Parent Requesting Allergy Testing for Their Child with Eczema — Free SCA Practice Case
Parent requesting allergy testing for their child with eczema
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
A live 12-minute consultation with an AI patient, marked. You see your verdict before we ask for anything.
Materials for Candidate
Please review before starting the consultation
Full Name
Noah Evans
Age
4 years
Consultation Type
TelephoneAge
4
Past Medical History
- ●Atopic Eczema (Diagnosed age 6 months).
- ●Viral induced wheeze (last admission 1 year ago).
- ●No known drug allergies.
Medication History
- ●Doublebase Gel (500g) – 1 pump prescribed per month
- ●Hydrocortisone 1% Cream – 1 tube prescribed 6 months ago.
- ●Chlorphenamine (Piriton) – bought over counter.
Recent Medical Notes
- ●6 Months Ago: Seen by Nurse Practitioner. Mild flare on flexures. Advised to increase emollient use.
- ●Current Situation: Telephone/Video appointment with Parent (Mother/Father).
- ●Reason for Encounter: "Eczema is getting worse. Need to discuss allergy testing."
Patient Script
For the friend playing the patient role
Character Overview: You are Alex, the parent of 4-year-old Noah. You are exhausted, frustrated, and feeling guilty. Noah has been scratching constantly, keeping the whole house awake. You are convinced that "something in his diet" is causing this because the creams "don't work." You have read online about dairy/gluten intolerance.
Opening Sentence: "Hi Doctor. I'm calling because Noah's skin is absolutely terrible. He's scratching until he bleeds. We've tried the creams you gave us, but they do nothing. I want him tested for allergies—I'm sure it's milk or wheat."
History if Asked (Data Gathering Phase)
- ●The Allergy Belief: You notice he seems worse after breakfast (cereal and milk). He gets itchy and irritable.
- ●Crucial Detail: He does not get swollen lips, difficulty breathing, or immediate hives after eating. The itching is constant but "peaks" in the evening.
- ●The "Online" Influence: You paid £50 for an online "hair strand analysis" test which said he is "intolerant" to dairy. You want a "proper blood test" to confirm this so you can ask the nursery to change his diet.
- ●Current Management (The Barrier):
- ●Emollients: You use the Doublebase "when his skin looks dry." (You don't realize it should be used liberally all the time as prevention).
- ●Steroids: You stopped using the Hydrocortisone after 3 days because you read it "thins the skin" and stunts growth. You are terrified of steroid side effects.
- ●Impact on Life: Noah is irritable at nursery. They have called you twice this week to pick him up because he was "distressed and scratching." You are at risk of losing your job due to leaving early.
- ●Infection Check: The skin is red and raw, but there is no "golden crust" (impetigo) or blisters (herpes) currently.
ICE — Ideas, Concerns, Expectations
The patient (parent) does not raise these unprompted. These surface only when the candidate directly explores the parent's perspective.
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Ideas: You are convinced this is a food allergy — specifically dairy or wheat. The hair strand test result has reinforced this belief. You think the eczema is a symptom of something being "wrong on the inside" rather than a skin condition to be managed topically. You don't really see it as eczema any more — you see it as an allergic reaction that nobody is investigating properly.
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Concerns: You are worried that Noah is suffering unnecessarily because nobody is taking this seriously. You fear the eczema is damaging his skin permanently. You are also privately terrified that the steroids you were given could be harming him — you read a forum post about a child whose skin "went paper thin" from steroid creams. On top of this, you are worried about losing your job because of the nursery call-outs, and you feel guilty that you might be failing Noah as a parent.
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Expectations: You want the doctor to order a proper NHS allergy blood test so you can get a definitive answer and tell nursery to remove dairy from his meals. Ideally, you want a referral to a specialist. You also want something that actually works for his skin that isn't a steroid — "something natural" if possible. Above all, you want to feel heard and taken seriously, not fobbed off with "just use more cream."
