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Diagnosis Reveal

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Opening the consultation:

• [ ] Washes hand and dons PPE if appropriate
• [ ] Introduces themselves to the patient including name and role
• [ ] Confirms the patient’s name and date of birth
• [ ] Explains that they’d like to take a history from the patient
• [ ] Gains consent to proceed

Perceptions:

• [ ] Explores the patient’s prior knowledge/perception of eczema to allow tailoring of the explanation at the appropriate level
• [ ] Explores concerns and expectations the patient may have
• [ ] Encourages the patient to ask questions and contribute throughout the consultation

Invitation:

• [ ] Offers to provide more information about eczema
• [ ] Ask if the patient has any specific questions
• [ ] Checks what areas of information the patient would like to hear about and clarifies if there is anything the patient would not like to know
• [ ] Confirms the patient wants to hear the information now and if they want anyone else in the room

Knowledge:

• [ ] Explains the normal anatomy and physiology of the skin
• [ ] Explains what eczema is
• [ ] Explains what causes eczema
• [ ] Explains the aim of eczema management
• [ ] Delivers information in appropriately sized chunks
• [ ] Pauses at appropriate intervals to check understanding
• [ ] Avoids unnecessary jargon and explains medical concepts in patient-friendly terms
• [ ] Takes a considered approach to the quantity/depth of information conveyed based in the patient’s prior knowledge and preference
• [ ] Corrects any misunderstanding as they are encountered in a patient-friendly manner
• [ ] Provides additional resources that the patient can access later including websites, apps, support organisations and leaflets

Exploration and empathy:

• [ ] Explores how the patient feels about the information that has been given
• [ ] Demonstrates empathy throughout the consultation

Strategy and summary:

• [ ] Checks the patient’s understanding by asking them to briefly summarise the key points of the consultations
• [ ] Clarifies any misunderstandings if needed
• [ ] Checks the patient feels like their questions/needs have been addressed
• [ ] Demonstrated shared decision making by negotiating a mutually acceptable plan
• [ ] Discusses follow-up arrangements

Answers to the patient’s questions

1. What do you think is the cause of my rashes?

   Eczema possibly exacerbated by dog fur, stress or smoking.

2. What is eczema?

The skin normally acts as a barrier to stop irritants and bacteria from getting into the body. It also helps to keep fluid within the body. Eczema is an inflammatory condition of the skin. It typically presents with areas of red, itchy, dry skin. Common areas affected are the scalp, neck, wrists, elbow creases and the back of the knees. In eczema, the skin becomes inflamed over time and cracked which allows moisture to escape and causes dry skin. The exact cause is not known but it can run in families and is associated with other conditions like hayfever and asthma.

3. Since you say it’s due to stress, what can I do to help with my stress?

To help reduce stress, you can establish a routine for your work such as breaking tasks into manageable blocks to avoid feeling overwhelmed. Regular exercise, such as daily walks can improve mood, while mindfulness techniques like deep breathing or meditation could help you relax. Limiting smoking and alcohol can further reduce anxiety, and prioritising rest with a consistent sleep schedule will help you recharge. I can refer you to a smoking cessation clinic, if you think this would be helpful for you. Lastly, leaning on your social support network like your girlfriend and family, and enjoying activities together can also be beneficial for managing stress.

1. I can’t give up on my pet dog isn’t it? What can I do about this then?

   Vacuum often, avoid sleeping together with your dog and keep the dog out of the bedroom. Avoid letting the dog on the couch as much as possible.

2. Is there any advice you can give me to help make my eczema better?

   If you notice any particular trigger for your symptoms, you should try to avoid them. Examples of triggers are detergents, wool, pets, and soaps with perfume. You can use non-aggravating clothing materials e.g., 100% cotton, bamboo and silk. Wool and other synthetic materials can cause overheating, sweating and irritation. You can also use emollients soap substitutes when bathing and washing hands because normal soap is alkaline, and this can cause dry skin and irritation. Other than that, you can also keep your fingernails short to prevent injuring the skin.

3. Is there any medication for my eczema?

   The management tends to follow a step-wise approach which allows for medication to be increased or decreased depending on symptom severity. We typically start patients on emollients. These help maintain the skin barrier and can be wrapped on affected areas during severe flares with severe itch or pain known as wet wrap therapy. They can be ointments, creams or lotions.

   To help manage flare-ups, we can give topical steroids. The strength prescribed will depend on the severity of symptoms and the area of the body affected. They should be used until 48 hours after the skin has returned to normal, as long term can thin the skin. Emollients should be continued alongside topical steroids during flare-ups.

   If a patient has moderate to severe eczema that has not responded to topical steroid treatment, then we can give patients topical calcineurin inhibitors. They work by reducing the inflammatory response in the skin but would normally only be started by a dermatologist. They are also used to reduce the risk of side effects from long-term topical steroids.

   Systemic treatment like taking tablets may be required in severe cases but these would normally be managed by a dermatologist. Typically, medications like methotrexate, azathioprine, ciclosporin will be used and they work by suppressing the immune system. This treatment may also be used alongside phototherapy. If your condition reaches this severity, then the dermatologist will discuss these options further.

   Antihistamines like cetirizine can potentially be used to help with itching that interferes with sleep.

4. When and how to apply the emollients?

   You need to use emollients frequently by applying at least twice a day, every few hours during a flare or when skin is very dry. Apply gently in the direction of hair growth to all of the skin, not just areas with eczema. After every washing/bathing, dry the skin thoroughly with a soft towel before re-applying emollients. Continue to apply emollients even when eczema has improved.

8. Does that mean my illness is incurable?

I understand that dealing with eczema can be challenging, and it’s completely natural to want a permanent solution. While eczema itself isn’t fully curable, many people find ways to manage it effectively and keep symptoms under control with the right treatment and lifestyle adjustments. Our goal will be to help you find a plan that works best for you, so you can experience relief and improve your quality of life.

9. What are the signs of my eczema getting worse to the point I need to come and see you again?

You should come back to the GP if the rash is infected. Signs of infected rash include discharge, redness, crusted lesions, ulcerations, bleeding, fever and malaise.

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