Contact Dermatitis — Free SCA Practice Case
Beautician with suspected contact dermatitis
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Sophie Miller
Age
29 years
Consultation Type
VideoAge
29
Past Medical History
Mild hay fever (seasonal).
- ●No known history of asthma or childhood eczema.
Medication History
- ●Cetirizine 10mg OD (as required).
- ●Combined Oral Contraceptive Pill (Lucette).
- ●NKDA.
Recent Medical Notes
- ●3 Months Ago: Presented with dry, itchy patches on the webs of her fingers. Advised to use over-the-counter E45 cream.
- ●Current Situation: Video Consultation.
- ●Reason for Encounter: "Hands are getting worse. It's affecting my work as a beautician."
Patient Script
For the friend playing the patient role
Character Overview: You are Sophie, a self-employed beautician specializing in acrylic nails and eyelash extensions. You are highly stressed because your hands are your livelihood. You are worried that you might be "allergic to your job" and are looking for a quick fix so you can keep working.
Opening Sentence: "Hi Doctor, I'm really worried about my hands. I've had this rash for a few months, but now the skin is cracking and it's so painful I can't even apply treatments to my clients properly."
History if Asked (Data Gathering Phase)
- ●The Rash: It is primarily on your fingertips and the webs of your fingers on both hands. It is red, scaly, and occasionally develops tiny, itchy blisters.
- ●Occupational Links: It definitely feels worse after a long day at the salon. You use acrylic monomers, nail glues, and various eyelash adhesives. You've noticed that even through gloves, your hands feel "hot" and itchy.
- ●Gloves: You wear latex-free nitrile gloves, but you often take them off to do "finer" detail work because you feel they get in the way.
- ●Home Life: You have a 6-month-old baby, so you are washing your hands constantly and doing lots of "wet work" (bottles, bathing) at home too.
- ●Impact: You've had to cancel three high-paying bridal bookings this week. You are terrified this is permanent.
ICE — Ideas, Concerns, Expectations
(The patient does not volunteer these unprompted — only surfaces if the candidate directly explores her perspective.)
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Ideas: You think you might be allergic to the chemicals you use at work — the acrylic monomers or the nail glues specifically. You've noticed it gets worse after long salon days, so in your mind the connection is obvious. Part of you wonders whether the constant hand-washing with the baby is making it worse too, but you mainly blame the salon products.
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Concerns: Your biggest fear is that this is permanent and you'll have to give up your career. You've spent years building your client base and your reputation — if you can't do nails and lashes, you don't know what else you'd do. You're also worried about money: you're self-employed with a mortgage and a baby, and every cancelled booking is money you can't get back. There's a quieter worry too — you feel like a bad mum because your cracked hands make you wince when you bathe the baby.
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Expectations: You want something that will clear it up quickly so you can get back to work — ideally a strong cream or treatment. You also want a clear answer about whether it's the chemicals or not, because if you knew exactly which product was causing it, you could just stop using that one and carry on with everything else.
If Asked — Medical History and Medications
(Actor guidance — respond naturally if the candidate asks about any of these items from the medical records.)
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Hay fever / Cetirizine: "Yeah, I get hay fever in the summer — itchy eyes, sneezy, the usual. I take cetirizine when it's bad but I haven't needed it recently, it's more of a seasonal thing. I did wonder if the cetirizine might help with the itching on my hands but it doesn't seem to make any difference."
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No history of eczema or asthma: "No, I've never had eczema before — not as a child, nothing. That's why this is so strange to me. And no asthma either."
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Contraceptive pill (Lucette): "I'm on the pill — Lucette. I've been on it for years with no problems."
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Previous GP visit (3 months ago): "Yes, I went about three months ago and the doctor said to try E45. I did use it for a few weeks but honestly it didn't really help — it felt okay for about ten minutes after I put it on but then my hands would just dry out again. I stopped bothering with it after a while."
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Allergies: "No, no allergies to any medicines that I know of."
Social History and Lifestyle Impact
(Actor guidance — details to weave naturally into conversation, not delivered as a monologue.)
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Work situation: You run your own mobile beauty business — you go to clients' homes, which means you can't easily control the environment. You work five or six days a week, and a typical day involves three to four clients back-to-back. You've built the business up from scratch since before the baby arrived and it's your sole income.
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Lifestyle impact of the condition: The cracking on your fingertips means you physically can't do fine detail work — applying individual lash extensions or shaping acrylic nails requires precise finger contact, and the pain is too much. You've had to cancel three bridal bookings this week alone, which has cost you roughly £600. Clients are starting to go elsewhere and you're terrified of losing regulars you've had for years. At home, bathing the baby stings badly and you've started asking your partner to do it, which makes you feel guilty. Even getting dressed in the morning is uncomfortable — pulling on jeans or doing buttons catches on the cracks.
If Asked — Associated Symptoms
(Actor guidance — respond only if the candidate specifically asks about these symptoms.)
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If asked about itching: "Yes, it itches a lot — especially the little blisters. I try not to scratch but sometimes I can't help it, especially at night."
