Cases/Dermatology

Worsening Eczema He Has Stopped Treating — Free SCA Practice Case

Young man with worsening eczema he has stopped treating

Station Timer

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

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Callum Hughes

Age

19 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"My eczema's gone really bad again. I stopped using the creams a while back and now it's worse than ever. I don't really know what I'm supposed to be doing with it anymore."

Medical Records

●PMH: Atopic eczema since childhood. Mild asthma. Allergic rhinitis.
●Medications: Salbutamol inhaler PRN. (Previously issued: emollient, hydrocortisone 1% cream, a moderate-potency topical steroid — none requested in the last 8 months.)
●Allergies: NKDA.

Examination (Visual provided during consult)

●Photograph (uploaded before the call): Widespread dry, red, and excoriated eczema across the flexures of both arms and the backs of the hands, with some cracking and a few small areas of yelldish crusting. No extensive weeping or spreading cellulitis.

Uploaded photo of flexural and hand eczema — ASSET TO CREATE

Patient Script

For the friend playing the patient role

Character Overview: You are Callum, a 19-year-old in your first year at college doing an engineering course. You have had eczema all your life and are fed up with it. You stopped using your creams several months ago partly because you got sick of the routine and partly because you read online that steroid creams "thin your skin" and can be dangerous, which scared you off. You are a bit sheepish about having stopped, and defensive if you feel told off. You want your skin sorted but you are wary of the steroids.

Opening Sentence: "Hi Doctor. So my eczema's flared up really badly — my arms and hands are cracked and sore and it's keeping me up at night. I stopped the steroid cream months ago because I read they're not good for you long-term. But now it's a mess and I don't know what to do."

History if Asked (Data Gathering Phase)

●The flare: "It's the worst it's been in years. Both arms, backs of my hands, really dry and red and itchy. Some bits are cracked and a couple are a bit crusty. It's been building up over the last couple of months since I stopped everything."
●Why he stopped: "Honestly? I got fed up with the whole routine — creams morning and night, it's a faff. And then I saw stuff online about steroid creams thinning your skin and 'steroid withdrawal', and it freaked me out, so I just stopped the lot."
●What he's using now: "Nothing, really. Maybe a bit of whatever moisturiser's in the bathroom now and then. Nothing proper."
●Itch and sleep: "It's so itchy, especially at night. I scratch in my sleep and wake up and I've made it bleed. I'm knackered."
●Impact: "It's embarrassing at college — people notice my hands. And I've stopped going to the gym because I don't want people seeing my arms."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Callum believes topical steroids are inherently harmful — "thin your skin," cause "withdrawal" — and that avoiding them is the safer choice, even though his skin is now much worse. "I sort of assumed staying off the steroids was the healthier option, even if it looks bad. That's what all the posts said."
●Concerns: He is worried both that the steroids will damage his skin if he restarts them, and — separately — that his skin will "never be normal." He is also quietly embarrassed at having let it get this bad. "I'm caught between being scared of the steroids and being scared this is just how my skin is now."
●Expectations: He wants his skin calmed down and, really, wants a clear, honest answer about whether steroid creams are safe and how he's meant to use them. "I just want someone to tell me straight — are these creams okay to use or not, and how do I actually do this properly?"

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Childhood eczema: "Had it since I was tiny. Bad as a kid, got better in my teens, flares up now and then."
●Asthma and hay fever: "Mild asthma, use the blue inhaler occasionally. Hay fever in summer."
●Previous treatments: "I used to have an emollient and a couple of steroid creams — a weak one and a stronger one. Haven't ordered any for ages."
●Family history: "My mum's got eczema and asthma too."
●Allergies: "No medicine allergies."

Social History and Lifestyle Impact

Callum is a first-year engineering student living in college halls.

●Living situation: "I'm in halls, first year. Shared bathroom, which doesn't help with keeping up a whole cream routine."
●Triggers: "Stress makes it worse — it's flared with exams and moving away from home. And I've been having really hot showers because it's cold in halls."
●Impact: "Sleep's rubbish from the itching. I've pulled back from the gym and from going out. It's getting me down a bit."
●Smoking, alcohol: "Don't smoke. Bit of drinking at weekends like everyone."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about weeping, spreading redness, fever (infection screen): "There's a couple of little crusty yellow bits but it's not weeping loads, and I don't feel unwell or feverish."
●If asked about the crusting in detail: "Just a couple of small spots on my hand that have gone a bit golden-crusty. Not spreading fast or anything."
●If asked about pain vs itch: "Mostly itch. The cracked bits sting, especially with water."
●If asked about where it is: "Insides of my elbows, wrists, backs of my hands mostly. A bit on my neck."
●If asked about eye or joint symptoms: "No, nothing like that."
●If asked about new products, soaps, detergents: "New shower gel in halls, cheap stuff. Different washing powder too, now you mention it."

