Father of A 7 Year Old with Crusted Sores At the Hairline and An Itchy Scalp — Free SCA Practice Case
Father of a 7 year old with crusted sores at the hairline and an itchy scalp
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
Callan Ridgway
Age
7 years
Consultation Type
TelephoneAge
7
Situation
Telephone Consultation. Mr Ridgway has parental responsibility and has booked a same day call. Callan is at home with him.
Reason for Encounter
"My son has crusty sores on his head and the school has sent him home."
Medical Records
- ●PMH: Nil of note. Immunisations up to date. No previous skin problems recorded.
- ●Medications: None regular.
- ●Allergies: No known drug allergies.
- ●Social: Lives with his parents and a younger sister. Year 3 at primary school.
- ●Recent notes: No consultations in the past year.
Patient Script
For the friend playing the patient role
Character Overview: You are Marek Ridgway, 39, calling about your son Callan, who is 7. You live with your wife Helena, Callan, and your daughter Winnie, who is 4. You are polite, practical and a bit flustered. You like a straight answer, and you are quietly embarrassed about this without saying so. You speak in ordinary everyday language and do not use medical words. You want a quick fix so Callan can go back to school tomorrow.
Opening Sentence: "Hello doctor, it's about my son Callan, he's seven. He's got crusty sores along his hairline and the back of his neck and the school has sent him home. They want to know when he can go back, so I need some antibiotic cream for it really."
History if Asked (Data Gathering Phase)
Gating note: Answer what is asked, in short natural sentences. Do not volunteer the scratching, the school letter or the shampoo unless the doctor asks about itching, scalp or what you have tried.
- ●The sores: "It started about five days ago with a couple of red spots at the back of his neck. Now there are, I don't know, six or seven patches along his hairline and round the back of his neck. The biggest is about the size of a fifty pence piece. They go yellowy brown and crusty, like honey that's dried on." If asked about fluid: "A couple of them are a bit wet and weepy underneath when the crust comes off." Blisters: "No proper blisters, no, just the crusty bits."
- ●Where they are: Only the hairline at the front and sides, and the back of the neck. None on his face, around his eyes or mouth, on his body, arms or legs. "It's all round the edge of his hair. Nowhere else."
- ●Pain: "It's only sore if he picks it. Mostly it itches."
- ●The itching: "He's been scratching his head for weeks. Three or four weeks at least. He scratches at the back and behind his ears, even in front of the telly. I thought it was dry skin or a new shampoo."
- ●How he is in himself: "He's absolutely fine. No temperature, he's eating, he's been bouncing round the house and driving his sister mad. He's not been off his food or sleepy." No vomiting, no headache, no neck stiffness.
- ●What you have tried: "I got a tea tree shampoo from the chemist's about two weeks ago and washed his hair with it three or four times. It didn't do anything for the itch. I've also been washing his hair every day since."
- ●The school letter: Only if asked about contacts, school or other children: "The school sent a letter home about a month ago. It said there had been nits in his class and to check the children's hair."
- ●Checking his hair: If asked whether you have looked: "I had a quick look with the torch on my phone at the weekend. I saw some little white flecks stuck to his hair near the neck, a bit like dandruff but they don't flick off. I didn't see anything moving. I wasn't sure what I was looking at." You have never used a fine comb.
- ●School today: The school rang this morning and sent him home because of the sores. The teacher asked when he can return. "I said I'd find out. I'm hoping tomorrow."
- ●Anyone else: No one else at home has sores, spots or a rash. "None of us have anything like that, just him."
Ideas, Concerns, Expectations
Gating note: Marek does not volunteer any of the following. Each part comes out only when the doctor directly asks what he thinks is going on, what worries him, or what he was hoping for. The shame comes out last and only when the doctor is gentle and open.
- ●Ideas: He thinks the sores are some sort of infection from the scalp being dry or sore, maybe from the tea tree shampoo being too harsh. He has not connected the sores with the scratching. If asked what he thinks is behind the itch: "I honestly thought it was dry skin, or the shampoo. I didn't really think about the nits letter until the school said something today." He has not put nits and sores together.
