Cases/Dermatology

Shingles in a Teacher Taking Methotrexate — Free SCA Practice Case

Teacher on methotrexate with a new shingles rash

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12:00

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

12:00

Golden Minute

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Materials for Candidate

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Patient Profile

Full Name

Farah Siddiqui

Age

44 years

Consultation Type

Video

Age

Situation

Video Consultation. Booked by the patient this morning.

Reason for Encounter

"Painful blistering rash on the right side of the chest for 4 days. Asking whether she can go back to work tomorrow."

Medical Records

●PMH: Rheumatoid arthritis for 6 years, under rheumatology. Copper coil.
●Medications: Methotrexate 15 mg weekly on Thursdays. Folic acid 5 mg weekly on Mondays.
●Allergies: NKDA.
●Social: Secondary school teacher. Non smoker.

Recent Notes

●Rheumatology letter, 4 months ago: Flare treated with intramuscular methylprednisolone, now in remission.
●Monitoring bloods, 3 weeks ago: Normal, including lymphocytes 1.7 x10⁹/L.

Patient Script

For the friend playing the patient role

Character Overview: You are Farah Siddiqui, a 44 year old head of geography at a large secondary school, where you have taught for 16 years. You live with your husband Imran and your sons, 15 and 12. You have had rheumatoid arthritis for six years and take methotrexate every Thursday evening, with folic acid on Mondays.

Today is Tuesday. Last Thursday you had a burning, tingling pain under your right breast and round your right side. On Saturday morning you found blisters there, and more have come since. You have been at home since Friday evening and phoned in sick on Monday and today. You want to go back tomorrow because on Friday you are leading the Year 7 geography field trip you organised. You hope for something stronger for the pain and a note saying you are fine to go back.

You are organised, capable and used to coping. You sound tired and sore and talk briskly because you want this sorted. Your voice tightens when your absence record comes up, and goes quiet if the doctor raises the risk to Theo, a boy in your tutor group having treatment for leukaemia.

Opening Sentence: "I've got this really painful rash on my right side, round under my bra. It's been blistering since Saturday and the pain's keeping me up at night. I rang in sick yesterday and today, but I really need to be back at school tomorrow."

History if Asked (Data Gathering Phase)

●Where the rash is and what it looks like: "Only the right side. A strip about a hand's width, from just under my breast round the side and onto my back under my shoulder blade. It stops in the middle at the front, and there's nothing on my left. Clusters of blisters on red skin, some popped and weepy, and the ones at the front going crusty. A few new little ones came up yesterday, all in the same strip."
●How it began: "The pain came first, on Thursday at school, before there was anything to see. A burning, tingly feeling. I took my methotrexate that night as normal. On Saturday morning there were tiny blisters, and by Sunday it had spread round to my back. On Friday and Saturday I felt shivery and achy, like flu coming. Today I'm tired and sore but not ill as such. I've never had it before."
●The pain now: "A constant burning, like a bad scald, with sharp stabs that take my breath away. About seven out of ten. I can't bear my bra touching it, and I wake two or three times a night."
●What she has taken and used: "Two paracetamol four times a day since Saturday, which takes the edge off for an hour. No ibuprofen, because the nurse says to check before I take anything new with my methotrexate. I stuck plasters over the weepy ones, and pulling them off was agony."

Ideas, Concerns, Expectations

Gating note: Farah does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for. The second worry comes out only if the doctor explores further.

●Ideas: She thinks it might be a reaction to a new washing powder, or something to do with her methotrexate. Imran thought she had pulled a muscle. "If it's my tablets that have let this in, I've wondered about just coming off them."
●Concerns: First the trip. "If I'm not there on Friday, I think the head will cancel it. Sixty kids." Then, voice tightening: "I was off three weeks about seven months ago with my joints. I had an absence review about five months ago. And I've applied for assistant head, the interview's in two weeks. I can't be the teacher who's always off."
●Expectations: Something stronger for the pain, and a note saying she is fine to go back. "When I rang in on Monday, the head said if I could get something from the doctor saying I'm not catching, she'd be happy for me to come back and do the trip."

