Cases/Dermatology

Young Man Whose Acne Is Affecting His Confidence — Free SCA Practice Case

Young man whose acne is affecting his confidence

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

Marcus Adeyemi

Age

17 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient has sent in a photograph ahead of the call.

Reason for Encounter

"My acne still isn't getting better even with the gel I was given. I've read about a tablet called Accutane and I want to try that instead — I'm sick of creams."

Medical Records

●PMH: Acne (ongoing ~1 year).
●Medications: Duac gel (benzoyl peroxide + clindamycin), once daily in the evening — issued 4 months ago.
●Allergies: NKDA.
●Recent notes: Seen 4 months ago — acne of 4–5 months' duration, inflammatory papules and pustules, no scarring; impression mild-to-moderate acne; Duac gel started with self-care advice; review in 3 months.

Examination (Visual provided during consult)

●Photograph (sent in before the call): Multiple inflammatory papules and pustules with some comedones across both cheeks and the forehead. No nodules, cysts, or established scarring visible. No truncal involvement shown.

Uploaded photo of facial acne — ASSET TO CREATE

Patient Script

For the friend playing the patient role

Character Overview: You are Marcus, a 17-year-old college student doing A-levels. You are polite but a bit deflated. Your acne has been going for about a year and it is really knocking your confidence — friends comment on it, and you find yourself keeping your head down. You have used the Duac gel as told for four months and seen little change, and you are fed up with creams. You have read about "Accutane" and have your heart set on getting it today. You are reluctant to consider more creams or tablets that are not Accutane.

Opening Sentence: "Hi Doctor. So I've been using that Duac gel for months like I was told, and honestly it's not really done anything. My face is still bad and it's really getting me down. I've looked it up and I want to try Accutane — I'm done with creams."

History if Asked (Data Gathering Phase)

●Duration and course: "It's been about a year now. It comes and goes but it's never really cleared. The gel maybe helped a tiny bit at first but it's stuck."
●Where: "Mostly my face — cheeks and forehead. Not really my chest or back."
●Scarring: "I don't think I've got scars as such. A few marks that hang around after a spot goes, but no proper pitting."
●The gel: "Duac, once at night. I've been good with it, used it every day for four months. Just hasn't worked."
●Why Accutane: "I've read it actually clears people up properly. I want the thing that works, not another cream I have to smear on every day for nothing."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Marcus believes creams simply do not work for him and that a tablet — specifically "Accutane" — is the only thing that will clear him properly. He assumes the GP can prescribe it today. "In my head, creams are a waste of time for me now, and Accutane is the real fix. I thought you could just start me on it."
●Concerns: His deeper worry is that the acne will not go away and that his confidence will keep sliding. He is affected by comments from peers, though he plays it down. "The thing that really gets me is that it might just... stay like this. And people say things. It chips away at you."
●Expectations: He is hoping to walk away with Accutane today and does not want to be offered "yet another cream." "Honestly I came in hoping you'd just prescribe the Accutane and that'd be that."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Acne history: "About a year. Started in the middle of last year, never fully went."
●Treatments tried: "Just the Duac gel from the doctor, and some face washes from the chemist before that."
●Other conditions / medications: "Nothing else. No other tablets."
●Family history: "My older brother had bad acne too — he grew out of it eventually."
●Allergies: "None."

Social History and Lifestyle Impact

Marcus is a 17-year-old A-level student living in college accommodation during term.

●Living and study: "I'm doing A-levels, staying in college digs during the week. Sharing with a few others."
●Impact: "My mates make comments — 'putting your cream on again?' — that kind of thing. I've started walking with my head down. I don't like photos."
●Mood: "My mood's generally okay, but it dips when people say stuff about my face. I still go to college, still do my work."
●Substances: "I don't drink, smoke, or take anything."

If Asked — Associated Symptoms and Safety Screen

The patient answers these only when directly asked.

●If asked about low mood or depression: "It gets me down at times, mostly when people comment, but I wouldn't say I'm depressed. I'm coping."
●If asked directly and sensitively about self-harm or suicidal thoughts: "No — nothing like that. I've never hurt myself or thought about it. It just knocks my confidence."
●If asked about truncal involvement (chest/back): "No, it's just my face."
●If asked about scarring or pigmentation: "A few dark marks after spots heal, but no proper scars or pitting that I can see."
●If asked about triggers (products, over-washing): "I wash my face a lot, maybe too much. I've tried loads of face washes."
●If asked about fever or joint pains (systemic): "No, nothing like that. I feel well in myself."
●If asked about bullying: "It's more comments than bullying. Annoying, not vicious."