- ●Concerns: He is worried the sores will scar or spread to Winnie. "Will it leave marks? Will his sister get it?" Underneath this, he is ashamed. If the doctor asks how he is feeling about it, or what is bothering him most, he admits: "To be honest, I'm a bit embarrassed. If it is nits, people think that's dirty, don't they? We keep a clean house. I've been washing his hair every day. I don't want the school thinking we're filthy, or the other parents."
- ●Expectations: He wants an antibiotic cream today so Callan can go back to school tomorrow, and says so when asked what he was hoping for. The reason behind "tomorrow" comes out only if the doctor asks why tomorrow matters to him, or how he thinks the other children will react: "Because the longer he's off, the more the other kids will say he's off with nits. It's bad enough already." That leads into the fuller shame above, which he gives only when the doctor is gentle and open.
If Asked: Medical History and Medications
Gating note: Marek answers direct questions plainly and briefly.
- ●Callan's health: "He's always been healthy. Never been in hospital. No eczema, no asthma, no hay fever. His jabs are all done." No history of impetigo or skin infections. Not on any regular medicines. No medicine allergies, "as far as we know, he's never reacted to anything".
- ●Recent illness and skin: No cold, chickenpox, insect bites or other rashes. His skin is normally fine.
- ●Cold sores or blisters: No one in the house gets cold sores. Nothing painful and blistery on his skin.
Social History and Lifestyle Impact
Gating note: Share this naturally, in a sentence or two, when asked about home, school or the effect on the family. Do not deliver it as a monologue.
- ●Home: Lives in a three bedroom semi with Helena, Callan and Winnie. Callan has his own bed. Winnie and Callan share a bathroom and play together all the time. Callan sometimes borrows his sister's hairbrush, and the children share towels.
- ●School: Callan is in Year 3 and likes school. His best friend sits next to him and they lean their heads together to do their reading.
- ●Callan's mood: If asked how he has been about it: "He's been a bit quiet. He told me a boy at lunch said he was 'nitty' and a couple of kids moved their chairs. He didn't want to talk about it." This is a small cue that should be picked up but not dramatised.
If Asked: Associated Symptoms
Gating note: Respond only to the specific question. Keep answers brief.
- ●Fever or feeling unwell: "No, he's fine in himself. No temperature."
- ●Swollen glands or neck lumps: "I haven't felt any lumps. He hasn't complained."
- ●Redness spreading around the sores: "A couple of the patches have a bit of pink around them but it's not hot and it's not spreading as far as I can see."
- ●Pain, swelling or heat: "No, nothing swollen. He doesn't flinch when I touch his neck."
- ●Itching elsewhere on his body or between his fingers: "No, only his head. Nothing on his hands."
- ●Anyone at home itching: "Winnie scratches her head now and then, but she's four, she's always fiddling with her hair. I haven't looked at her hair. Helena and I haven't noticed anything. I don't think I've been itchy, no." Nobody has any sores or rash.
Responses to Management (The Negotiation Phase)
- ●If the Doctor suggests hydrogen peroxide cream rather than an antibiotic:
- ●Reaction: Doubtful. "Peroxide? Isn't that what you bleach your hair with? I thought he'd get an actual antibiotic cream." If the doctor explains it is as effective for small patches and helps avoid antibiotic resistance, he accepts: "Right, OK. As long as it works." If the doctor offers an antibiotic cream instead, he accepts that immediately. If the doctor mentions tablets, he asks if they are needed: "Are tablets really necessary for this? He hates the taste of medicine."
- ●If the Doctor says Callan cannot go back to school tomorrow:
- ●Reaction: Disappointed and a little sharp. "Tomorrow's out? Why? He's perfectly well. How long is it going to be?" Wants a concrete answer: "So if I start the cream today, when exactly can he go back?" If asked why tomorrow matters so much, he says the longer Callan is off, the more the other children will say he is off with nits. He also asks: "And what about the nits? Does the school keep him off for those too?" He relaxes if told there is no exclusion for lice.