If Asked: Medical History and Medications

Gating note: Farah answers each of these plainly when the doctor asks about it.

●Rheumatoid arthritis and methotrexate: "Six years, mainly hands and wrists, really good lately. About seven months ago the hospital gave me a steroid injection for a flare, and no steroid tablets in the last year. Six tablets every Thursday evening. My last lot was last Thursday, the night the pain started, and the next are due this Thursday. Folic acid on Mondays. Blood tests every three months, the last three weeks ago, fine. I have the rheumatology advice line number."
●Everything else: "No other medicines, no allergies, no kidney problems. I had chickenpox when I was about seven. Flu jab every year. I've got the copper coil, so there's no chance I'm pregnant."

Social History and Lifestyle Impact

●Work and the trip: Farah is a form tutor to a Year 7 group of 30. "It's the Year 7 trip to a river and then the seaside, sixty kids on a coach, about an hour each way. I organised it and the risk assessment's in my name. The other geography teacher is in her first year."
●Theo (only if asked about anyone vulnerable at school, a weak immune system, or who is on the trip): "There's a boy in my tutor group, Theo, he's eleven. He's having chemotherapy tablets for leukaemia and he's doing really well. He's coming on the trip, and his mum asked me to keep a special eye on him. I see him every morning in registration and teach him twice a week."
●Contacts since the rash (if asked): "Just Imran and the boys, and my mum came round on Sunday. We've all had chickenpox. I've not been in school since Friday afternoon."
●Lifestyle impact: "I'm exhausted and can't wear a proper bra. The boys have had to sort their own dinners." No alcohol, never smoked. Her family is supportive.

If Asked: Associated Symptoms

Gating note: Farah gives these only when the doctor asks about them directly.

●Negatives, grouped: no blisters anywhere else; no fever now; no cough or breathlessness, "it hurts to take a deep breath but only in the skin"; no chest pain beyond the skin pain; no headache, stiff neck, light hurting her eyes, confusion or drowsiness; nothing near her eyes, face or mouth; no tummy pain, vomiting or diarrhoea; no weakness or numbness, just tingling; no spreading redness, pus or smell; no sore throat, mouth ulcers or bruising; joints fine.

Responses to Management (The Negotiation Phase)

●
If the doctor explains the diagnosis, the cause or the antiviral:
- ●Reaction: Surprised. "Shingles? I'm only 44. Is that from the methotrexate?" Told it is the chickenpox virus waking up: "So can my class catch this off me?" If told it is too late for tablets: "Oh. So there's nothing that'll stop it?" If antiviral tablets are prescribed: "What do they actually do at this stage? Five times a day? I'd never manage that in school."
●
If the doctor discusses returning to school, the trip, Theo or the note:
- ●Reaction: Frustrated if told not to return tomorrow. "It's all under my top. Can't I just wear something loose over it?" If told she could return covered but must keep away from Theo: "Someone would have to take my form and swap those lessons. I suppose that's doable, if the head will sort it." On Theo, quiet and worried: "Oh no. I had him in registration and for geography on Friday. Have I already put him at risk?" She settles if told when she started to be catching and what to do now. If told not to lead the trip: "Then it'll probably be cancelled. Could I go if I just kept my distance from Theo?" If no: "Okay. I'd never forgive myself. What do I tell the head? She wanted a note saying I'm not catching." If told no such note can be given: "What can you give me? I don't want it to look like I'm skiving again." Then: "How will I know when it's safe?"
●
If the doctor advises about Thursday's methotrexate:
- ●Reaction: If told to skip this Thursday: relieved, then testing. "I was half thinking of stopping it altogether. Wouldn't that be safer?" If told why not: "I couldn't go through another flare like that one. So when do I start it again?" If told to carry on as normal without explanation: "Are you sure? I thought it was the methotrexate that let this in." She accepts if it is explained or checked with her rheumatology team.
●
If the doctor suggests pain relief:
- ●Reaction: Amitriptyline: "Isn't that an antidepressant? I'm not depressed." Once explained: "Will it make me groggy in the mornings?" Codeine: "Will it make me drowsy? I'm the one who drives everyone about." Ibuprofen: "Is that alright with my methotrexate? The nurse always says to check."
●
If the doctor asks to see the rash on camera, or arranges to see her, refers her to hospital or asks for a blood test:
- ●Reaction: Declines politely to show the rash. "It's right under my bra and I'm at the kitchen table. Could I come in instead?" Relieved when it is arranged: "Should I sit in the waiting room? It's always full of mums with tiny babies." About hospital: "Is it that serious? I'm not that ill." She accepts if the reason is explained.
●
If the doctor gives safety netting or advice on looking after the rash:
- ●Reaction: If vague ("come back if it gets worse"): "Worse how? It's already pretty bad. What would actually mean I need to ring someone straight away?" Told no plasters: "That's a relief, honestly." Once a plan is agreed: "Will the pain go when the rash goes? And can I get this again?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Farah wants to go back to school tomorrow and lead a trip, and asks for a note. The skill is to treat shingles in an immunosuppressed woman actively on day four, make an explicit decision about methotrexate, and protect a child having chemotherapy without a flat refusal that ignores her pressures.
●Model answer: diagnose shingles, start an oral antiviral today, arrange an in person check today or tomorrow, pause Thursday's methotrexate until blisters crust (checked with rheumatology), give nerve pain treatment without oral steroids, advise staying off until every blister has crusted and not leading the trip, tell the school so Theo can be protected, and give specific safety netting.
●Also acceptable: remote management with a call back within 48 hours; same day advice from the on call or rheumatology team or a hospital referral; continuing methotrexate with clear hold triggers; a covered return with no contact with Theo and the school told.

