History Taking · Foundation · Dermatology

Itchy, Dry Skin with Redness

Practise this PLAB 2 history taking station on Contact Dermatitis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Rebecca Sharp, a 36-year-old woman, has come to see you because she has developed itchy, dry, red skin, particularly on her hands and forearms. The symptoms have been worsening over the past few weeks. She is struggling with the constant itching and finding it affecting her sleep and daily activities. Please take a focused history and discuss management options.

Background notes: PMH: no previous eczema

What this station tests

  • Occupational association: hand dermatitis improving on days off and worsening during shifts in a healthcare worker
  • Distinguishing irritant from allergic contact dermatitis: cumulative damage versus specific allergen hypersensitivity
  • Infection control implications: broken skin on a healthcare worker's hands is a risk for both patient and worker
  • Occupational health referral: workplace assessment, patch testing, glove alternatives, possible temporary redeployment
  • Emollient-based management: soap substitutes, frequent moisturising, barrier cream as foundation before corticosteroids

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

New-onset hand dermatitis in a healthcare worker requires the candidate to identify the occupational component (hand hygiene products, gloves), assess severity, and address the occupational health implications. Mrs Sharp is 36, a nursing assistant, with 6 to 7 weeks of itchy, dry, red skin on hands and forearms. Open with: 'Mrs Sharp, tell me about the rash and when it started in relation to your work.'

Core approach

Establish the occupational link. She is a healthcare worker who washes her hands frequently with hospital soap, uses alcohol gel multiple times daily, and wears latex or nitrile gloves for extended periods. The rash started 6 to 7 weeks ago and is worst on her hands (especially the backs and between fingers) and forearms. It is bilateral and symmetrical. It improves on days off and worsens during work shifts. This pattern, new onset on hands, occupational association, improving away from work, strongly suggests irritant or allergic contact dermatitis.

Distinguish irritant from allergic contact dermatitis. Irritant: cumulative damage from repeated exposure (soap, alcohol, water), gradual onset, worst on most exposed areas. Allergic: delayed hypersensitivity reaction to specific allergen (latex, preservatives in soap, fragrances), may have sharper borders matching contact area. Both can coexist. She may need patch testing to determine if there is a specific allergen.

Assess severity: broken skin (infection control risk in healthcare), sleep disruption from itching, impact on ability to work. Broken skin on a healthcare worker's hands is an infection control issue for both the patient and the healthcare worker.

Closing and safety netting

Management: emollients as the foundation (use frequently, including before and after handwashing). Soap substitute (emollient wash instead of soap where possible). Topical corticosteroid (moderate potency, e.g. betamethasone valerate 0.025% for hands) for the inflammatory component. Barrier cream before work. Glove choice: if latex allergy suspected, switch to nitrile.

Occupational health referral is essential. She needs workplace assessment, possible patch testing, and a management plan that allows her to continue working safely. If her skin is broken, she may need temporary redeployment until it heals (infection control requirement).

Reassure: 'With the right treatment and workplace adjustments, this can be managed and you can continue working.' Safety net: 'If the rash spreads, becomes weepy or infected, or does not improve with treatment within 2 weeks, come back.' Follow-up in 2 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for contact dermatitis. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Occupational association identified. Work patterns correlating with symptoms. Irritant vs allergic distinguished. Severity assessed (broken skin, sleep, work impact). Infection control risk noted.

Costs marks: Not identifying occupational link. Not assessing severity. Not noting infection control.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Emollients as foundation. Soap substitute. Appropriate topical steroid. Occupational health referral. Patch testing if allergic suspected. Infection control advice. Follow-up in 2 weeks.

Costs marks: Steroid without emollient. No occupational health. No infection control advice.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Reassuring she can continue working with management. Addressing work concern practically. Explaining the condition without blame. Supporting her through workplace adjustments.

Costs marks: Not addressing work impact. Making her feel her job is at risk. Not providing reassurance about treatability.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not identifying the occupational link. The temporal association with work (improving on days off) is the diagnostic clue. Candidates who diagnose 'eczema' without exploring the work relationship miss the cause.
  2. Not referring to occupational health. A healthcare worker with hand dermatitis needs workplace assessment and management. Candidates who prescribe cream without occupational health referral provide incomplete management.
  3. Not addressing the infection control issue. Broken skin on a healthcare worker's hands is an infection control risk. Candidates who do not mention this miss a patient safety dimension.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the contact dermatitis history in this PLAB 2 station?

New-onset hand dermatitis in a healthcare worker requires the candidate to identify the occupational component (hand hygiene products, gloves), assess severity, and address the occupational health implications. Mrs Sharp is 36, a nursing assistant, with 6 to 7 weeks of itchy, dry, red skin on hands and forearms. Open with: 'Mrs Sharp, tell me about the rash and when it started in relation to your work.'

What are examiners marking in this contact dermatitis station?

Marks are won for: Occupational association identified. Work patterns correlating with symptoms. Irritant vs allergic distinguished. Severity assessed (broken skin, sleep, work impact). Marks are lost for: Not identifying occupational link. Not assessing severity. Not noting infection control.

What is the most common mistake candidates make in this contact dermatitis station?

Not identifying the occupational link. The temporal association with work (improving on days off) is the diagnostic clue. Candidates who diagnose 'eczema' without exploring the work relationship miss the cause.

How do I prepare for this station if I have not managed contact dermatitis in clinical practice?

Structure beats experience here. Focus on distinguishing irritant from allergic contact dermatitis: cumulative damage versus specific allergen hypersensitivity. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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