- ●If the Doctor mentions treating the scalp for lice:
- ●Reaction: Practical and wary. "I've already done a shampoo. It didn't work." He asks how it works: "Is that a comb thing? It'll take ages, he won't sit still." If a lotion is suggested: "How long does it stay on? Does it have to be done again?"
- ●If the Doctor says the family should be checked:
- ●Reaction: Anxious. "Do I have to treat all of us? Winnie scratches her head sometimes. Do I need to put the stuff on everyone?" Accepts the answer if told to check each person and treat only those with live lice.
- ●If the Doctor addresses his embarrassment or says lice are not about being clean:
- ●Reaction: Relieved and a bit emotional. "Honestly, that's a weight off. I thought it was something about us." He asks: "Will you tell the school anything? Do they need to know it's nits?" He is reassured that the school already knows and that no exclusion applies for lice.
- ●If the Doctor gives vague safety netting, or if asked about what to look out for:
- ●Reaction: Wants specifics. "What counts as getting worse? When do I ring? Would it be the same day?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
The core dilemma and the model plan
A father rings for an antibiotic cream so his son can go back to school tomorrow, because the longer Callan is off, the more the other children will say he is off with nits. The real problem is a chain: weeks of head scratching (almost certainly head lice, after a class letter about nits), broken skin, then impetigo along the hairline and nape. Treating only the sores will fail, and the school return date he wants is not available.
The model plan:
- ●Explain the link between itch, scratching and infection in plain words.
- ●Judge the impetigo as localised, non bullous, in a well child, and treat it topically for a short course.
- ●Ask the father to comb Callan's hair with a detection comb tonight, and treat live lice with wet combing or a physical insecticide, repeated.
- ●Check the household and treat only people with live lice.
- ●Give the exclusion rule for each condition, specific safety netting and follow up, and respond to his shame without judgement.
Why this is impetigo secondary to scratching
Impetigo is a superficial bacterial skin infection caused by Staphylococcus aureus or group A streptococcus. It often complicates another skin problem that breaks the barrier, such as eczema, scabies, insect bites or here, head lice. Honey coloured crusts, patches confined to the hairline and nape, and no blisters point to non bullous impetigo. Callan is bright, eating and afebrile, with no swollen painful areas, so he is well and low risk. Itch from lice is a sensitisation reaction that can take several weeks to develop, which fits weeks of scratching before the sores. Ask about eczema, recent chickenpox, cold sores or grouped painful blisters (herpes simplex), immunosuppression and drug allergy, because these change the diagnosis or drug choice.
Treating impetigo by extent (NICE NG153)
NICE NG153 (2020) is the guide.
- ●Localised non bullous impetigo in a well child: consider hydrogen peroxide 1% cream, applied two or three times a day for 5 days. If it is unsuitable (for example sores near the eyes) or ineffective, offer a topical antibiotic: fusidic acid 2% three times a day for 5 days, or mupirocin 2% if fusidic acid resistance is suspected.
- ●Widespread non bullous impetigo, not systemically unwell: a topical or oral antibiotic, weighing preference and practicality of covering large areas.
- ●Bullous impetigo, or a child who is unwell or at high risk of complications: an oral antibiotic, usually flucloxacillin, with a macrolide if penicillin allergic.
- ●Never offer a topical and an oral antibiotic together.
- ●Reassess if it worsens rapidly or has not improved after the course. Consider other diagnoses such as herpes simplex, signs of cellulitis, and a swab if topical treatment has failed.
A candidate who prescribes fusidic acid because Marek asks for an antibiotic cream, with a clear course length and a reason, has made a guideline supported choice. Peroxide is preferred because it is as useful for small areas and avoids adding to antibiotic resistance. Oral antibiotics for a few patches in a well child are not recommended.
Head lice: confirm, then treat properly (NICE CKS)
CKS advises treating when live lice are found. Itch and white flecks are not proof, because flecks may be hair casts or dandruff, and eggs may be empty. Detection combing of wet, conditioned hair from the roots is the test.
