Station 31
Rose Ashburn
Age: 28 years old female
Full Case
Patient’s Data
Name: Rose Ashburn
Age: 28 years old female
Past medical history
- Asthma
- Eczema
Drug and Allergy history
- Oilatum cream
- Mometasone furoate 0.1% cream apply once daily (Acute prescription)
- Symbicort 100/6 Turbohaler – 1 puff as needed, may be increased up to 6 puffs as required (maximum 8 puffs per day)
Recent notes/ consultation
Letter from St Mary’s Dermatology Clinic 4 months ago
Rose Ashburn | 28 years old | Female
Dear GP,
Thank you for referring this 28-year-old lady with a background history of Eczema and Asthma to our clinic with a query of contact dermatitis or work-related eczema.
Ms. Ashburn works as a beautician and nail technician, with occasional exposure to products such as hair creams and nail polishes. She reports no history of immediate skin reactions to these substances and is currently not experiencing an active eczema flare.
A patch test was performed prior to today’s consultation and showed no positive reactions. Based on this, I have advised her that her eczema is unlikely to be occupational in origin.
She has been advised to keep a symptom diary to help identify and avoid potential triggers. No further dermatological input is required at this stage, and she has therefore been discharged from our clinic.
Yours sincerely,
Dr Blerina Frashëri, MBChB, FRCP
Consultant Dermatologist
Seen 2 weeks ago by Dr Nigel Durant (General Practitioner).
Presenting complaint: Patient presented with a recurrent flare of eczema affecting both upper limbs, particularly around the elbows and hands. She suspects psychological stress as a possible trigger, but stated her mood is currently fine and was not keen to discuss psychological factors, expressing confidence in managing that aspect herself.
Examination findings: Erythema and scaling noted around the elbows and dorsal aspect of both hands. All vitals stable
Impression: Eczema flare.
Plan: Prescribed mometasone furoate 0.1% cream to be used once daily and advised on liberal use of emollients. Safety netting and worsening advice given.
Patient booked routine telephone appointment to discuss concerns
Patient's Story (Role player’s brief)
Patient’s Story
You are Rose Ashburn, a 28-year-old woman. You have booked a telephone consultation to request a sick note because your eczema flare-ups are making it difficult for you to cope at work.
Opening Statement: “Hi doctor, I was hoping to speak with you about getting a sick note”
IF ASKED TO EXPLAIN FURTHER:
You work as a nail technician and beautician in a beauty salon. 3 months ago, while attending to a client, the customer refused your service and made a comment about the appearance of your hands and elbows, which left you feeling self-conscious and upset. Since then, you have felt more anxious about your flares, and the condition has started to affect you psychologically. You find yourself constantly worrying about when the next eczema flare might happen — it’s something that’s always on your mind and affecting your peace of mind.
You are currently experiencing a flare that is starting to settle, but you still feel unable to face work and would like some time off to recover. You’re not entirely sure what triggers your eczema flares, but you have noticed that they tend to occur more frequently when you’re feeling mentally stressed. It often seems that any time you’re under emotional pressure, a flare follows shortly after.
If asked about the frequency of your flares: You usually experience around one flare every two months.
You haven’t noticed any other specific triggers and don’t believe your work directly contributes to your eczema flares.
If asked about emollient use: You explain that you tend to use them regularly only during a flare, but once the symptoms settle, you stop using them.
Social History: Non-smoker, no alcohol or illicit drug use, you live with your boyfriend, who has also commented on your eczema. Your relationship has been affected, as you tend to withdraw and avoid intimacy or social interaction during flares
Idea: You are not sure what is likely causing your flare.
Concerns: You are worried about having visible flares at work, particularly as they affect your confidence and ability to perform your job.
Expectations: You would like the GP to issue a sick note so you can take time off work while your eczema settles.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask why she is requesting a sick note today
- Ask about her current eczema flare – whether the recent treatment has helped, and whether symptoms have improved or worsened since her last consultation
- Clarify whether she currently has any itching, cracking, weeping, or signs of infection such as fever or yellow crusting
- Ask about the pattern of her flares – how often they occur, how long they last, and if any particular triggers have been identified (e.g. work-related irritants, soaps, detergents, food, stress, pets)
- Ask how frequently she uses topical steroids, and how often she applies emollients
- Ask how she usually manages her skin when not in flare, including whether she uses emollients regularly as maintenance
- Ask about the emotional impact of her recent experience at work – specifically how the comment from the client made her feel
- Ask about her mood – whether she feels low, whether she still enjoys activities she used to like, and whether she has noticed any changes in sleep or appetite
- Ask if she has had any thoughts of self-harm or suicide
- Ask about her job role and how her eczema has affected her ability to work, particularly in relation to confidence, client interaction, or manual tasks
- Ask about her home and relationship situation, especially how the flares have impacted things with her boyfriend
- Ask about smoking, alcohol use, and any recreational drug use to complete her social history
- Make a diagnosis of recurrent eczema flare with significant psychological impact, potentially exacerbated by emotional stress or anxiety.
Example of explanation to patient
Thank you for taking the time to speak with me today, Rose. I can really see how much your eczema flares have been affecting both your work and your wellbeing.
From everything you’ve shared, I suspect that your recurrent flares may be linked to emotional stress, which we know can aggravate eczema. It also sounds like you may not always be using emollients regularly outside of flare-ups, and that can contribute as well. Understandably, all of this seems to be causing some anxiety, especially in social and work situations.”
The good news is that there are lots of things we can do to support you. First of all, you’ve asked for a sick note, and I’m happy to provide that today to help you take time off while your current flare settles.
