CASE INFORMATION

Case ID: CCE-DERM-002
Case Name: Emily Carter
Age: 16
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S03 (Warts)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and gathers relevant history, including psychosocial impact. 1.2 Provides patient-centred education about the condition and treatment options.
2. Clinical Information Gathering and Interpretation	2.1 Conducts a focused dermatological history and physical examination. 2.2 Differentiates common warts from other skin lesions.
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises warts as the most likely diagnosis but considers differentials. 3.2 Identifies red flags suggestive of alternative or serious conditions.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an individualised management plan, including first-line and alternative treatments. 4.2 Discusses when referral to a dermatologist is required.
5. Preventive and Population Health	5.1 Provides education on HPV transmission and prevention. 5.2 Promotes HPV vaccination and general skin health.
6. Professionalism	6.1 Demonstrates empathy, particularly addressing cosmetic concerns and social impact.
7. General Practice Systems and Regulatory Requirements	7.1 Documents lesion characteristics, treatment plan, and follow-up clearly.
8. Procedural Skills	8.1 Demonstrates safe and effective wart treatment techniques if needed.
9. Managing Uncertainty	9.1 Provides reassurance regarding benign nature while planning follow-up.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when lesions require biopsy or specialist referral.

CASE FEATURES

Teenage girl presenting with multiple warts on hands and feet.
Warts persisting for over a year, resistant to over-the-counter treatments.
Concerns about cosmetic appearance, affecting confidence at school.
No pain, bleeding, or rapid growth, but some discomfort when walking.
No immunosuppressive conditions or recent illness.

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: Emily Carter
Age: 16
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

Generally well, no significant past medical history

Social History

High school student, socially active
Plays netball and wears tight shoes for long hours
Self-conscious about warts on hands, impacting confidence
No recent travel or exposure to unusual infections

Family History

Brother had similar warts that resolved with treatment
No family history of skin cancers or immune disorders

Vaccination and Preventative Activities

HPV vaccination completed as per the National Immunisation Program

SCENARIO

Emily Carter, a 16-year-old high school student, presents with multiple warts on her hands and feet, which have been present for over a year. She has tried over-the-counter salicylic acid but has seen little improvement.

She reports no pain or bleeding but experiences some discomfort while playing netball due to plantar warts. She is particularly concerned about the appearance of the warts on her hands, which is affecting her confidence at school.

Emily is otherwise well, with no history of immunosuppression, diabetes, or other skin conditions.

EXAMINATION FINDINGS

General Appearance: Well, no systemic illness
Skin Examination:

Multiple verrucous lesions on fingers and palms, ranging from 2-5 mm
Plantar warts on the heel and forefoot, mildly tender to pressure
No ulceration, bleeding, or inflammation
No periungual involvement or nail changes
Dermatoscopic findings: Punctate black dots (thrombosed capillaries), no suspicious features

INVESTIGATION FINDINGS

None required unless differentials suspected

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Emily’s skin lesions?

Prompt: How would you differentiate common warts from other skin lesions?
Prompt: When would you consider biopsy or referral?

Q2. What further history would you elicit to confirm the diagnosis?

Prompt: What risk factors would influence management?
Prompt: What psychosocial factors are relevant?

Q3. What treatment options would you offer Emily?

Prompt: What are first-line and alternative treatments?
Prompt: How would you address her cosmetic concerns?

Q4. What preventive advice would you provide regarding wart transmission?

Prompt: What hygiene measures should she follow?
Prompt: What is the role of HPV vaccination?

Q5. What are the follow-up and safety-netting considerations?

Prompt: When should she return for review?
Prompt: What red flags should she be aware of?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Emily’s skin lesions?

A competent candidate should provide a structured differential diagnosis, considering:

Common warts (verruca vulgaris) – most likely: Well-defined, rough, hyperkeratotic papules with thrombosed capillaries, commonly on fingers, hands, and feet.
Plantar warts: Occur on pressure points of feet, often painful, with a mosaic pattern.
Flat warts (verruca plana): Smooth, slightly raised lesions, more common on the face and hands.
Molluscum contagiosum: Dome-shaped, umbilicated papules with central white core, often in clusters.
Calluses/corns: Thickened skin due to pressure, lacking thrombosed capillaries seen in warts.
Actinic keratosis: Sun-exposed areas, rough scaly patches, usually in older patients.
Squamous cell carcinoma (rare in teenagers): Rapidly growing, ulcerating, or non-healing lesions.