Treatment options, chosen by preference, previous treatment and cost:
- ●Wet combing: wash with ordinary shampoo, apply plenty of conditioner, and comb the whole head with a detection comb on days 1, 5, 9 and 13, with a check on day 17.
- ●A physical insecticide such as dimeticone 4% lotion, left on for the time recommended (overnight is usual) and applied twice, one week apart, so that lice hatching from surviving eggs are killed. The BNF says once weekly for two doses.
Shampoo products are less effective because they are diluted. Essential oils and herbal products, which include tea tree, are not recommended, so the shampoo he tried was never likely to work. Malathion has resistance problems. After treatment check the hair weekly for a month, and do not repeat treatment when no live lice are found.
Household members, close family and close friends should be checked, and only those with live lice treated, all on the same day. Environmental cleaning is not necessary, because lice do not survive away from the head. Only towels, pillowcases and brushes used in the last two days need washing. Daily hair washing adds nothing.
School exclusion rules differ for the two problems
The current UKHSA guidance for children and young people's settings (updated in July 2026) says a child with impetigo should stay away until all sores or blisters have formed scabs, or until 2 days after starting treatment with antibiotics or hydrogen peroxide 1% cream where indicated. Older sources said lesions should be crusted and healed; the current wording is the one to use. Head lice need no exclusion. The child can attend as usual.
So Callan cannot go back tomorrow whichever treatment is started today. The expectation Marek brought cannot be met, and the honest answer is the date two days after the first application, or sooner only if the sores have all scabbed. Give a concrete date, since the school is asking. Telling a father the child must stay off "until the lice are gone" is wrong.
Shame and judgement
Marek's request for a quick fix, and for a return tomorrow, hides shame. He gives the reason only when asked why tomorrow matters: the longer Callan is off, the more the other children will say he is off with nits. He has washed Callan's hair daily and fears the school and other parents will think the family dirty. The date cannot move, so what he needs is reassurance and a clear plan. The fact helps: head lice are spread by head to head contact, are common in primary school children, and have nothing to do with cleanliness. They can live on clean hair. Say so early, and add that checking and treating promptly is what a careful parent does. Callan has been teased as "nitty" and is quiet. A brief, kind enquiry about how Callan is coping, and a suggestion to speak to the class teacher if it continues, shows the consultation has considered the child. Lice are not a safeguarding matter.
The telephone consultation, safety netting and follow up
The description of localised crusted patches in a well child is reasonable to treat without seeing him. Offering a face to face appointment is equally acceptable, particularly if the picture is unclear, the sores are widespread, or the father is uncertain. Do not penalise either. Whichever route, use specific safety netting. Same day contact for fever or an unwell child, spreading redness, hot swelling or increasing pain, tender neck glands, sores near the eyes or spreading across the face, or no improvement after the course (NG153 recommends reassessment). Give a timeframe, such as the end of the 5 day course. Arrange to recheck the hair, and for the lice to be treated again on the planned day.
Practical plan
Pull the advice into one plan the family can run tonight and over the next fortnight: peroxide cream tonight and each day, combing or lotion tonight, who in the household gets checked, the repeat date, and the return date. Ask Marek to say the plan back, so the key steps are secure before the call ends.
Common mistakes in this station
- ●Prescribing an antibiotic cream and finishing, never linking the sores to the scalp.
- ●Giving oral antibiotics for a few patches in a well child, or both oral and topical together.
- ●Saying Callan can return tomorrow, or excluding him for lice.
- ●Recommending an insecticide shampoo, more tea tree or daily washing.
- ●Treating every family member without finding live lice, or ignoring Winnie.
- ●Offering a single application of lice treatment with no repeat or recheck.
- ●Saying "come back if it gets worse" without naming symptoms.
- ●Implying lice reflect poor hygiene, ignoring the teasing, or answering his push for tomorrow with a date and nothing about the shame behind it.
Mapped to the RCGP curriculum topic: Infectious Disease and Travel Health.
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