EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take and what are your differential diagnoses?

• Prompt: Explore symptom progression, hygiene practices, and potential exposures.
• Prompt: Consider differentials such as candidiasis, psoriasis, intertrigo.

Q2. How would you confirm the diagnosis and what investigations are appropriate?

• Prompt: Discuss KOH microscopy, fungal cultures, and when to consider skin biopsy.

Q3. What is your management plan for this patient?

• Prompt: Include pharmacological treatment (topical vs oral antifungals), non-pharmacological advice, and infection control measures.

Q4. How would you counsel Peter on preventing recurrence and protecting close contacts?

• Prompt: Focus on hygiene, clothing advice, and gym practices.

Q5. What would be your approach if Peter’s infection did not improve with standard treatment?

• Prompt: Discuss possible reasons for treatment failure, need for systemic therapy, and further investigations (e.g., for immunosuppression).

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take and what are your differential diagnoses?

The competent candidate should:

• Clarify symptom onset, progression, and any previous treatments trialed.
• Explore hygiene practices, including footwear and clothing habits, particularly post-exercise routines.
• Ask about exposure risks, including use of shared facilities (e.g., gym showers, swimming pools).
• Review sexual history, considering spread to partner.
• Clarify past medical history, including immunocompromising conditions (e.g., diabetes, HIV).
• Differential diagnoses include:
  • Tinea cruris/pedis (most likely)
  • Candidiasis (especially in moist intertriginous areas)
  • Intertrigo
  • Psoriasis (inverse type)
  • Seborrhoeic dermatitis
  • Erythrasma

Q2: How would you confirm the diagnosis and what investigations are appropriate?

The competent candidate should:

• Explain the clinical diagnosis is often made by history and examination.
• Confirm with:
  • Skin scrapings for KOH microscopy—detects fungal hyphae.
  • Fungal culture—helps identify species and guide management if resistant.
• Additional tests if atypical features present:
  • Wood’s lamp examination (limited utility for dermatophytes, more for erythrasma).
  • Skin biopsy—rarely indicated unless suspecting alternative pathology.
• Consider BGL or HbA1c if recurrent or resistant to treatment to exclude diabetes.

Q3: What is your management plan for this patient?

The competent candidate should:

• Recommend topical antifungal therapy as first-line:
  • Terbinafine 1% cream, applied once or twice daily for 2-4 weeks.
  • Alternatives: clotrimazole or miconazole.
• Educate on correct application, extending beyond lesion edges.
• For extensive/recalcitrant cases, consider oral antifungals:
  • Terbinafine 250 mg daily for 2-4 weeks.
  • Monitor liver function if prolonged use.
• Advise hygiene modifications:
  • Keep skin dry, especially in skin folds.
  • Wear loose, breathable clothing.
  • Change socks and underwear daily.
  • Avoid sharing towels.
• Provide PBS prescriptions if eligible.

Q4: How would you counsel Peter on preventing recurrence and protecting close contacts?

The competent candidate should:

• Emphasise personal hygiene:
  • Thorough drying after bathing, particularly between toes and groin.
• Recommend antifungal powders/sprays for shoes and socks.
• Encourage regular changing of clothing, especially after exercise.
• Avoid sharing personal items (e.g., towels, shoes).
• Advise on cleaning gym equipment before use.
• Educate his partner on signs/symptoms and encourage simultaneous treatment if symptomatic.
• Reiterate importance of compliance with the full course of treatment.

Q5: What would be your approach if Peter’s infection did not improve with standard treatment?

The competent candidate should:

• Review compliance with treatment regimen and application technique.
• Consider repeating KOH microscopy/culture to confirm diagnosis and rule out resistant organisms.
• Investigate underlying conditions:
  • Diabetes
  • Immunosuppression (HIV, corticosteroid use)
• Escalate to oral antifungals if not already done.
• Refer to dermatology if:
  • Infection persists despite optimal therapy.
  • Uncertain diagnosis.
• Look for secondary bacterial infection, manage accordingly.
• Review liver function tests if oral antifungals are prescribed long-term.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history taking, exploring risk factors and differentials.
• Appropriate use of KOH microscopy and fungal culture for confirmation.
• Topical antifungal first-line treatment, escalation to oral antifungals when indicated.
• Comprehensive patient education on hygiene and prevention.
• Structured approach for treatment failure, considering resistance or comorbidity.

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PITFALLS

• Failure to differentiate between dermatophyte infection and other dermatoses (e.g., candidiasis, psoriasis).
• Neglecting to address hygiene practices, increasing recurrence risk.
• Overlooking the need for systemic antifungal therapy in widespread or resistant cases.
• Not considering comorbidities, such as diabetes or immunosuppression, in recurrent infection.
• Inadequate follow-up or lack of partner notification/treatment.

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REFERENCES

• RACGP Red Book, 10th Edition
• Australian Therapeutic Guidelines, Dermatology
• DermNet NZ

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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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information relevant to the skin lesion.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates differential diagnoses based on clinical findings.
3.2 Uses diagnostic tools and clinical reasoning.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements an evidence-based management plan, including pharmacological and non-pharmacological interventions.

5. Preventive and Population Health

5.1 Provides education to prevent transmission and recurrence of fungal infections.

6. Professionalism

6.1 Maintains a respectful and patient-centred approach throughout the consultation.

7. General Practice Systems and Regulatory Requirements

7.1 Prescribes in accordance with guidelines and legal requirements (PBS, antifungal prescribing).

9. Managing Uncertainty

9.1 Manages uncertainty regarding treatment-resistant or recurrent dermatophyte infections.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies signs of secondary bacterial infection requiring escalation of care.

Competency at Fellowship Level

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