Woman Whose Eczema Flares Every Winter and Who Wants to Avoid Steroids — Free SCA Practice Case

Character Overview: You are Siobhan Gallagher, a 30 year old primary school teacher with a Year 2 class of 28 children. You live with your partner Rhys, an electrician. You have had eczema since you were a baby, and since your early twenties it has settled on your face and hands, flaring every winter and clearing in summer. This flare began about three weeks ago. Your cheeks and chin are red, dry and itchy, and the backs of your hands are red and rough with cracks that bleed.

You buy hydrocortisone 1% cream from the chemist but use as little as you can, because you are frightened it will thin your skin. You dab a tiny amount on the worst patches every two or three days and stop as soon as the redness fades, so it comes straight back. Last week a pharmacist said it is not meant for the face and that you should see a GP, and now you worry you have damaged your face. Your fear comes from your nan, who took steroid tablets every day for years; by the end her skin was like tissue paper. You do not volunteer that story, the pharmacist's comment or your worry until the doctor asks what is worrying you or why you use so little cream. You are warm, chatty and articulate, a little embarrassed about using it on your face, and your voice tightens when you talk about the children noticing your skin. You are hoping for something that is not a steroid.

Opening Sentence: "Hi, thanks for calling. It's my eczema again. It flares up every winter on my face and hands, and this time it's really bad. I've been trying to manage with a cream from the chemist, but it's not working, and the pharmacist said I should speak to a doctor."

History if Asked (Data Gathering Phase)

• ●Face and hands: "My cheeks and chin are red and dry and flaky, and itchy. It stings when I wash my face or put make up on. My hands are rough and red, the skin over my knuckles has gone thick, and I've got cracks on my knuckles and down two fingers that split and bleed. I've had plasters on at school all week."
• ●Timing and itch: "About three weeks ago when the heating came on. My hands are the worst at night. A couple of nights a week the itching wakes me up."
• ●Pattern over the years (if asked): "Every winter until about April, and fine in summer. As a child it was in my elbow creases and behind my knees. It went quiet as a teenager and in my twenties it moved to my face and hands."
• ●The cream she uses (if asked): "The one percent hydrocortisone from the chemist. I dab a tiny bit on the worst bits, maybe every two or three days, and stop as soon as it looks less red. One small tube lasted nearly all of last winter. It calms for a few days, then it's straight back."
• ●Moisturiser (if asked): "A supermarket unperfumed body lotion on my face and hands in the morning. Nothing at school. There's no time, and I don't want greasy hands when I'm marking books."
• ●Washing (if asked about soap, baths or showers): "At school I wash my hands about twenty times a day with liquid soap, and there's hand gel everywhere. At home I use a foaming face wash and love a long hot bath."
• ●Anything new (if asked): "No. Same face wash, same foundation, same washing powder for years. I don't dye my hair. It does exactly the same thing every winter."

Ideas, Concerns, Expectations

Gating note: Siobhan 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, why she uses so little of the cream, or what she was hoping for.

• ●Ideas: She thinks the cold, the heating and the hand washing are to blame, and that it is "just my skin". She believes steroid creams are harmful and a last resort, so the less she uses the safer she is.
• ●Concerns: Her main worry is that steroids will thin the skin on her face for good. If the doctor asks why: "My nan was on steroid tablets for her chest for years. By the end her skin was like tissue paper. I don't want my face ending up like that. I'm only thirty." If the doctor explores further: "And the pharmacist told me that cream isn't meant for the face. I've been putting it on my cheeks for years. Have I already damaged my skin?" A third worry is school: "One of my little ones asked me if my face was catching. And it's parents' evening in three weeks, and I'm dreading shaking hands."
• ●Expectations: She hoped for something that is not a steroid, or a specialist. "My friend Leanne's little boy got a non steroid ointment for his face from the skin clinic. Could I have something like that?"