Responses to Management (The Negotiation Phase)

●If the Doctor explains isotretinoin (Accutane) cannot be started in primary care: "So you can't just give it to me? Why not? That's what I came for." (The tested point is explaining, without dismissing him, that isotretinoin requires specialist initiation and monitoring and so needs a dermatology referral.)
●If the Doctor offers to refer to dermatology: "How long will that take? What do I do in the meantime — just put up with it?"
●If the Doctor suggests a next-step treatment (oral antibiotic plus a topical) while waiting: "Another antibiotic and another cream? Will that even do anything if the gel didn't?"
●If the Doctor explores his mood: "Why are you asking about how I'm feeling? It's just spots, isn't it?"
●If the Doctor offers talking-therapy support: "I'm not sure I need counselling for spots... do you really think that would help?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

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

Grading Acne Severity

●Mild: predominantly comedones, few inflammatory lesions. Moderate: more widespread inflammatory papules and pustules. Severe: nodules, cysts, extensive involvement, or scarring.
●Assess distribution (face, chest, back), lesion types, and — importantly — scarring and psychological impact, both of which raise the urgency of effective treatment.

The Stepped Treatment Ladder (NICE NG198)

●First-line: a 12-week course of a topical combination — e.g. adapalene + benzoyl peroxide, benzoyl peroxide + clindamycin (Duac), or a topical retinoid + topical antibiotic, or azelaic acid.
●Next step (moderate acne or topical failure): a topical preparation combined with an oral antibiotic (lymecycline or doxycycline) for up to ~3–6 months.
●Do not use oral or topical antibiotics as monotherapy, and avoid combining a topical and an oral antibiotic — always pair an antibiotic with benzoyl peroxide or a topical retinoid to reduce resistance.

Oral Antibiotics — Use Correctly

●Lymecycline 408 mg once daily or doxycycline 100 mg once daily are typical choices for moderate acne, for a defined course (review at ~3 months, maximum ~6 months).
●Tetracyclines are contraindicated in pregnancy and in children under 12; consider alternatives (e.g. a macrolide) where tetracyclines are unsuitable.
●Always co-prescribe a non-antibiotic topical (benzoyl peroxide or a retinoid) to limit antibiotic resistance.

Isotretinoin — Specialist Only

●Oral isotretinoin ("Accutane") is highly effective but is initiated and monitored only by dermatology specialists because of its side-effect profile and monitoring requirements (including teratogenicity and pregnancy-prevention requirements in those who can become pregnant, lipid and liver monitoring, and mental-health monitoring).
●The GP's role is to refer, not to prescribe — and to explain this as a route to the treatment, not a refusal.

When to Refer to Dermatology

●Refer for: acne of any severity causing or contributing to persistent psychological distress or a mental-health disorder (as in this case); moderate acne unresponsive to a full course of treatment including an oral antibiotic; severe/nodulocystic acne or scarring; or diagnostic uncertainty.
●The psychological criterion is easily missed but is explicitly part of NICE guidance.

The Psychological Impact of Acne

●Acne commonly affects self-esteem, mood, and social functioning, particularly in adolescents. This impact should be actively explored and addressed, not treated as secondary to the skin.
●Offer psychological support (e.g. NHS talking therapies / CBT) framed as help to cope and rebuild confidence.

Screening for Mood and Self-Harm

●In a distressed adolescent, screen sensitively for low mood, self-harm, and suicidal ideation. Establish current risk and safety-net clearly for deterioration.
●The association between acne, isotretinoin, and mood also makes baseline mental-health assessment important ahead of specialist treatment.

Self-Care Advice

●Advise against picking or squeezing lesions (worsens scarring and pigmentation) and against over-cleansing (irritates and dries the skin); a gentle, non-comedogenic routine is preferable.
●Set realistic expectations: treatments typically take 6–12 weeks to show benefit, and improvement is gradual.

Post-Inflammatory Pigmentation

●In skin of colour, acne frequently leaves post-inflammatory hyperpigmentation that is often more distressing to the patient than the active lesions; acknowledge it and explain that controlling the acne is the route to its gradual fading.

Common Candidate Mistakes in This Case

●Prescribing an oral antibiotic alone: the specific NICE error — always pair with a non-antibiotic topical.
●Refusing Accutane bluntly: rather than explaining it is specialist-initiated and offering a dermatology referral.
●Missing the psychological criterion for referral: not recognising that persistent psychological distress alone justifies dermatology referral.
●Failing to screen for mood and self-harm: a safety omission in a distressed adolescent.
●Trivialising the acne: dismissing it as "just spots" and losing the patient's trust and engagement.

Free MRCGP SCA practice case for GP registrars covering Young Man Whose Acne Is Affecting His Confidence — 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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