EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for David’s skin condition?

• 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 systemic psoriasis?
• Prompt: What initial investigations would you consider if red flags were present?

Q3. How would you manage David’s condition?

• Prompt: What topical and systemic treatment options would you consider?
• Prompt: When would referral to dermatology be warranted?

Q4. David is concerned about the long-term impact of psoriasis on his work and quality of life. How would you counsel him?

• Prompt: How can he manage his symptoms while working in construction?
• Prompt: What support resources are available for patients with psoriasis?

Q5. What preventive strategies can David implement to reduce flare-ups and disease progression?

• Prompt: How can he modify his lifestyle to improve psoriasis control?
• Prompt: What role does smoking, alcohol, and weight management play in psoriasis severity?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for David’s skin condition?

David’s most likely diagnosis is chronic plaque psoriasis, given the well-demarcated erythematous plaques with silvery scale on extensor surfaces and scalp involvement, along with a family history of psoriasis.

Key Differential Diagnoses:

1. Chronic Plaque Psoriasis (Most Likely) – Well-demarcated erythematous plaques with thick silvery scale, common on elbows, knees, scalp.
2. Seborrhoeic Dermatitis – Scalp involvement with greasy scale, may extend to nasolabial folds, chest.
3. Tinea Corporis (Fungal Infection) – Annular, scaly lesions with central clearing, confirmed with fungal scraping.
4. Eczema (Atopic Dermatitis) – Poorly demarcated, intensely pruritic patches, often with flexural involvement.
5. Pityriasis Rosea – Initial herald patch, followed by generalised fine scaling rash.

Further assessment, including history of triggers, systemic symptoms, and nail/musculoskeletal examination, will clarify the 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 skin involvement (>10% body surface area) – Consider systemic treatment.
• Joint pain, stiffness, or swelling – Concern for psoriatic arthritis (PsA).
• Severe scalp psoriasis with hair loss.
• Pustular or erythrodermic psoriasis – Requires urgent dermatology referral.
• Significant psychosocial distress, depression, or suicidal thoughts.

Recommended Investigations (if red flags present):

• FBC, CRP, ESR – Assess for systemic inflammation (PsA or erythrodermic psoriasis).
• Skin biopsy – If uncertain diagnosis.
• Uric acid levels – If concern for gout (associated with PsA).
• Joint X-ray or MRI – If suspected psoriatic arthritis.

David has no immediate red flags, but requires ongoing monitoring for psoriatic arthritis.

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Q3: How would you manage David’s condition?

1. First-Line Treatment – Topical Therapy:

• Corticosteroids (Betamethasone dipropionate 0.05% cream daily) – First-line for mild-to-moderate psoriasis.
• Vitamin D analogues (Calcipotriol BD) – Reduces scaling and inflammation.
• Coal tar or salicylic acid preparations – Useful for scalp psoriasis.

2. Systemic Therapy (If Severe or Unresponsive to Topical Therapy):

• Methotrexate or cyclosporin – Requires specialist initiation.
• Biologic therapy (TNF inhibitors, IL-17/IL-23 inhibitors) – For moderate-to-severe cases under dermatology care.

3. Lifestyle Modifications:

• Smoking cessation – Strongly linked to psoriasis severity.
• Reduce alcohol intake – Heavy drinking worsens inflammation and treatment response.
• Weight loss and exercise – Improves treatment response and cardiovascular risk.
• Stress management (mindfulness, counselling) – Reduces flare frequency.

4. Follow-Up and Monitoring:

• Review in 4–6 weeks to assess treatment response.
• Monitor for psoriatic arthritis symptoms (joint pain, stiffness).
• Escalate treatment if significant impact on quality of life or inadequate response.

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Q4: David is concerned about the long-term impact of psoriasis on his work and quality of life. How would you counsel him?

1. Acknowledge Concerns & Provide Reassurance
   • “Psoriasis is a chronic condition, but there are effective treatments to control symptoms.”
   • “Managing triggers like stress and smoking can significantly reduce flare-ups.”
2. Workplace Considerations:
   • “As a construction worker, prolonged sun exposure can help or worsen psoriasis depending on protection.”
   • “Using moisturiser and sun protection can reduce skin irritation and flaking.”
3. Psychosocial Support:
   • Encourage engagement with support groups (e.g., Psoriasis Australia).
   • If significant distress, consider referral for psychological support.
4. Prognosis and Disease Monitoring:
   • “Psoriasis can wax and wane, but early treatment improves outcomes.”
   • “If you develop joint pain or stiffness, let me know early, as psoriatic arthritis needs prompt treatment.”

Addressing physical and psychological concerns enhances patient engagement and quality of life.

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Q5: What preventive strategies can David implement to reduce flare-ups and disease progression?

1. Lifestyle Modifications:
   • Quit smoking – Reduces psoriasis severity and cardiovascular risk.
   • Limit alcohol to ≤4 standard drinks/week – Improves treatment response.
   • Maintain a healthy weight (BMI <25) – Linked to lower psoriasis severity.
2. Daily Skin Care:
   • Use emollients (e.g., sorbolene, QV cream) daily to prevent dryness and scaling.
   • Avoid harsh soaps and long hot showers.
3. Reduce Triggers:
   • Manage stress through exercise, mindfulness, or therapy.
   • Monitor and avoid known triggers, such as certain medications (beta-blockers, lithium, NSAIDs).
4. Regular GP and Dermatology Reviews:
   • Monitor for psoriatic arthritis symptoms.
   • Escalate treatment early if psoriasis worsens.

Preventing flares requires a combination of medical treatment, lifestyle changes, and stress management.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing psoriasis from eczema, seborrhoeic dermatitis, and fungal infections.
• Identification of red flags, ensuring timely specialist referral if needed.
• Structured evidence-based management plan, including topical steroids, vitamin D analogues, lifestyle changes, and systemic therapy if indicated.
• Clear patient-centred counselling, addressing quality of life concerns, work impact, and long-term management.
• Preventive strategies, including smoking cessation, weight management, and reducing alcohol intake.

PITFALLS

• Failing to assess for psoriatic arthritis, missing early diagnosis and treatment.
• Overprescribing topical steroids, without considering vitamin D analogues or emollients.
• Not addressing lifestyle factors, such as smoking, alcohol, and stress management.
• Delaying dermatology referral, leading to poor disease control in severe cases.
• Lack of structured follow-up, missing progression to systemic disease.

REFERENCES

• RACGP – RACGP Clinical Guidelines for Psoriasis Management
• GP Exams – Psoriasis

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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.
1.2 Provides clear explanations about the diagnosis, treatment, and prevention.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic skin examination.
2.2 Identifies and evaluates systemic associations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses psoriasis based on clinical features.
3.2 Differentiates psoriasis from other chronic dermatoses.

Competency at Fellowship Level

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