Shingles, Diagnosis and Where to Treat

●Shingles is reactivation of varicella zoster virus in a sensory nerve. NICE Clinical Knowledge Summaries (CKS) list immunosuppression and rheumatoid arthritis as risk factors. Pain precedes the rash by 2 to 3 days, blisters form within 1 to 2 days, new ones can appear for 3 to 4 days, and healing takes 2 to 4 weeks.
●Diagnosis is clinical. Farah declines to show the rash, which is reasonable, but confirming a single dermatome and no satellite lesions needs an in person look. Start treatment first and do not delay it.
●CKS advise admission or immediate advice for meningitis or encephalitis, eye involvement, several dermatomes, scattered satellite blisters, mucosal involvement, severe immunosuppression, or any visceral or nervous system sign. Dissemination carries a case fatality of 5 to 15%, mostly pneumonia.
●UKHSA (Green Book chapter 28a) defines severe immunosuppression as, for example, methotrexate above 20 mg a week, with leflunomide, prednisolone 20 mg or more daily for over 10 days, biologics or lymphocytes below 1.0 x10⁹/L. Farah takes 15 mg, has no steroid tablets and normal lymphocytes, so she is immunosuppressed but not severely. CKS support home oral treatment with close follow up in that situation. A German consensus favours intravenous aciclovir for all immunosuppressed people, so same day specialist advice is also reasonable.

Antiviral After 72 Hours

●CKS advise an antiviral within 72 hours for immunocompromised people, and consider it up to a week after onset with continued blister formation, immunocompromise or severe pain. Farah has all three. Telling her it is too late is the central error.
●Doses for immunocompromised adults (BNF, CKS): aciclovir 800 mg five times daily for at least 7 days, valaciclovir 1 g three times daily for at least 7 days, or famciclovir 500 mg three times daily for 10 days, each continued until 2 days after all lesions have crusted. Valaciclovir and famciclovir may give less pain at one month and need fewer doses.
●Reduce doses in renal impairment. Aciclovir and valaciclovir can be nephrotoxic like methotrexate, so advise fluids. Farah's eGFR is above 90.
●CKS advise referral or specialist advice if new blisters are still forming after 7 days of treatment, healing is delayed, shingles recurs, or pain is uncontrolled.