If Asked — Medical History and Medications
Actor guidance — respond naturally only when the candidate asks about these specific items.
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Doublebase Gel: "We've got a big pump bottle in the bathroom. I put it on when his skin looks dry or flaky — maybe once a day, sometimes I forget if we're rushing in the morning. To be honest, it doesn't seem to do much. It just makes him greasy and he hates it — he wriggles and cries when I try to put it on."
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Hydrocortisone 1% Cream: "We used it for about three days and I stopped. I read online that steroid creams thin children's skin and can stunt their growth. He's only four — I don't want to do that to him. The tube is still in the cupboard, barely used."
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Chlorphenamine (Piriton): "I bought that from Boots. The pharmacist suggested it. I give it to him at night sometimes when he's really scratching and can't sleep. It helps him drop off, but it doesn't seem to stop the itching during the day. I wasn't sure if I'm allowed to give it to a four-year-old so I only use it when things are really bad."
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Viral-induced wheeze / previous hospital admission: "He was in hospital about a year ago — he had this awful cough and was really wheezy. They gave him an inhaler and kept him in overnight. He hasn't had anything like that since, touch wood. They said it was a virus, not asthma, but I do wonder sometimes if it's all connected — the skin, the wheeze, the allergies. It feels like his immune system is just not right."
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Nurse Practitioner visit 6 months ago: "Yes, I took him in because his skin was playing up again — the creases of his elbows and behind his knees. The nurse said to use more of the Doublebase and it should settle down. I did try for a bit but it didn't make much difference, so I kind of gave up with it."
Social History and Lifestyle Impact
Actor guidance — this context is volunteered naturally in conversation, not delivered as a monologue. Integrate with the character's existing tone of exhaustion and frustration.
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Occupation and daily life: You work part-time as an admin assistant at a local estate agent — three days a week, the other two days Noah is at home with you. Your partner works full-time. Noah is at nursery on your working days. There is no other family nearby to help with childcare.
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Lifestyle impact of the condition: The eczema is now dominating your entire family life. Noah wakes two or three times a night scratching — you have to go in, hold his hands, re-apply cream, and try to settle him. You are averaging about four hours of sleep a night and it's affecting your concentration at work. The nursery has called you twice this week asking you to collect him early because he was so distressed — your manager has pulled you aside and said this can't keep happening. You've already used all your annual leave and you're genuinely frightened you could lose your job. At home, you've stripped his bedding, changed washing powder, cut out bubble bath — you've tried everything you can think of. You feel like you're running out of options and nobody is helping.
If Asked — Associated Symptoms
Actor guidance — respond only when the candidate asks about specific symptoms. Keep answers brief and natural.
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If asked about sleep disturbance: "He's up two or three times a night scratching. None of us are sleeping properly — it's been like this for weeks now."
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If asked about wheeze or breathing difficulties currently: "No, his breathing has been fine. Nothing like when he was in hospital. No coughing either."
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If asked about hay fever or sneezing: "He does get a runny nose sometimes, especially in spring, but nothing terrible. I give him Piriton for that too."
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If asked about eye symptoms (itchy/red/watery eyes): "Actually, yes — his eyes do get red and itchy sometimes. I assumed it was because he rubs his face when his skin is bad."
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If asked about any swelling of lips, tongue or throat after eating: "No, never. Nothing like that. He eats everything fine — no swelling, no being sick, nothing."
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If asked about vomiting or diarrhoea after food: "No, his tummy is fine. He eats well. No sickness or funny nappies — well, he's out of nappies now, but no, his bowels are normal."
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If asked about urticaria / hives: "No, he doesn't get hives. It's not like bumps — it's just red, dry, cracked skin that he scratches raw."
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If asked about whether the rash is weeping or oozing: "It does weep a bit sometimes when he's really scratched it open, but it's not yellow or crusty — just clear fluid."