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If asked about pain or burning: "The cracks really sting, especially when I wash my hands or use hand sanitiser. It's more of a burning pain than an ache."
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If asked about rash anywhere else on the body: "No, it's just my hands — nowhere else."
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If asked about face or eyelid involvement: "No, my face is fine. No rash there at all."
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If asked about nail changes: "No, my nails themselves look normal — it's just the skin around them."
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If asked about joint pain or swelling: "No, nothing like that — just the skin."
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If asked about fever or feeling unwell: "No, I feel fine in myself — it's just the hands."
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If asked about recent infections or illness: "No, nothing like that recently."
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If asked about new products at home (detergents, soaps, cosmetics): "No, I haven't changed anything at home — same washing-up liquid, same soap. It's only the salon stuff I'm suspicious of."
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If asked about whether the rash clears on days off or holidays: "It does get a bit better if I have a couple of days off, but it never fully goes. It was actually a bit better over Christmas when I had a week off, but it came straight back when I went back to work."
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If asked about stress: "I mean, yeah, I'm stressed — I've got a baby, I'm trying to run a business, and now my hands are falling apart. But I don't think stress is causing it, if that's what you mean."
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If asked about smoking: "No, I don't smoke."
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If asked about alcohol: "The odd glass of wine at the weekend, nothing much."
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If asked about family history of eczema, asthma, or atopy: "My mum has asthma, but no one in the family has eczema as far as I know."
Responses to Management (The Negotiation Phase)
- ●If the Doctor suggests "stopping work":
- ●Reaction: Distressed. "I'm self-employed. If I don't work, I don't get paid. I have a mortgage and a baby. Surely there is a cream that will just clear it up so I can keep going?"
- ●If the Doctor suggests Patch Testing:
- ●Reaction: Hopeful but impatient. "Will that tell me exactly which chemical it is? How long does the referral take? I need an answer now."
- ●If the Doctor mentions 'Irritant' vs 'Allergic' dermatitis:
- ●Reaction: "I thought it was just the soap at work, but even when I use my own stuff, it's still there. Does that mean it's an allergy?" (Tests the doctor's ability to explain the difference).
- ●If the Doctor suggests soap substitutes:
- ●Reaction: Skeptical. "How can I get my hands clean without soap? I'm a beautician, I have to be hygienic for my clients."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diagnostic Distinction: ICD vs ACD
- ●Irritant Contact Dermatitis (ICD) results from cumulative physical and chemical damage to the skin barrier — repeated wet work, soap, and chemical irritants cause inflammation without immune sensitisation. It is the more common of the two in Sophie's situation.
- ●Allergic Contact Dermatitis (ACD) is a Type IV (delayed) hypersensitivity reaction requiring prior sensitisation. Once sensitised, even trace exposures trigger a response — which is why symptoms can occur through gloves or on days when fewer products are used.
- ●In beauticians, the principal allergens are acrylates (in acrylic monomer systems and UV gel products) and cyanoacrylates (in nail and lash adhesives). Both are potent sensitisers and among the most common occupational allergens in this profession.
- ●The two types frequently coexist: ICD damages the skin barrier and lowers the threshold for sensitisation, making ACD more likely over time. Treating them as mutually exclusive is a common diagnostic error.
- ●A key distinguishing clue is the temporal pattern: ICD tends to correlate with total exposure burden (worse after long shifts, better on sustained rest); ACD may flare with even brief contact once sensitisation is established. In Sophie's case, improvement over her Christmas break but rapid relapse on return to work supports an occupational aetiology for both.
- ●Atopic individuals — including those with hay fever or a family history of asthma — have a lower threshold for ICD due to baseline skin barrier impairment. Sophie's atopic background (hay fever, maternal asthma) is clinically relevant.
Investigations: Patch Testing
- ●Patch testing is the gold standard investigation for suspected ACD and is essential when occupational allergen sensitisation is suspected. It cannot be performed in primary care.
- ●Referral to dermatology for patch testing is indicated when: occupational allergy is clinically suspected; the diagnosis is uncertain; or dermatitis is not responding adequately to treatment.
- ●The patch test series used in occupational dermatology includes the acrylate series and adhesive/cyanoacrylate series — these are not part of the standard European baseline series and must be specifically requested.
- ●Patch testing should not be performed during an acute flare or while the patient is using potent topical steroids — timing of referral and treatment should account for this.
- ●Advise Sophie to check Safety Data Sheets (SDS) for the specific products she uses — this information is useful to share with the dermatologist and may help target the patch test series.
Acute Flare Management
- ●Emollients — soap substitutes: Replace all soap and hand sanitiser with a soap substitute (e.g., Dermol 500 lotion, Cetraben wash, or emulsifying ointment) for every hand wash. Soap is a significant irritant that disrupts the skin barrier and perpetuates ICD. Soap substitutes are effective cleansers and do not compromise hygiene — this must be explicitly explained, as patients frequently doubt it.
- ●Emollients — leave-on: Prescribe a greasy emollient (e.g., Diprobase ointment, Epaderm ointment, or white soft paraffin) to be applied frequently throughout the day — after every hand wash and at bedtime. Ointments are significantly more effective than lotions for hand dermatitis; E45 cream (previously recommended) is insufficient for an acute flare with fissuring.