But alongside the sick note, I’d also like us to look at ways to help prevent this from continuing. One option I’d suggest is a referral to talking therapy, which many people find helpful when stress or anxiety start to impact their health. In addition to that, there are practical techniques that can help manage stress, such as breathing exercises, and using apps like Headspace, which offer guided relaxation and mindfulness sessions you can do in your own time.
We also have the option of medication, such as antidepressants, but that’s something we would consider if the symptoms continue or become more difficult to manage, and only if you feel comfortable with it. What are your thoughts on exploring some of these options?
In terms of managing the eczema itself, it’s really important to keep the skin well hydrated, that means using emollients regularly, even when you’re not having a flare, to maintain your skin barrier and reduce future episodes. Using an emollient as a soap substitute is also recommended.
At work, if it’s possible, wearing long sleeves or gloves might help you feel more confident and protect your skin from further irritation. Ideally, these should be cotton-lined rubber or plastic gloves, which are gentler on the skin. Just make sure to remove them regularly, as sweating inside gloves can worsen eczema or cause irritation.
It could also help to keep a symptom diary — noting what’s going on around the time of your flares, including skincare, stress levels, diet, or exposure to irritants, so we can identify patterns and fine-tune your management plan.
You mentioned your partner made a comment that affected you. Sometimes people just don’t fully understand how challenging eczema can be. If you’re comfortable, we can give you a leaflet or information to share with him, it might help increase his awareness and support. If the condition is putting a strain on your relationship, couples counselling might also be helpful. There are services like Relate that specialise in that kind of support.
How does that all sound to you? I’d like to check in with you again in 3–4 weeks to see how you’re doing, both physically and emotionally. And of course, if things get worse, for example, if the skin becomes weeping, crusted, very painful, or if you develop a fever, do contact us straight away, as that could suggest an infection. Likewise, if your mood drops or you start feeling overwhelmed, we want to address that promptly too.
Management
Management
- Provide a sick note to allow time off work while her current eczema flare settles.
- Reinforce regular use of emollients, even when asymptomatic, to maintain skin hydration and reduce the risk of flares.
- Advise emollient use as a soap substitute to minimise irritation from conventional soaps and cleansers.
- Recommend wearing cotton-lined rubber or plastic gloves at work if appropriate, with frequent removal to avoid sweating, which can aggravate eczema.
- Suggest wearing long sleeves, if permitted, to protect affected areas and reduce self-consciousness.
- Encourage keeping a symptom diary to help identify potential triggers (e.g. stress, environmental exposures, products).
- Discuss psychological impact and offer a referral to talking therapy to support stress and anxiety management.
- Recommend trying self-help strategies such as breathing techniques and mindfulness apps (e.g. Headspace) for managing stress independently.
- Explain that medication (e.g. antidepressants) can be considered in the future if symptoms persist or worsen, based on her preference.
- Offer to provide leaflets or information for her partner to help improve understanding of eczema and its impact.
- Suggest relationship support services, such as Relate, if the condition is placing strain on her relationship.
- Book a follow-up appointment in 3–4 weeks to review her skin, emotional wellbeing, and overall progress.
- Safety-netting: Advise to seek medical attention if symptoms worsen, skin becomes weeping or infected, she develops a fever, or if her mood deteriorates.
Learning point from this station:
Emotional stress and anxiety are well-recognised triggers for eczema, and their impact on disease flares should not be overlooked. Recognising and addressing the psychological impact of eczema is essential for holistic management, particularly in young adults and those in public-facing roles.
Psychosocial effects of eczema may include:
- Disturbed sleep patterns
- Reduced self-esteem due to the visibility of the condition
- Social isolation, especially in activities that involve skin exposure (e.g. swimming or intimacy)
- In children: adverse effects on behaviour, development, and school performance
To assess the psychological burden, clinicians should ask about the impact of eczema on daily activities, work or school, relationships, mood, and sleep. If left unaddressed, this can create a vicious cycle where stress and anxiety exacerbate eczema, leading to more frequent and severe flares, which in turn worsen emotional wellbeing.
In patients with frequent flares, review should include:
- Checking treatment adherence (especially regular use of emollients even outside flares)
- Whether known triggers (e.g. soaps, allergens, stress, weather) are being identified and avoided
Management includes
- Advise on regular emollient use even when there is no active flare
- Consider changing emollients to those with higher lipid content
- Consideration of maintenance therapy to reduce flare frequency
Maintenance treatment options for chronic eczema (excluding face/genitals/axillae) include:
- Step-down therapy – using the lowest potency corticosteroid that effectively maintains control. This typically involves stepping down to a lower potency corticosteroid than the one used during a flare — for example, using a moderate-potency steroid for maintenance in patients who usually require a potent steroid during flares.
- Intermittent therapy – applying the usual corticosteroid: Twice weekly (e.g. every 3–4 days) or Weekend-only regimen (two consecutive days weekly- Saturday and Sunday)
These should be continued even when skin appears normal, as the goal is to prevent flare-ups.
- For eczema on sensitive areas (face, genitals, axillae), use a mild topical corticosteroid. If this is insufficient, consider referral to dermatology.
Always counsel patients on the potential side effects of topical corticosteroids, including; skin thinning, striae (stretch marks), burning/stinging sensation, mild depigmentation, excessive hair growth at the application site (hypertrichosis), systemic absorption in rare cases, particularly with prolonged or excessive use etc.
Topical calcineurin inhibitors (e.g. tacrolimus, pimecrolimus) may be considered as second-line agents, but should only be prescribed by dermatology specialists or GPs with a specialist interest.