History Taking · Intermediate · Dermatology

Severe Facial Acne in Young Woman

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Miss Eileen Lucas, a 19-year-old university student, has come to see you with severe facial acne that is causing significant distress. The acne has been present for several years and has not responded to conventional treatments. She is asking about isotretinoin (Accutane) as a treatment option. Please take a focused history and discuss the risks, benefits, and requirements of isotretinoin therapy.

Background notes: PMH: Good health, occasional migraines

What this station tests

  • NICE criteria for isotretinoin: severe acne, significant scarring, failed conventional treatment
  • Pregnancy prevention programme: two forms of contraception, monthly pregnancy tests, teratogenicity counselling
  • Balanced mood discussion: isotretinoin mood effects are controversial; severe acne itself causes depression
  • Validating the psychological impact of severe acne: this is not vanity, it has measurable morbidity
  • Dermatology referral for initiation: isotretinoin should not be started in primary care

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

Severe acne with scarring in a young woman who has failed conventional treatment warrants dermatology referral for isotretinoin consideration. The candidate must validate the severity, acknowledge the psychological impact, and discuss isotretinoin's specific risks. Miss Lucas is 19, university student, with severe facial acne causing significant distress. She has researched isotretinoin and wants it. Open with: 'Miss Lucas, I can see this has been really difficult for you. Tell me about the acne and how it is affecting your life.'

Core approach

Assess severity and treatment history. Acne for several years, worsening. Multiple failed treatments: topical retinoids, benzoyl peroxide, topical antibiotics, oral antibiotics (multiple courses). She still has nodular and cystic lesions with scarring. This treatment history meets NICE criteria for isotretinoin consideration (severe acne unresponsive to conventional treatment, significant scarring).

The psychological impact is central. She avoids social situations, has cancelled nights out, is struggling at university, and her self-esteem is severely affected. This is not vanity: severe acne has measurable psychological morbidity. Screen for depression sensitively: 'How has this been affecting your mood?'

Discuss isotretinoin honestly. She has researched it. Benefits: highly effective (85%+ clearance rates), often produces lasting remission after one course. Risks she will ask about: dryness (lips, skin, eyes, universal), mood changes (controversial, monitor closely), teratogenicity (absolute contraindication in pregnancy, requires pregnancy prevention programme), liver effects (monitored with blood tests), musculoskeletal effects.

Pregnancy prevention programme: she must use two forms of contraception. Monthly pregnancy tests. She cannot donate blood during or for 1 month after treatment.

Closing and safety netting

Refer to dermatology for isotretinoin. 'Based on the severity of your acne, the scarring, and the fact that you have already tried the standard treatments without success, I agree that isotretinoin is the right next step. I will refer you to dermatology.' The dermatologist will initiate and monitor treatment.

Address the mood concern specifically: 'There has been a lot of discussion about isotretinoin and mood. The evidence is not clear-cut. What is clear is that severe acne itself causes depression, and treating it often improves mood. The dermatologist will monitor your mood throughout.' Do not dismiss the concern but do not overstate the risk either.

Safety net: 'If your acne worsens significantly or your mood drops before the dermatology appointment, come back.' Interim: continue current treatment. Support: acne support resources.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for severe acne. 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: Severity assessed (nodular/cystic, scarring). Treatment history documented. NICE criteria met. Psychological impact explored. Mood screened. Contraception checked.

Costs marks: Not assessing severity. Missing treatment history. Not screening mood. Not checking contraception.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Dermatology referral for isotretinoin. NICE criteria articulated. Pregnancy prevention programme discussed. Mood monitoring planned. Interim treatment continued.

Costs marks: Not referring. Trying to prescribe in primary care. Not discussing pregnancy prevention. Refusing based on mood concerns alone.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Validating the severity and psychological impact. Taking her request seriously. Balanced isotretinoin discussion. Addressing mood concern without dismissing or overstating. Empowering her.

Costs marks: Dismissing as cosmetic. Being paternalistic. Overstating mood risk. Not taking her seriously.

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. Dismissing acne as a cosmetic problem. Severe acne with scarring in a young woman has profound psychological impact. Candidates who treat it as trivial lose the patient's trust and miss the clinical severity.
  2. Overstating the mood risk. The evidence linking isotretinoin to depression is inconsistent. Severe acne itself causes depression. Candidates who refuse to refer because of mood concerns deny an effective treatment based on uncertain evidence.
  3. Trying to prescribe isotretinoin in primary care. Isotretinoin requires specialist initiation and monitoring (pregnancy prevention programme, blood tests). Candidates who attempt to start it demonstrate scope confusion.

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 do I approach the consultation in this severe acne station?

Severe acne with scarring in a young woman who has failed conventional treatment warrants dermatology referral for isotretinoin consideration. The candidate must validate the severity, acknowledge the psychological impact, and discuss isotretinoin's specific risks. Miss Lucas is 19, university student, with severe facial acne causing significant distress.

What does a strong performance look like to the examiner in this station?

Strong performances show: Severity assessed (nodular/cystic, scarring). Treatment history documented. NICE criteria met. Psychological impact explored. Mood screened. Contraception checked. Weak performances: Not assessing severity. Missing treatment history. Not screening mood. Not checking contraception.

What is the biggest pitfall in this severe acne station?

Dismissing acne as a cosmetic problem. Severe acne with scarring in a young woman has profound psychological impact.

How should I prepare for severe acne if I have never seen it in practice?

Structure beats experience here. Focus on pregnancy prevention programme: two forms of contraception, monthly pregnancy tests, teratogenicity counselling. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

Related cases