Persistent Itchy Rash — Free SCA Practice Case
Elderly woman with persistent itchy rash
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
Dorothy Higgins
Age
78 years
Consultation Type
VideoAge
78
Situation
Telephone or Video Consultation.
Reason for Encounter
"Patient complaining of a severe, itchy rash all over her body. Seen 2 weeks ago by a colleague and prescribed Zerobase emollient for suspected dry skin, but symptoms are worsening and affecting her sleep."
Medical Records
- ●PMH: Osteoarthritis, Hypertension.
- ●Medications: Amlodipine 5mg OD, Paracetamol PRN.
- ●Allergies: NKDA.
- ●Social: Lives independently in a warden-assisted sheltered housing complex.
Patient Script
For the friend playing the patient role
Character Overview: You are Dorothy. You are exhausted and incredibly distressed by this constant itching. You are scratching so much that your skin is raw and bleeding in places. You are usually a very proud, immaculately presented woman. You are secretly terrified that you have caught some kind of "dirty bug" or parasite, and your biggest fear is that you might have passed it to your newborn great-grandson whom you cuddled extensively at the weekend. You feel deeply ashamed and will not volunteer this fear or the word "bug" unless the doctor explicitly asks what you are worried about.
Opening Sentence: "Good morning, Doctor. I'm at my wits' end with this itching. It's all over my arms, my tummy, and my legs. The moisturizer the other doctor gave me two weeks ago hasn't done a single thing. I'm scratching myself raw, especially at night—I haven't slept properly in days."
History if Asked (Data Gathering Phase)
- ●
The Rash/Itch:
- ●
"It's little red, angry bumps. Mostly between my fingers, around my wrists, and around my tummy button."
- ●
"The itch is unbearable. It's definitely worse the minute I get into bed and get warm."
- ●
Contacts & Context:
- ●
"I live in sheltered housing. We have a communal lounge where I play bingo twice a week with the other ladies."
- ●
"My daughter comes to visit me every Sunday, and she brings my new great-grandson."
- ●
Systemic Screen (Ruling out other causes of pruritus):
- ●
"No, I haven't changed my washing powder or soap."
- ●
"No yellowing of my skin or eyes (jaundice), my wee is normal."
- ●
"No new medications, just my usual blood pressure pill I've been on for years."
ICE — Ideas, Concerns, Expectations
The patient does not raise any of the following unprompted. These responses surface only if the doctor directly explores the patient's perspective.
- ●
Ideas: Dorothy suspects she has caught some kind of parasite or "dirty bug" — something crawling under her skin. She does not have a specific medical term for it, but the sensation of something crawling and the pattern of worsening have convinced her it is an infestation rather than simple dry skin. She will not use the word "bug" or volunteer this belief unless directly asked.
- ●
Concerns: Her deepest fear is that she may have passed the infestation to her newborn great-grandson, whom she cuddled extensively the previous Sunday. She is also terrified that the housing warden will find out and fumigate her flat, and that the other residents will learn she has "bugs" — this would be devastating to her pride. She feels deeply ashamed and becomes tearful when disclosing this.
- ●
Reaction (The Reveal): You sound tearful and deeply ashamed. "Doctor, I keep a spotless house. I wash every single day. But this feels like something crawling. I'm terrified I've caught some sort of dirty bug. And worse... my daughter brought the new baby over on Sunday and I held him for hours. Have I given a parasite to a newborn baby? If the housing warden finds out I have bugs, they'll fumigate my flat and everyone will know."
- ●
Expectations: Dorothy wants a clear answer about what is causing the itching and something that will actually get rid of it — the moisturiser clearly hasn't worked and she is losing faith that anyone is taking it seriously. She also wants reassurance about the baby and practical guidance she can manage given her arthritis.
If Asked — Medical History and Medications
The patient confirms the following if the doctor enquires about her medical history or current medications. She answers straightforwardly but without medical jargon.
- ●
Amlodipine (blood pressure tablet): "I've been on the same blood pressure tablet for years — I think it's called amlodipine. One a day, every morning. I've not had any changes to it recently and I've never had any problems with it."
- ●
Paracetamol: "I take paracetamol when my joints are playing up — maybe a couple of times a week, sometimes more if I've been busy. I don't take anything stronger."