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If asked about fever or generally unwell: "No, he's fine in himself — eating, playing, normal energy. He's just miserable with the itching."
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If asked about distribution of eczema: "It's worst in the creases — elbows, behind the knees, wrists. But it's also on his neck now and a bit on his cheeks. It's spreading."
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If asked about contact with anyone with cold sores: "No, not that I know of. Nobody at home gets them."
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If asked about pets: "We've got a cat. We've had her since before Noah was born. Do you think that could be causing it?"
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If asked about recent changes in washing powder, soap, or clothing: "I've already changed everything — I use non-bio washing powder now, no fabric softener, we stopped bubble bath months ago. Cotton clothes only. It hasn't made any difference."
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If asked about nursery environment / triggers: "I have wondered about nursery — whether there's something there. Sand, paint, that sort of thing. But he's been going there for two years and this has only got this bad recently."
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If asked about family history of eczema, asthma, or allergies: "My partner had asthma as a child — grew out of it. My mum has hay fever. Nobody else has eczema though."
Responses to Management (The Negotiation Phase)
- ●If the Doctor refuses the allergy test:
- ●Reaction: Defensive. "So you're just going to let him suffer? I have a test result here that says it's milk. Why won't you do the NHS one?" (Tests the doctor's ability to explain Type 1 vs Delayed hypersensitivity and the validity of hair tests).
- ●If the Doctor suggests more steroids:
- ●Reaction: Fearful. "Absolutely not. He's only 4. I don't want to damage his skin permanently. Isn't there a natural alternative?"
- ●If the Doctor explains 'emollient overuse':
- ●Reaction: Skeptical. "We put it on. It just sits on the skin and makes his clothes greasy. He hates it."
- ●If the Doctor mentions 'Finger Tip Units' (FTU):
- ●Reaction: Confused. "I just put a thin smear on. What is a finger tip unit?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Allergy Testing in Atopic Eczema
- ●IgE-mediated (immediate) allergy presents with urticaria, angioedema, vomiting, wheeze, or anaphylaxis within minutes of exposure. This is the only scenario where specific IgE blood tests (RAST/ImmunoCAP) or skin prick testing are clinically indicated in a child with eczema.
- ●Delayed food hypersensitivity — which may worsen eczema — does not produce immediate symptoms and cannot be diagnosed by blood tests or skin prick testing. The evidence-based approach is a supervised dietary exclusion trial (strict exclusion for 4–6 weeks, then structured reintroduction), conducted alongside optimised skin care.
- ●Hair strand analysis and similar commercial "intolerance" tests are not validated diagnostic tools. They are not recognised by NICE, the British Society for Allergy and Clinical Immunology (BSACI), or the NHS. Candidates should address these gently, acknowledging the parent's motivation to find answers, without ridiculing the decision.
- ●Routine IgE testing in the absence of immediate-type symptoms adds no diagnostic value and may cause harm — dietary restriction in a 4-year-old without justification risks nutritional deficiency (particularly calcium if dairy is excluded).
The Atopic March — Understanding the Bigger Picture
- ●Noah has three features of the atopic triad: atopic eczema, viral-induced wheeze, and probable allergic rhinoconjunctivitis (seasonal runny nose, red itchy eyes). Family history of childhood asthma (partner) and hay fever (grandmother) confirms strong atopic predisposition.
- ●The atopic march describes the typical developmental sequence: eczema in infancy → food allergy → allergic rhinitis → asthma. Recognising this in a 4-year-old is clinically important — it does not mean something is "fundamentally wrong" with the immune system, but it does guide surveillance and parental education.
- ●Explaining atopy to parents in simple terms (a tendency to overreact to harmless triggers, shared across skin, nose, and airways) directly addresses their fear that Noah has a systemic problem "on the inside."
Emollient Therapy — Getting the Basics Right
- ●Emollients are the foundation of eczema management and must be used preventatively — not only when the skin looks dry. The correct instruction is to apply at least 3–4 times daily as a leave-on moisturiser, regardless of whether a flare is active.