- ●Topical corticosteroid — potency: The thick skin of the palms and dorsal hands requires a potent topical corticosteroid (e.g., betamethasone valerate 0.1% or mometasone furoate 0.1%). Mild steroids such as hydrocortisone 1% are inadequate and represent one of the most common prescribing errors in hand dermatitis.
- ●Topical corticosteroid — regimen: Apply once or twice daily to affected areas only for a defined course (typically 2 weeks), then review. Provide clear guidance using fingertip units to help the patient understand appropriate quantity.
- ●Steroid safety counselling: Briefly acknowledge the risk of skin thinning with prolonged use, but reassure that a supervised 2-week course on the hands is safe and necessary to break the inflammatory cycle. Over-emphasising steroid side effects leads to under-treatment and poor outcomes — do not allow safety counselling to undermine adherence.
Skin Protection Strategy
- ●Glove technique: Wearing nitrile gloves is necessary but insufficient if gloves are removed for fine work. Advise Sophie to keep gloves on for all chemical contact, including during detail work. Consider thinner nitrile gloves that allow greater tactile sensitivity.
- ●Cotton liner gloves: Wearing white cotton gloves underneath nitrile gloves reduces sweat accumulation and chemical penetration through micro-perforations. Paradoxically, sweat trapped inside gloves is itself an irritant — cotton liners address this.
- ●Wet work reduction — domestic: Advise wearing cotton-lined rubber gloves for all domestic wet work (washing up, bathing the baby). Hands should be dried thoroughly after washing and emollient reapplied immediately.
- ●Barrier creams: A silicone-based barrier cream applied before glove use or wet work provides an additional layer of protection, though evidence for barrier creams is weaker than for emollient use. They are a useful adjunct, not a replacement for other measures.
- ●Latex avoidance: Confirm gloves are latex-free (Sophie already uses nitrile) — latex contact urticaria is a separate but important occupational risk in this profession.
Referral Criteria
- ●Refer to dermatology for patch testing when occupational ACD is suspected — this applies to Sophie given the clinical picture, acrylate exposure, and the career implications of identifying the specific allergen.
- ●Referral is also indicated when: the diagnosis is uncertain; the condition is not responding to potent topical steroids after an adequate trial; or the patient has features atypical for contact dermatitis (e.g., nail involvement, systemic symptoms, widespread rash).
- ●Occupational health referral or signposting to the patient's professional body (e.g., Hairdressing and Beauty Industry Authority — HABIA) may assist with workplace adaptations for self-employed beauticians.
- ●Confirmed occupational dermatitis may be reportable under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) if the employer-employee relationship applies, and may be relevant to industrial injury benefit — worth flagging even for self-employed workers if subcontracting arrangements exist.
Safety Netting and Follow-up
- ●Secondary infection: Fissured and cracked skin is a portal of entry for bacterial infection. Advise Sophie to watch for signs of secondary infection — spreading redness, increasing pain, warmth, weeping, purulent discharge, or systemic unwellness — and to seek urgent review if these develop. Eczema herpeticum (widespread painful vesicles with systemic upset) is rare but serious and requires same-day assessment.
- ●Review at 2–3 weeks: Arrange a specific follow-up appointment to assess the response to the potent steroid course, check emollient use, and chase the dermatology referral. Do not leave follow-up entirely to the patient.
- ●Non-response: If the flare has not improved after a 2-week course of potent steroid, consider: secondary infection, poor adherence (explore sensitively), wrong diagnosis, or need for short-course oral prednisolone — discuss with dermatology.
- ●Provide a clear, written plan where possible — Sophie has a high cognitive load (new baby, self-employed business) and is more likely to adhere to a plan she can refer back to.
Common Candidate Mistakes
- ●Prescribing mild steroid for hand dermatitis is the most common error in this case. Hydrocortisone 1% is appropriate for facial or flexural eczema but is inadequate for the thickened, fissured skin of the hands. Potent steroids are required.
- ●Failing to recommend soap substitutes — or recommending them without addressing the patient's hygiene concerns — results in a management plan the patient will not follow. The question "how can I clean my hands without soap?" is a deliberate test of the candidate's ability to explain the rationale.
- ●Omitting emollient escalation: Recommending E45 (or an equivalent light cream) when a greasy ointment-based emollient is what the guidelines and clinical picture require represents inadequate treatment escalation.
- ●Not discussing domestic wet work: Candidates focused on the occupational chemicals often miss the equally significant contribution of frequent hand-washing and baby care at home. Both need to be addressed in the management plan.
- ●Telling the patient to stop working without exploring alternatives: This is both clinically unhelpful and fails the consultation skills domain. Workplace modification — not cessation — is the appropriate first step.
- ●Omitting patch testing referral: If the candidate fails to identify or discuss patch testing, Sophie leaves without a route to definitive diagnosis. This is clinically significant given the career implications of identifying the specific allergen.
Mapped to the RCGP curriculum topic: Allergy and Immunology.
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