- ●
Osteoarthritis: "I've had arthritis for a good few years now, mainly my hands and my knees. It's manageable most days but it does make things like gripping and lifting heavy things quite difficult. It's been worse recently with the cold weather."
- ●
Previous GP visit (Zerobase emollient): "Yes, I saw another doctor about two weeks ago. She had a look and said it was probably dry skin — gave me a big tub of moisturiser, Zerobase I think it was called. I've been putting it on religiously but it hasn't made any difference at all. If anything, the itching has got worse since then."
- ●
Allergies: "No, I've never had any allergies to medicines that I know of."
Social History and Lifestyle Impact
Dorothy lives independently in a warden-assisted sheltered housing complex. She is a retired school dinner lady. She is fiercely independent and takes great pride in keeping herself and her flat immaculate.
- ●
Daily life: "I keep myself busy — I do my own shopping, I cook for myself, and I keep the flat spotless. I play bingo in the communal lounge on Tuesdays and Thursdays. It's my social life, really — I look forward to it all week."
- ●
Lifestyle impact of the condition: "I've stopped going to bingo. I can't sit there scratching like I've got fleas in front of everyone — what would they think? And the itching at night is the worst part. I used to sleep right through, but now I'm up half the night tearing at my skin. I'm absolutely shattered during the day. I've even stopped having my daughter and the baby round because I'm terrified of passing something on. I haven't told her why — I just said I wasn't feeling well. It's breaking my heart not seeing that little one."
If Asked — Associated Symptoms
The patient responds to direct questions about the following symptoms. All answers are in patient voice.
- ●
If asked about burrows or tracks on the skin: "Now you mention it, there are a few little silvery lines between my fingers — I thought they were just scratches from where I'd been itching."
- ●
If asked about the rash on the hands specifically: "Yes, the worst of it is between my fingers and on the insides of my wrists. It's red raw there from scratching."
- ●
If asked about rash in the groin or buttocks area: "Well, actually, yes — I didn't like to say, but I have got some itchy bumps down below as well. I thought that was a separate thing."
- ●
If asked whether anyone else in the housing complex is itching: "Funnily enough, my friend Mavis who I sit next to at bingo said her arms have been itchy too. I didn't think anything of it at the time."
- ●
If asked about the baby having any rash: "My daughter hasn't mentioned anything, but I've been too scared to ask. I've been worrying myself sick about it."
- ●
If asked about fever or feeling generally unwell: "No, I don't feel ill in myself — just exhausted from not sleeping."
- ●
If asked about weight loss: "No, my weight's been the same. I'm still eating fine."
- ●
If asked about feeling excessively hot or cold / thyroid symptoms: "No, nothing like that. I'm not more hot or cold than usual."
- ●
If asked about excessive thirst or urination: "No, nothing like that — my wee is perfectly normal."
- ●
If asked about any lumps or swollen glands: "No, I haven't noticed any lumps."
- ●
If asked about bruising or bleeding easily: "No more than the odd bruise from bumping into things. Nothing unusual."
- ●
If asked about mood or low mood: "I'm not depressed, Doctor, I'm just fed up and tired. Anyone would be with this itching."
- ●
If asked about any pets: "No, I don't have any pets. They don't allow them in the sheltered housing."
- ●
If asked about recent travel: "No, I haven't been anywhere. I haven't left the local area in months."
Responses to Management (The Negotiation Phase)
- ●
If the Doctor diagnoses Scabies: Reaction: Horrified. "Scabies?! But that's for people who don't wash! How on earth could I have caught scabies? Am I unclean?"
- ●
If the Doctor tells you to wash all your bedding and clothes: Reaction: Overwhelmed. "Wash everything? At 60 degrees? Doctor, my arthritis is terrible at the moment. I can't strip the bed and do all that laundry in one day by myself." (Testing the doctor's holistic care—can they suggest bagging items or asking the daughter for help?)
- ●
If the Doctor just prescribes a steroid cream to stop the itch: Reaction: "But if it's a bug, will a cream to stop the itch actually kill the things? What about the baby?"
- ●
If the Doctor forgets to mention treating contacts: Reaction: "So I just put the cream on myself? Do I need to warn my daughter about the baby?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diagnosis: Recognising Scabies
- ●The causative agent is Sarcoptes scabiei, a mite that burrows into the stratum corneum to lay eggs, triggering an intense delayed type IV hypersensitivity reaction.
