiseptic baths (e.g., bleach baths if recurrent).

2. Lichenification and Skin Thickening

Risk: Chronic scratching leads to persistent thickened, hyperpigmented plaques.
Prevention: Adequate corticosteroid use, trigger avoidance, and itch control.

3. Steroid Side Effects

Risk: Skin thinning, telangiectasia with prolonged high-potency steroid use.
Prevention: Use lowest effective potency for shortest duration, taper as needed.

4. Psychological Impact

Risk: Stress, anxiety, and low self-esteem due to visible skin disease.
Prevention: Address cosmetic concerns, offer psychological support if needed.

Monitoring and early intervention prevent long-term morbidity.

Q5: How would you counsel Sarah about long-term management and prognosis?

1. Chronic Nature and Flare Management

Atopic dermatitis is a long-term condition with remissions and flares.
Regular skincare is key to reducing frequency and severity of flare-ups.

2. Importance of Moisturisation

Daily use of thick emollients helps prevent barrier dysfunction.

3. Trigger Avoidance

Reduce exposure to known irritants (harsh soaps, allergens, excessive handwashing).
Stress management techniques may help reduce flare severity.

4. When to Seek Further Help

If symptoms persist despite treatment, consider dermatology referral for immunosuppressants (e.g., dupilumab, methotrexate).

5. Psychological and Occupational Impact

Acknowledge the distress and impact on confidence.
Work modifications (e.g., protective gloves if hand eczema is present).

Providing realistic expectations and a structured approach empowers the patient.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering triggers, atopic background, and treatment response.
Accurate diagnosis of atopic dermatitis, ruling out other dermatological conditions.
Evidence-based management, including topical steroids, emollients, and lifestyle modifications.
Identification of complications, such as infection, lichenification, and steroid overuse.
Clear patient education, addressing chronicity, trigger avoidance, and psychological impact.

PITFALLS

Failing to assess triggers, leading to continued flare-ups.
Not addressing itch management, impacting quality of life and adherence to treatment.
Overusing or underusing corticosteroids, risking poor control or skin thinning.
Neglecting psychological impact, missing stress-related exacerbations.
Delaying dermatology referral if severe disease persists despite appropriate therapy.

REFERENCES

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

Competency at Fellowship Level

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