If Asked: Medical History and Medications

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

• ●Other health: "Just hay fever in summer, cetirizine from the chemist. No asthma. I get a cold sore on my lip about once a year, but not now."
• ●Medicines and pregnancy: "Just the implant, in about a year and a bit, and the chemist things. No plans for a baby for a few years. No allergies to any medicines."
• ●Family: "My dad gets eczema on his hands and has hay fever. My brother had asthma as a boy."
• ●Make up and food: "Foundation most days, the same one for years. It stings at the moment. No food makes it worse."

Social History and Lifestyle Impact

• ●Work: In school from quarter to eight until about five, with playground duty twice a week, writing on a whiteboard, marking and helping with glue and coats.
• ●Lifestyle impact: "Holding a whiteboard pen splits the cracks open. I bled on a child's reading book last week. I've stopped wearing my rings." On playground duty she wears a wool scarf but no gloves, because of the zips. At home she washes up by hand without gloves.
• ●Sleep and mood: "A couple of nights a week I wake scratching and I'm shattered at work. I'm fed up and a bit self conscious, but I'm not depressed."
• ●Lifestyle: Netball on Wednesdays, a glass or two of wine at weekends, never smoked.

If Asked: Associated Symptoms

• ●Negatives, grouped: no weeping, yellow crusts or pus ("it's dry and cracked"); no painful blisters, clustered sores or rapid spread; no fever; no cold sore now; nothing around her eyes; no spots or flushing; no greasy scale on her scalp, eyebrows or nose; nails fine and no scaly patches elsewhere; nobody at home is itchy; no thin skin or visible blood vessels.

Responses to Management (The Negotiation Phase)

• ●If the doctor recommends a steroid cream for her face, explains the difference from her nan's tablets, or reassures her about damage:
  • ●Reaction: Anxious. "But the pharmacist said hydrocortisone isn't for the face. Why is it alright if you prescribe it?" She accepts once told the leaflet is about buying it without advice, with a clear plan for how much and how long: "So it's about using it properly for a short time, not dabbing it on for months?" Told about the tablets: "I never thought of it like that." Told she has not damaged her face: "That's a weight off." If there is no offer to look: "How can you tell without seeing it properly?"
• ●If the doctor prescribes a stronger steroid for her hands, or suggests using it two days a week once they settle:
  • ●Reaction: Alarmed. "Stronger? Isn't that the opposite of what I want?" Once the reason is explained: "How long do I use it for? What do I do if it comes back once I've stopped?" On two days a week even when her hands look fine: "That feels like the opposite of what I've been doing." She accepts once told why.
• ●If the doctor advises moisturiser, a thick ointment, an emollient instead of soap, gloves or going without make up:
  • ●Reaction: "I wash my hands twenty times a day. I can't be greasing them up in front of the class." If offered practical options: "A pump on my desk would work." A greasy ointment: "I can't mark books with greasy hands." She is happy with ointment at night and a lighter cream by day. About washing with moisturiser: "Will that get my hands clean after toilet trips?" She accepts gloves and a break from foundation.
• ●If the doctor discusses a non steroid ointment, says there is no alternative to steroids, or refers her to a skin specialist:
  • ●Reaction: Interested. "What's the catch? Is it safe for a long time?" If told about stinging or sun protection: "I'd rather know before it happens." If told it is the next step should her face need steroid often: "So I try the weak one properly first?" If told there is no alternative: "So it's steroids or nothing?" Referred straight away: "Parents' evening is in three weeks. What do I do in the meantime?"
• ●If the doctor asks her to show her skin on camera, or offers a tablet for the itch:
  • ●Reaction: She declines politely. "I'm on my phone in the kitchen and the light's terrible. I'd rather come in so you can have a proper look." About a night time tablet: "Will it make me groggy? I'm up at six for school."
• ●If the doctor gives vague safety netting, asks her to say the plan back, or explains the long run:
  • ●Reaction: Vague safety netting: "Worse how? What would actually mean I need to be seen quickly?" Asked to say the plan back, she repeats it accurately if it was clear, and muddles which cream goes where if it was not. Told about the long run: "Will I always have this? Am I going to be dreading every winter?" She is reassured by an honest answer about control, not cure.