- ●Incubation period: Up to 6–8 weeks in a first infection (sensitisation lag). In re-infection, symptoms appear within 1–4 days. This is why contacts can harbour the infestation asymptomatically and still transmit it.
- ●Classic triad: Widespread, intense pruritus with marked nocturnal exacerbation; burrows (silvery or grey linear tracks, 1–10 mm) in characteristic sites; erythematous papules and excoriations.
- ●Classic sites: Finger web spaces, flexor surfaces of wrists, axillae, periumbilical skin, buttocks, and genitalia. In elderly patients, the distribution can be more atypical — involvement of the trunk and lower limbs is common.
- ●Pathognomonic sign: Burrows are the most specific clinical feature. They are easily missed or attributed to scratch marks by the patient. Always ask directly: "Have you noticed any fine silvery lines or tracks between your fingers?"
- ●Treatment failure with emollient is itself a diagnostic clue. Dry skin and eczema respond to moisturisers; scabies does not. A patient returning with worsening pruritus despite emollient therapy should prompt active reconsideration of the diagnosis.
Pharmacological Treatment
- ●First-line: Permethrin 5% dermal cream (NICE CKS). Apply to the entire body surface. In adults this is from the neck down; in elderly patients, immunocompromised individuals, and children under 2 years, the face, scalp, and ears must also be treated.
- ●Application detail matters: Pay particular attention to finger web spaces, under nails (use a soft brush), genital area, and soles of feet. If hands are washed during the application period, cream must be immediately reapplied to the hands.
- ●Contact time: Leave on for 8–12 hours (overnight application is standard) before washing off.
- ●The 7-day rule: A second full application must be given exactly 7 days later to kill mites that have hatched from eggs surviving the first treatment. Eggs are not killed by permethrin; the interval is critical. Ensure patients understand why this is mandatory, not optional.
- ●Second-line: Malathion 0.5% aqueous liquid — used if permethrin is contraindicated or the patient cannot tolerate it. Apply for 24 hours then wash off. The same whole-body application rules and 7-day repeat apply.
- ●Adjunct symptom relief: While scabicides take effect, offer a sedating antihistamine (e.g. chlorphenamine) at night to manage nocturnal pruritus and sleep disruption. Check it is safe alongside the patient's existing medications.
Simultaneous Treatment of All Close Contacts
- ●This is the single most common reason treatment fails. All household members and close physical contacts must be treated simultaneously with the index case, even if they are completely asymptomatic — because of the long incubation period, contacts may already be infested before any itch develops.
- ●"Close contact" means: people sharing a bed or household, anyone with whom there has been prolonged skin-to-skin contact (including holding, cuddling, or sexual contact).
- ●Infants and young children must be assessed by their own GP or health visitor before treatment is prescribed, as application technique and treatment area differ from adults. Do not prescribe for a child you have not seen.
- ●Contacts should be treated on the same day as the index case — staggered treatment guarantees reinfection.
Environmental Decontamination
- ●Scabies mites cannot survive off the human host for more than 72 hours — environmental decontamination requirements are therefore limited.
- ●On the day of treatment: wash all bedding, towels, and clothing worn in the past 3 days at 50°C or above.
- ●Practical alternative: Items that cannot be machine-washed (heavy coats, shoes, items too bulky to launder) can be sealed in a plastic bag for at least 72 hours, after which any mites will have died. This is equally effective and is the correct guidance for patients who are physically unable to complete all laundry in one day.
- ●There is no indication for fumigation of the home. This is a common misconception and causes significant unnecessary distress to patients.
Post-Treatment Itch: The Most Common Reason for Re-consultation
- ●Pruritus commonly persists for 2–6 weeks after successful treatment. This is a normal immune response to dead mite material (mite proteins and faeces) remaining in the skin — it does not indicate treatment failure or active infestation.
- ●Patients must be explicitly warned about this before treatment is started. Failure to counsel on this point leads to anxiety, unnecessary re-presentations, and inappropriate retreatment.
- ●Do not retreat with a scabicide purely because pruritus persists at week 2 or 3.