Responses to Management (The Negotiation Phase)

●If the Doctor recommends restarting a topical steroid: "But that's the thing I'm scared of. Won't it thin my skin? What about the withdrawal thing I read about?" (The tested point is addressing steroid phobia with accurate, reassuring information on safe use — potency, site, duration, fingertip units — rather than dismissing his fear.)
●If the Doctor emphasises emollients: "I know I should moisturise but it's such a faff, especially in shared halls. Do I really need to do it that much?"
●If the Doctor points out the possible early infection: "Is that crusty bit an infection? Do I need antibiotics?"
●If the Doctor asks about how he stopped treatment: "I know I should've kept it up. Are you annoyed with me?"
●If the Doctor discusses long-term control: "Is this just going to keep happening forever?"

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 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Atopic Eczema in Young Adults

●Atopic eczema is a chronic relapsing condition; childhood eczema commonly persists or relapses into adolescence and early adulthood.
●The atopic triad (eczema, asthma, allergic rhinitis) and a family history support the diagnosis.
●Transitions such as leaving home for college introduce new triggers (stress, different products, shared facilities) and often disrupt established self-care routines.

Topical Corticosteroid Phobia — A Central Barrier

●Fear of topical corticosteroids ("steroid phobia"), often amplified by online material about skin thinning and "topical steroid withdrawal," is a major and common cause of undertreatment and poor adherence.
●Correct message: used appropriately — right potency for the site, in defined courses, stepped down once controlled — topical steroids are safe and effective. Skin atrophy is associated with prolonged, inappropriate use of potent steroids on delicate sites (face, flexures, genitals), not with appropriate short courses on the limbs.
●Addressing the fear with accurate information — rather than dismissing it — is essential to restoring effective treatment.

Matching Potency to Site and Severity

●Use the lowest potency that will control the flare for each site: milder agents (e.g. hydrocortisone 1%) for the face and flexures; moderate-to-potent agents for thicker skin and more severe flares on the limbs and hands.
●Provide explicit instructions: frequency (usually once or twice daily), duration (treat the flare, then step down/stop), quantity using fingertip units (FTU), and where to apply.

Emollients — The Foundation

●Emollients are the cornerstone of eczema management and should be used liberally and continuously, including when the skin is clear, not only during flares.
●Use a soap substitute and avoid ordinary soaps/shower gels that strip the skin barrier. Aqueous cream should not be used as a leave-on emollient.
●Apply emollient and topical steroid at different times (allow the emollient to absorb) to avoid diluting the steroid.

Recognising and Managing Secondary Infection

●Bacterial (staphylococcal) infection presents with weeping, golden/honey-coloured crusting, increased redness, pain, and sometimes fever; treat with antibiotics (flucloxacillin first-line if systemic) only when genuinely infected.
●Eczema herpeticum (herpes simplex superinfection) is a dermatological emergency: rapidly spreading painful clustered vesicles/punched-out erosions, often with malaise — requires urgent assessment and antiviral treatment.

Trigger Identification and Avoidance

●Common triggers: stress, heat and hot showers, sweat, irritant soaps and detergents, and low humidity.
●Tailor advice to the individual's circumstances — here, lukewarm showers, a gentler soap substitute, and managing exam-related stress in a student living in shared halls.

Breaking the Itch–Scratch Cycle

●Nocturnal itch and scratching perpetuate the flare and disrupt sleep. Keep nails short, wear cotton layers, keep cool, and consider a sedating antihistamine at night to aid sleep (it does not treat the eczema itself but reduces night-time scratching).

Supporting Adherence and Self-Management

●Non-adherence is common and often driven by treatment burden and fear. Co-create a realistic, sustainable routine, explain the rationale, and frame ongoing emollient use as maintenance.
●Signpost reputable resources (e.g. National Eczema Society) for accurate information that counters online misinformation.

When to Refer

●Refer to dermatology for eczema not responding to optimised topical treatment, diagnostic uncertainty, severe or extensive disease, recurrent infections, or significant psychological impact — where second-line options (phototherapy, systemic agents, biologics such as dupilumab) may be considered.

Common Candidate Mistakes in This Case

●Not addressing the steroid phobia: prescribing a steroid without tackling the specific fear that made him stop, so he simply stops again.
●Under-treating the flare: offering only a mild steroid for a moderate-to-severe flare on the limbs and hands.
●Neglecting emollients or ignoring adherence barriers: handing over a routine that does not fit his life in halls.
●Missing or over-treating infection: ignoring the crusted areas, or reflexively prescribing antibiotics without assessing for genuine infection; and omitting eczema herpeticum from safety-netting.
●Blaming him for stopping: reacting with judgement, which entrenches guilt and disengagement in a young patient learning to manage a lifelong condition.

Free MRCGP SCA practice case for GP registrars covering Worsening Eczema He Has Stopped Treating — Dermatology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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