EXAMINER ONLY INFORMATION

QUESTIONS

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

• Prompt: What is the most likely diagnosis and why?
• Prompt: What other conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What features suggest severe or complicated impetigo?
• Prompt: What initial investigations would you consider?

Q3. How would you manage Jack’s condition?

• Prompt: What topical and systemic treatment options would you consider?
• Prompt: What infection control advice would you provide?

Q4. Jack’s mother is concerned about him missing school. How would you counsel her?

• Prompt: How long should Jack be kept away from school?
• Prompt: What hygiene measures can prevent reinfection?

Q5. What preventive strategies can Jack’s family implement to reduce recurrence?

• Prompt: How can they address risk factors such as eczema?
• Prompt: What household and hygiene measures are important?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

Jack’s most likely diagnosis is non-bullous impetigo, given the honey-coloured crusted lesions around the nose and mouth, mild erythema, and absence of systemic symptoms.

Key Differential Diagnoses:

1. Non-bullous impetigo (Most Likely) – Superficial skin infection, typically caused by Staphylococcus aureus or Streptococcus pyogenes.
2. Eczema with Secondary Infection – Jack has a history of mild eczema, which can predispose to impetiginisation.
3. Herpes Simplex Virus (HSV) Infection – Grouped vesicles on an erythematous base, often with prodromal symptoms.
4. Contact Dermatitis – Irritant or allergic reaction, usually well-demarcated and itchy.
5. Tinea Faciei (Fungal Infection) – Annular, scaly lesions with central clearing.

Further assessment will confirm the diagnosis, but impetigo is primarily a clinical diagnosis.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral:

• Extensive lesions or rapid spread.
• Painful, swollen skin with warmth (concern for cellulitis).
• Bullous lesions (possible Staphylococcal Scalded Skin Syndrome).
• Fever, malaise, lymphadenopathy (systemic involvement).
• Periorbital involvement (risk of orbital cellulitis).
• Recurrent impetigo (may require swabbing for resistant organisms).

Recommended Investigations (if red flags present):

• Skin swab for bacterial culture – If recurrent, severe, or not responding to treatment.
• FBC, CRP – If systemic infection suspected.
• Blood cultures – If concern for bacteraemia or invasive infection.

Jack has no red flags, so empirical treatment is appropriate.

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Q3: How would you manage Jack’s condition?

1. First-Line Treatment – Topical Therapy (If Localised Lesions):

• Mupirocin 2% ointment (Bactroban) applied TDS for 5 days.
• Fusidic acid cream (if mupirocin resistance suspected).
• Gentle cleaning of lesions with warm water and soap.

2. Oral Antibiotics (If Extensive or Recurrent Lesions):

• Cephalexin 12.5mg/kg BD for 7 days (first-line).
• Trimethoprim-sulfamethoxazole (if MRSA suspected).
• Avoid flucloxacillin in children due to poor palatability.

3. Infection Control and Hygiene Advice:

• Hand hygiene, avoid scratching.
• Keep lesions covered with a dressing if possible.
• Wash towels, bed linen, and clothing in hot water.

4. Follow-Up and Monitoring:

• Review in 5–7 days.
• Escalate treatment if worsening symptoms or no improvement.

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Q4: Jack’s mother is concerned about him missing school. How would you counsel her?

1. Acknowledge Concerns & Provide Clear Guidelines
   • “Impetigo is highly contagious, so school exclusion is necessary.”
2. Explain School Exclusion Guidelines
   • “Jack should stay home until 24 hours after starting antibiotic treatment.”
   • “If lesions are still present but crusted over, he can return to school.”
3. Preventing Transmission
   • “Encourage frequent handwashing and avoid sharing towels or toys.”
   • “Keep lesions covered if possible to prevent spread.”
4. Reassure About Treatment Response
   • “Most cases improve within 5–7 days with appropriate treatment.”

Providing clear infection control advice helps reduce spread while addressing parental concerns.

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Q5: What preventive strategies can Jack’s family implement to reduce recurrence?

1. Addressing Skin Barrier Dysfunction:
   • Manage eczema with regular emollients to reduce scratching.
   • Avoid irritants (e.g., harsh soaps, allergens).
2. Good Hygiene Practices:
   • Regular handwashing with soap.
   • Short, clean fingernails to reduce bacterial spread.
   • Daily bathing and clean clothing.
3. Household Infection Control:
   • Disinfect high-contact surfaces (e.g., door handles, toys).
   • Wash towels and bedding regularly in hot water.
4. Screening & Treatment for Carriers (If Recurrent Impetigo):
   • Consider nasal swab for Staphylococcus aureus carriage.
   • Topical intranasal mupirocin for 5 days if positive.

By implementing hygiene and skin care measures, recurrence risk can be minimised.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing impetigo from viral, fungal, and inflammatory skin conditions.
• Identification of red flags, ensuring escalation if needed.
• Structured evidence-based management plan, including topical/oral antibiotics and hygiene measures.
• Clear patient-centred counselling, addressing school exclusion and infection control.
• Preventive strategies, including eczema management, hygiene, and household infection control.

PITFALLS

• Failing to assess for red flags, missing cellulitis or systemic infection.
• Overprescribing oral antibiotics, when topical therapy is sufficient.
• Not providing infection control advice, leading to household transmission.
• Ignoring underlying eczema, missing an opportunity to reduce recurrence.
• Lack of follow-up planning, leading to delayed recognition of treatment failure.

REFERENCES

• RACGP – RACGP Guidelines to Skin Infections in Children
• GP Exams – Impetigo

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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 Takes a structured dermatological history from the parent and child.
1.2 Provides clear explanations about the diagnosis, treatment, and prevention.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic skin examination to assess extent and severity.
2.2 Differentiates impetigo from other paediatric skin conditions.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses impetigo based on clinical features.
3.2 Determines when further investigations or escalation of care is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate treatment plan, including topical and systemic therapy options.
4.2 Provides infection control advice to prevent transmission.

5. Preventive and Population Health

5.1 Educates on hygiene measures to reduce the spread of impetigo.
5.2 Identifies and addresses risk factors, such as eczema or skin trauma.

6. Professionalism

6.1 Provides empathetic care and addresses parental concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation, prescribing, and follow-up.

9. Managing Uncertainty

9.1 Recognises when specialist referral (dermatology, infectious diseases) is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies severe or complicated impetigo requiring systemic therapy.

Competency at Fellowship Level

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