- ●Symptomatic measures during the post-treatment period: continue emollients; consider crotamiton cream (which has mild antipruritic properties); a mild topical corticosteroid (e.g. hydrocortisone 1%) can be applied to localised inflamed areas; sedating antihistamines at night if sleep remains disrupted.
- ●Retreatment is appropriate if: new burrows appear, or pruritus has not begun to settle by 6 weeks — at which point treatment failure, reinfection from an untreated contact, or an alternative diagnosis should be considered.
Safety Netting: Secondary Bacterial Infection
- ●Heavily excoriated skin — particularly in an elderly patient who has been scratching for weeks — carries a significant risk of secondary bacterial infection (impetiginisation).
- ●Advise the patient to watch for: increasing redness or warmth, swelling, weeping or crusting of the skin, or the development of fever or systemic unwellness.
- ●These features warrant urgent review; antibiotic treatment (topical or systemic depending on extent) may be required.
Institutional Outbreaks: A Public Health Responsibility
- ●When a patient in a communal or institutional setting (sheltered housing, care home, hospital ward) is diagnosed with scabies and a contact in the same setting is also symptomatic, this constitutes a potential institutional outbreak.
- ●The GP has a responsibility to consider notifying the UKHSA Health Protection Team (HPT), who will coordinate an outbreak response — this typically involves simultaneous mass treatment of all residents and staff on a set date.
- ●Approach this sensitively with the patient: explain the rationale, reassure about medical confidentiality, and seek consent before contacting third parties where possible. The goal is containment, not exposure.
- ●Fumigation is not part of outbreak management and should not be suggested to patients or housing providers.
Holistic Management: Adapting Treatment to the Patient
- ●Whole-body permethrin application is physically demanding. In a patient with hand or knee osteoarthritis, applying cream independently to the back, soles of feet, and under nails may be impossible. Failing to consider this sets the patient up to fail.
- ●Practical solutions: ask a family member or carer to assist with hard-to-reach areas; a long-handled applicator can help with the back and lower legs.
- ●Similarly, stripping beds and completing multiple hot washes is a significant physical task. Proactively offer the plastic bag alternative and suggest enlisting family help rather than presenting the textbook instructions as non-negotiable.
De-stigmatising the Diagnosis
- ●Scabies carries significant social stigma, particularly for older patients who associate it with uncleanliness. Many patients will feel ashamed before, during, and after the consultation.
- ●Use clear, explicit de-stigmatising language: "Scabies has absolutely nothing to do with personal hygiene or how clean your home is. It is caused by a tiny mite that passes between people through prolonged skin-to-skin contact — it can affect anyone."
- ●Do not use the word "infestation" in conversation with the patient — it amplifies the shame. Prefer "mite" or "skin mite."
- ●Address guilt about transmitting the infection to contacts, particularly vulnerable ones such as infants, with proportionate reassurance: acknowledge the fear honestly, confirm that the contact will need to be assessed, but emphasise that scabies is very treatable and does not cause lasting harm.
Common Candidate Mistakes in This Station
- ●Treating the itch, not the cause: Prescribing topical steroids or further emollients without a scabicide leaves the infestation entirely untreated. Steroids may temporarily suppress the itch while the mite population continues to proliferate.
- ●Inadequate application instructions: Telling the patient to "apply to the affected areas" is incorrect and will result in treatment failure. The whole body must be treated.
- ●Omitting the face and scalp in an elderly patient: This is a specific and commonly missed point — the standard "neck down" rule does not apply to the elderly.
- ●Forgetting the 7-day repeat: A single application is insufficient. Candidates frequently omit this or mention it without explaining why it is essential.
- ●Not treating contacts: The most clinically consequential omission. Untreated contacts will reinfect the patient within weeks, creating a cycle of apparent treatment failure. All contacts, including asymptomatic ones, must be treated simultaneously.
- ●Not warning about post-treatment itch: A patient who is not warned about persistent pruritus after treatment will assume it has failed, will re-present, and may be inappropriately retreated.
- ●Ignoring the institutional dimension: Failing to consider the wider sheltered housing complex when a second resident (Mavis) is also symptomatic misses an important public health responsibility.
Mapped to the RCGP curriculum topic: Infectious Disease and Travel Health.
← Back to Free SCA Practice Cases