A biopsy should be considered if:

The wart is atypical, rapidly growing, ulcerated, or unresponsive to treatment.
Concern for malignancy (e.g., immunocompromised patient).

Q2: What further history would you elicit to confirm the diagnosis?

Lesion history: Duration, evolution, symptoms (pain, itch, bleeding), previous treatments.
Exposure history: Contact with infected individuals, communal showers, gym use, barefoot activities.
Immunological status: Recurrent infections, history of immunosuppression (e.g., diabetes, immunosuppressive therapy).
Impact on daily life: Cosmetic concerns, school activities, psychological distress.
Treatment history: Previous self-treatment (salicylic acid, cryotherapy) and response.
Vaccination status: HPV vaccination history, as HPV types 6 and 11 are linked to some wart subtypes.

Q3: What treatment options would you offer Emily?

First-line options:

Topical salicylic acid (17-40%) with occlusion: Daily application, effective but requires patient adherence.
Cryotherapy (liquid nitrogen): Used every 2-3 weeks, may require multiple sessions.

Second-line options:

Cantharidin: Induces blistering to remove warts, typically used in clinics.
Immunomodulatory treatments (imiquimod, topical 5-FU): For refractory cases.
Curettage and electrocautery: Reserved for persistent or cosmetically significant warts.

Cosmetic concerns:

Reassure Emily about the benign nature and self-limiting course of warts.
Offer treatments that minimise scarring, especially for visible areas like the hands.

Q4: What preventive advice would you provide regarding wart transmission?

Avoid direct skin contact: Do not touch, pick, or scratch warts.
Hygiene measures: Wash hands regularly, especially after touching affected areas.
Foot protection: Wear thongs in communal showers, swimming pools, and gyms.
Avoid sharing personal items: No sharing of towels, socks, or shoes.
HPV vaccination: Emily has completed her vaccination, but educating on its role in preventing genital warts and HPV-related cancers is beneficial.

Q5: What are the follow-up and safety-netting considerations?

Review in 3-4 weeks if undergoing treatment, sooner if worsening.
Monitor for treatment response and adjust therapy as needed.
Referral to dermatology if:
- Atypical lesions requiring biopsy.
- Failure of treatment after 3-6 months.
- Significant psychosocial distress impacting daily life.
Red flags: Rapid growth, bleeding, ulceration, pain disproportionate to usual warts.

SUMMARY OF A COMPETENT ANSWER

Provides a structured differential diagnosis, considering benign and malignant causes.
Takes a thorough history, including lesion evolution, immune status, and psychosocial impact.
Offers first-line and alternative treatments, ensuring patient-centred care.
Educates on prevention, including hygiene measures and transmission risk.
Implements safety-netting strategies, including follow-up and referral indications.

PITFALLS

Failing to consider differentials, especially SCC in atypical cases.
Overlooking the psychosocial impact, particularly in a teenager.
Not explaining treatment duration, leading to unrealistic expectations.
Inappropriate use of aggressive treatments (e.g., curettage causing scarring on visible areas).
Lack of preventive advice, missing an opportunity to reduce recurrence.

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

1. Communication and Consultation Skills

1.1 Establishes rapport and gathers relevant history, including psychosocial impact.
1.2 Provides patient-centred education about the condition and treatment options.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a focused dermatological history and physical examination.
2.2 Differentiates common warts from other skin lesions.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises warts as the most likely diagnosis but considers differentials.
3.2 Identifies red flags suggestive of alternative or serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an individualised management plan, including first-line and alternative treatments.
4.2 Discusses when referral to a dermatologist is required.

5. Preventive and Population Health

5.1 Provides education on HPV transmission and prevention.
5.2 Promotes HPV vaccination and general skin health.

6. Professionalism

6.1 Demonstrates empathy, particularly addressing cosmetic concerns and social impact.

7. General Practice Systems and Regulatory Requirements

7.1 Documents lesion characteristics, treatment plan, and follow-up clearly.

8. Procedural Skills

8.1 Demonstrates safe and effective wart treatment techniques if needed.

9. Managing Uncertainty

9.1 Provides reassurance regarding benign nature while planning follow-up.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises when lesions require biopsy or specialist referral.

Competency at Fellowship Level

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