- ●Quantity is the most commonly under-prescribed element. A child of Noah's age with moderate-to-severe eczema typically requires 250–500g of emollient per week. A prescription of "1 pump per month" represents significant under-treatment and should be corrected proactively.
- ●Complete emollient therapy means using the emollient as a soap substitute (for washing and bathing) as well as a leave-on moisturiser. Soap and bubble bath are irritants that disrupt the epidermal barrier and should be avoided entirely.
- ●Application technique: Apply in the direction of hair growth (downward strokes) to reduce the risk of folliculitis. Do not rub vigorously.
- ●Product choice matters for adherence. If a child dislikes a particular formulation (e.g., finds Doublebase too greasy), switching to a lighter cream-based alternative (e.g., Cetraben, Diprobase cream, Aveeno) is clinically appropriate and improves the chance of consistent use. Finding an emollient the child will tolerate is more important than which specific product is chosen.
Topical Corticosteroids — Safety, Dosing, and Phobia
- ●Steroid phobia is one of the most common and clinically significant barriers to eczema management in primary care. It must be addressed proactively, with empathy and evidence.
- ●Hydrocortisone 1% is the mildest topical corticosteroid available. Skin thinning (atrophy) and systemic absorption are associated with prolonged use of potent steroids, not short courses of mild ones. Untreated eczema — with its ongoing barrier disruption and inflammation — causes more skin damage than appropriately used topical steroids.
- ●Finger Tip Units (FTUs) provide practical dosing guidance. One FTU is the amount of cream squeezed from the tip of the index finger to the first joint — this covers an area equivalent to two adult palms. Using FTUs gives parents a concrete, safe framework and counters the tendency to under-apply out of fear.
- ●Duration of use for a flare: Apply once daily for 7–14 days until the skin is completely smooth (not just less red). For courses under two weeks with a mild-to-moderate steroid, abrupt cessation is appropriate — tapering is reserved for prolonged use of potent steroids.
Stepped-Care Approach — Escalating Appropriately
- ●NICE CKS recommends a step-up approach based on eczema severity:
- ●Step 1 (Mild): Emollients alone
- ●Step 2 (Mild flare): Emollients + Hydrocortisone 1% (mild topical corticosteroid)
- ●Step 3 (Moderate flare): Emollients + moderate-potency topical corticosteroid — e.g., Clobetasone butyrate 0.05% (Eumovate) for the body, or Betamethasone valerate 0.025% for the body in older children. Hydrocortisone 1% remains the appropriate choice for the face at all ages.
- ●Step 4: Tacrolimus ointment (calcineurin inhibitor) — second-line for face/flexures where steroid-sparing is needed; requires specialist initiation in children.
- ●Noah's current flare — which has not responded to Hydrocortisone used for only 3 days — likely represents inadequate treatment rather than treatment failure. Before stepping up, ensure the mild steroid is being used correctly. If it genuinely fails after a proper trial, stepping up to a moderate-potency steroid is appropriate.
Maintenance Therapy — Preventing Relapse
- ●For children who flare frequently (2 or more times per month), proactive weekend therapy is recommended: apply the topical corticosteroid to previously affected sites on two consecutive days per week (e.g., Saturday and Sunday) once the skin has cleared. This significantly reduces relapse frequency.
- ●This approach is supported by NICE CKS and should be offered — and explained clearly — once the acute flare is controlled.
Antihistamines in Eczema
- ●Sedating antihistamines (e.g., Chlorphenamine/Piriton) do not reduce eczema itch, which is driven by skin inflammation rather than histamine. Their role is limited to aiding sleep during severe flares.
- ●Chlorphenamine is licensed from age 1 and is appropriate for a 4-year-old. The BNFC dose for ages 2–5 is 1 mg every 4 to 6 hours (1 mg twice daily is the dose for under-2s). If it is used purely to help sleep during a flare, a single 1 mg dose at night is reasonable.
