EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Emma’s skin condition and determine the likely cause?

• Prompt: What key elements of the history and examination are important?
• Prompt: What differentials should be considered?

Q2. What investigations would you order, and why?

• Prompt: When is patch testing required?
• Prompt: When would you consider microbiological testing (e.g., skin swab, fungal scraping)?

Q3. How would you manage Emma’s skin condition?

• Prompt: What are the first-line treatment options?
• Prompt: How would you address symptom control and prevention?

Q4. When would you refer Emma to a dermatologist?

• Prompt: What features would prompt specialist referral?
• Prompt: What are the indications for skin biopsy?

Q5. What lifestyle and preventive measures would you recommend?

• Prompt: How can Emma modify her work environment to reduce flare-ups?
• Prompt: What general skin care advice is beneficial for chronic dermatitis?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Emma’s skin condition and determine the likely cause?

Emma presents with a three-month history of an itchy rash on her hands and forearms, worse with glove use and exposure to flowers. A structured approach includes history, examination, and differential diagnosis.

1. History

• Onset and progression – acute vs chronic, pattern of flare-ups
• Triggers – exposure to irritants (flowers, gloves, soaps)
• Relieving/worsening factors – moisturisers, steroids, weather changes
• Associated symptoms – systemic symptoms (fever, malaise) or spreading rash
• Personal and family history – eczema, psoriasis, atopy (asthma, hay fever)

2. Differential Diagnosis

• Irritant contact dermatitis – most likely, due to prolonged exposure to irritants
• Allergic contact dermatitis – possible, consider patch testing
• Atopic dermatitis (eczema) – less likely given late onset
• Fungal infection (tinea manuum) – if unilateral, scaling, confirmed with skin scraping
• Psoriasis – less likely due to absence of nail changes and well-demarcated plaques

Emma’s history and examination findings suggest contact dermatitis, likely irritant-related, but patch testing may be needed for allergens.

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Q2: What investigations would you order, and why?

1. Patch Testing

• If allergic contact dermatitis suspected (e.g., symptoms worsening despite avoidance)
• Common allergens: rubber (gloves), fragrances, preservatives in lotions

2. Skin Swab (If Indicated)

• If secondary infection suspected (weeping, crusting, pain)

3. Fungal Scrapings

• If tinea is a differential (unilateral, well-demarcated, scaly lesions)

Investigations are tailored based on clinical findings, with patch testing being the most relevant.

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Q3: How would you manage Emma’s skin condition?

1. First-Line Treatment

• Topical corticosteroid (mild-moderate potency) – e.g., hydrocortisone or mometasone
• Regular emollients – fragrance-free, applied frequently
• Avoidance of irritants – protective gloves with cotton liners

2. Symptom Control and Prevention

• Antihistamines (if significant itching)
• Short courses of oral steroids only if severe flare-up

3. Patient Education

• Minimise water exposure, use soap substitutes
• Monitor for secondary infection

Emma’s treatment focuses on reducing inflammation and preventing further irritation.

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Q4: When would you refer Emma to a dermatologist?

1. Indications for Dermatology Referral

• Failure to improve despite appropriate treatment
• Suspected allergic contact dermatitis requiring specialist patch testing
• Diagnostic uncertainty (e.g., psoriasis, chronic urticaria)

2. Indications for Skin Biopsy

• Atypical or treatment-resistant lesions
• Suspicion of an alternative diagnosis (e.g., autoimmune disease, malignancy)

Dermatology input is required for persistent, atypical, or severe cases.

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Q5: What lifestyle and preventive measures would you recommend?

1. Workplace Modifications

• Wear protective gloves with cotton liners
• Identify and avoid known irritants

2. Skin Care Advice

• Use fragrance-free moisturisers and soap substitutes
• Avoid excessive hand washing or exposure to hot water

3. Long-Term Management

• Regular follow-ups to monitor symptoms and treatment response
• Consider patch testing if symptoms persist despite irritant avoidance

Preventive strategies reduce recurrence and improve skin barrier function.

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SUMMARY OF A COMPETENT ANSWER

• Takes a structured dermatological history to identify triggers and symptoms
• Recognises irritant contact dermatitis as the most likely cause
• Orders appropriate investigations, with patch testing if allergy suspected
• Provides first-line treatment with topical steroids, emollients, and avoidance strategies
• Refers to dermatology if symptoms persist or diagnosis is uncertain
• Advises on workplace modifications and long-term skin care

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PITFALLS

• Failing to distinguish irritant vs allergic contact dermatitis
• Overlooking patch testing in unresolved cases
• Delaying treatment, leading to chronic skin changes
• Not addressing workplace modifications and irritant avoidance
• Ignoring the potential for secondary infection requiring skin swabs

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REFERENCES

• RACGP Guidelines on Dermatological Conditions
• Australian Society of Dermatology on Common Skin Conditions
• Therapeutic Guidelines on Dermatology
• HealthDirect on Eczema and Skin Rashes

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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 Uses patient-centred communication to explore skin concerns.
1.3 Provides clear explanations of diagnosis, investigations, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough dermatological history, including triggers and lifestyle factors.
2.3 Identifies red flags for serious skin conditions (e.g., malignancy, infection).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common dermatological conditions.
3.3 Determines when investigations or specialist referral are required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate first-line treatments for dermatological conditions.
4.4 Develops an individualised management plan based on symptoms and triggers.

5. Preventive and Population Health

5.1 Provides education on skin care, sun protection, and allergen avoidance.

6. Professionalism

6.2 Ensures a non-judgmental and empathetic approach to chronic skin conditions.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up of skin conditions.

8. Procedural Skills

8.2 Performs skin examination and considers bedside tests (e.g., dermatoscopy, skin scraping).

9. Managing Uncertainty

9.1 Recognises when empirical treatment is appropriate vs when further testing is needed.

10. Identifying and Managing the Patient with Significant Illness

10.2 Identifies complications such as secondary infection or skin malignancy.

Competency at Fellowship Level

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