Methotrexate During an Infection

●The BNF lists active infection as a contraindication to methotrexate. CKS on disease modifying drugs advise specialist advice because treatment may need pausing during intercurrent illness. The British Society for Rheumatology 2025 guideline advises stopping during severe infection needing intravenous treatment or admission and generally continuing through minor infections.
●Both plans are defensible. Model answer: skip this Thursday's dose while blisters are active, restart once crusted and well, and agree this with rheumatology before Thursday. Continuing, with clear advice to hold it and seek help if she becomes unwell or the rash spreads, also passes. The plan must be explicit.
●Folic acid can continue. Methotrexate should not stop for good, as it controls her arthritis. If a bacterial infection develops, avoid trimethoprim with methotrexate because of serious blood toxicity.

Managing the Pain

●Mild to moderate pain: paracetamol or an anti inflammatory, alone or with codeine. Moderate to severe pain: amitriptyline 10 to 25 mg at night, increased every 3 to 7 days to no more than 75 mg, or duloxetine, gabapentin or pregabalin. Amitriptyline's sedation helps night waking.
●The BNF warns that ibuprofen and naproxen can increase methotrexate toxicity. With acute illness and a possibly nephrotoxic antiviral, many would avoid them.
●Oral steroids are for immunocompetent adults with severe localised pain (CKS), not for Farah. Post herpetic neuralgia, pain beyond 90 days, is the commonest complication.

How Infectious She Is, and to Whom

●Nobody can catch shingles, but someone who has never had chickenpox or the vaccine can catch chickenpox from blister fluid. She is infectious from rash onset until every lesion has crusted, about 7 days. UKHSA notes immunosuppressed people may also spread virus through respiratory secretions, and contact with an immunosuppressed person with shingles on any body site counts as a possible significant exposure.
●Her 15 mg dose is below the severe threshold, but with a child having chemotherapy among her contacts the safe course is to treat her as possibly shedding more and leave any judgement about exposure to Theo's hospital team.
●She was not infectious before Saturday, so Friday at school exposed nobody. Her family have had chickenpox. Routine chickenpox vaccination for children began in January 2026, so her Year 7 pupils have not been vaccinated and some are not immune.

Work, School and the Trip

●UKHSA guidance for education says people with shingles should stay off only if the rash is weeping and cannot be covered, and may return once blisters have scabbed. Three things push Farah towards staying off until every blister has crusted: new blisters yesterday, possible greater shedding, and Theo. That is the model answer.
●Following the education guidance is also acceptable: she returns once well, fully covered with loose clothing or a non sticky dressing, with no face to face or same room contact with Theo until crusted, and the school told so it can cover her form and his lessons. Clearing her with nothing in place for Theo is the error.
●Employees can self certify for 7 days, then need a fit note, which can name the illness. Friday is day seven, she will probably not be crusted, and leading a coach trip means prolonged close contact with sixty children. The school should arrange cover now. No letter can say she is not infectious.
●If Theo is exposed, his family contact his hospital team the same day. Oral aciclovir or valaciclovir post exposure treatment starts from day 7 to 14 after exposure, with urgent antibody testing, and the news reaches the family through the school with Farah's agreement.

Recurrence and Vaccination

●Recurrence is uncommon but more likely with immunosuppression and needs specialist advice. The non live shingles vaccine is offered at 65 to 70, and to severely immunosuppressed adults from 18 (Green Book). At 44 on methotrexate 15 mg alone she is not eligible now, but would be if she crossed a threshold. Avoid live vaccines on methotrexate.

Common Mistakes in This Station

●Withholding the antiviral because more than 72 hours have passed.
●Managing her as routine shingles with no screen for spread, no in person check and no planned follow up.
●Clearing her to return with nothing in place for Theo, or to lead the trip with uncrusted blisters, because the rash is under her clothes.
●Writing the note the head asked for.
●Making no plan for Thursday's methotrexate, or agreeing she should stop it for good.
●Prescribing oral steroids, or an anti inflammatory without considering the methotrexate.
●Leaving adhesive plasters on the blisters.
●Telling her she may have put Theo at risk on Friday, before the rash appeared.
●Safety netting limited to "come back if it gets worse".

Mapped to the RCGP curriculum topic: Dermatology.

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