- ●If Noah has concurrent allergic rhinitis or conjunctivitis, a non-sedating antihistamine (e.g., Cetirizine, licensed from age 2; or Loratadine, licensed from age 2) would be more appropriate for daytime symptom control and avoids the sedation that may affect nursery performance.
Referral Criteria
- ●Referral to paediatric dermatology is indicated when:
- ●Eczema remains uncontrolled despite optimised topical therapy (correct emollient use + appropriate steroid, used correctly, for an adequate trial period of 4–6 weeks)
- ●Recurrent secondary infections (bacterial or viral)
- ●Diagnostic uncertainty (e.g., contact dermatitis, scabies, or rare dermatoses need excluding)
- ●The child's quality of life (or the family's) is severely and persistently affected
- ●Referral to paediatric allergy is appropriate if there is a genuine clinical suspicion of IgE-mediated food allergy (immediate-type symptoms) — not indicated for Noah at this stage.
- ●Offering referral as a clear, defined pathway — conditional on the outcome of an optimised treatment trial — preserves trust with the parent without making an immediate referral that bypasses primary care management.
Secondary Infection — Recognition and Management
- ●Bacterial superinfection (usually Staphylococcus aureus) presents with weeping, golden or yellow crusting, increased pain, and rapid local worsening. Treatment: topical fusidic acid (for localised infection) or oral flucloxacillin (for widespread or treatment-resistant bacterial infection).
- ●Eczema herpeticum is a dermatological emergency. It presents with rapidly spreading clusters of monomorphic punched-out vesicles or erosions, often with fever and malaise. It requires same-day emergency review and systemic aciclovir. Parents must be safety-netted specifically for this.
- ●Clear safety-netting advice about what infected eczema looks like — with explicit instruction to seek same-day help — is an essential part of every eczema consultation.
Safety Netting and Follow-Up
- ●Signs of bacterial infection: increased weeping, golden/yellow crusting, pustules, rapidly worsening pain — seek same-day review.
- ●Signs of eczema herpeticum: widespread painful punched-out blisters or erosions, especially if febrile — attend emergency care immediately.
- ●Acute allergic reaction: angioedema, urticaria, wheeze, or difficulty breathing after food exposure — call 999.
- ●Review interval: 2–4 weeks to assess response to optimised therapy. Consider face-to-face review to allow direct skin examination — a telephone or video consultation limits clinical assessment.
- ●If no improvement after 2 weeks of correctly used moderate-potency steroid plus emollients: review the diagnosis (consider scabies, allergic contact dermatitis) before escalating further or referring.
Nursery, Occupational, and Practical Considerations
- ●A written eczema care plan for nursery — outlining emollient application during the day, trigger avoidance, and when to call the parent — can reduce the number of call-outs and protect the parent's employment.
- ●GP letters supporting a parent's employment situation in the context of a child's significant medical condition are an appropriate medicolegal output of this consultation. This is a practical intervention that directly addresses the psychosocial burden raised in the case.
Common Candidate Mistakes in This Case
- ●Ordering allergy tests to avoid conflict rather than explaining clearly why they are not indicated — this represents clinical capitulation and does not serve the patient.
- ●Failing to explore steroid phobia before prescribing or re-prescribing the topical corticosteroid. Issuing a prescription the parent has already decided not to use achieves nothing.
- ●Advising dairy exclusion without structure — cutting out dairy in a 4-year-old without a supervised trial, reintroduction plan, or nutritional safety-netting risks harm.
- ●Under-prescribing emollients — failing to correct the quantity, frequency, or technique means the most important treatment in eczema remains ineffective.
- ●Treating the flare but missing the maintenance plan — failing to mention weekend therapy or a clear follow-up interval leaves the family without a strategy for preventing the next flare.
Mapped to the RCGP curriculum topic: Allergy and Immunology.
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