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Table of Contents
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Being able to share information in a clear and concise way is an essential skill in all fields of medicine. This can range from simple explanations, such as why a blood test may be needed, to more complex situations, such as explaining a new diagnosis. Often, sharing information with a patient occurs naturally during a consultation. However, providing clinical information may also be the primary focus of an appointment, and in these situations, it is crucial to have a structured format to communicate effectively.
Eczema is a common dermatological condition seen in both the paediatric and adult population. This guide provides an overview of the steps involved in explaining the diagnosis and management of eczema to a patient in an OSCE setting.
Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better understanding of their problem. After introducing yourself, it is important to take a brief history (this is the first part of the BUCES structure):
- What has brought the patient in to see you today?
- What are their symptoms?
- Are there any risk factors that can be identified? (e.g. lifestyle/family history)
For example, a patient with eczema may present describing itchy areas of skin. They may have risk factors such as pre-existing atopy (e.g. asthma, hay fever) and a family history of eczema.
Tip: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction and brief history between 1-2 minutes maximum.
What does the patient understand?
Following a brief history, it is important to gauge the patient’s knowledge of their condition. Some patients may have a family member with eczema and therefore have a fairly good understanding of what the condition entails. Other patients may have heard of eczema but only have a vague understanding of the important details.
Due to these reasons, it is important to start with open questioning. Good examples include:
- “What do you think is causing your symptoms?”
- “What do you know about eczema?”
- “What has been explained to you about eczema so far?”
Open questioning should help you to determine what the patient currently understands, allowing you to tailor your explanation at an appropriate level.
At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks (i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal communication such as nodding).
Checking the patient’s understanding should not be solely confined to this point of the consultation but should be done throughout by repeatedly ‘chunking and checking’.
Tip: Try using phrases such as: “Just to check that I am explaining eczema clearly, can you repeat back to me what you understand so far?”. This is far better than only saying “What do you understand so far?” as the onus is placed upon the quality of your explanation rather than there being an issue with the patient’s ability to understand.
What are the patient’s concerns?
The patient’s concerns should never be overlooked. Asking the patient if they have any concerns before beginning your explanation allows you to specifically tailor what is most relevant to the patient, placing them at the centre of the explanation. The “ICE” (ideas, concerns and expectations) format, can provide a useful structure for exploring this area further.
- What does the patient think is causing their symptoms?
- What is their understanding of the diagnosis?
- What are the patient’s concerns regarding their symptoms and diagnosis?
- What is the patient hoping to get out of the consultation today?
After determining the patient’s current level of understanding and concerns, you should be able to explain their condition clearly. Avoid medical jargon so as not to confuse your patient.
You should begin by signposting what you are going to explain to give the patient an idea of what to expect.
Tip: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.
“The normal function of the skin is to act as a barrier. We can imagine the skin to be layers of bricks stacked on top of each other. In normal skin, the mortar between the bricks prevents irritants from getting in and prevents water from getting out which stops the skin from drying out.”
What the disease is
Eczema (a.k.a atopic dermatitis) is a chronic inflammatory condition of the skin that can affect people of all ages. It is a relapsing and remitting condition that presents with areas of red, itchy, dry skin on the body, face and/or scalp.
The most frequently affected areas are the flexor surfaces of the elbows and the backs of the knees, wrists and neck:
- Infants are predominantly affected on the face and extensor surfaces of limbs
- Adults with new presentations are often affected on the hands due to exposure to irritants
- Children and adults with chronic eczema are typically affected on the flexor surfaces
“In eczema, the ‘bricks’ become dry and cracked, and the mortar between the bricks can be lost, compromising the waterproofing. This means that the moisture from the skin can escape, causing it to become dry and itchy, and increasing the exposure to irritants which causes it to become red, inflamed and itchy. These patches of skin are most commonly located in skin creases, such as the front of the elbows and wrists, backs of the knees and around the neck.”
Cause of the disease
“Eczema is a condition that mostly affects children, who may grow out of it, however sometimes it can affect adults. We typically see eczema come and go in what we call flares, in which affected skin becomes more sore, dry, and red than usual, after which it may settle down.”
“We don’t know exactly what causes eczema, but we do know that it can run in families. Family members can have eczema, hay fever or asthma or a combination of these conditions. People who suffer from eczema are more likely to get allergic reactions to food, clothing, dyes etc. but eczema is not an allergy itself. It is caused by a complex immune reaction in the skin.”
“Eczema is normally diagnosed by inspecting the affected skin for signs of the disease. We don’t usually need to do any additional tests for eczema. It is not caused by an allergy, so allergy tests do not help us make the diagnosis.”
Outlining potential complications of eczema is necessary so that the patients can identify problems early and seek medical advice. Being aware of common problems will also encourage patients to adhere to their treatment.
It is important not to scare the patient, but to explain that you are outlining the potentials risks so that they are aware of them. When discussing potential complications explain that you and the patient will need to work together as a team to reduce the likelihood that they’ll occur.
Common complications of eczema can include:
- Sudden worsening of eczema symptoms known as flares
- Thickening of the skin affected by eczema due to repeated scratching of the area
- Infection of the skin due to loss of the protective barrier. These infections can be bacterial (e.g. Staphylococcus aureus) or viral (e.g. herpes simplex virus) and require urgent medical review to prevent them from worsening.
“One of the serious complications of eczema is an infection of the skin. The signs to look out for are if your skin starts to ooze, crust, you see clusters of blisters or if you have any of these symptoms with a fever. If at any point you feel like your eczema is infected or is getting worse quickly you should see your doctor the same day and attend A&E if that is not possible.”
Reinforce to the patient that they need to work with you as a team to achieve a good result.
Patients should be advised to avoid any exacerbating factors/triggers such as soaps with perfumes, detergents, wool, pets etc.
The management of eczema follows a stepwise approach, which allows room for increasing the strength and effectiveness of treatments in patients that do not respond to first-line treatments. As the effectiveness of treatments increases up the stepwise ladder, so do the side effects associated with them. Topical emollients are the first step, followed by topical steroids and immunomodulators, then phototherapy, and finally systemic treatments. Antihistamines are only used to reduce itching when this causes problems with sleeping.
Emollients should be used regularly regardless of how well-controlled eczema is (up to 8 times a day) and regular application has been shown to reduce the number of flares. Advise the patient to apply emollients gently to the skin in the direction of hair growth (to help prevent folliculitis).
- paraffin based
- oily/greasy, thick
- can stain clothing
- the most effective emollient if used properly
- soak in and disappear
- replacement for soaps and shampoos
- not used as an emollient alone
Topical steroids are typically used to manage eczema flares and not to prevent flare-ups. The strength of the steroid used differs depending on the body site. Topical steroids should be continued for 48 hours after the skin has returned to normal and then stopped. Long-term use of topical steroids can cause the skin to become thin and weakened.
Emollients should continue to be used alongside treating acute eczema flares with topical steroids. Allow 30 minutes after applying emollients before using topical steroids.
Topical calcineurin inhibitors
Tacrolimus and pimecrolimus are topical calcineurin inhibitors which are only used in cases of moderate to severe eczema that has not responded to other treatments or to minimise the side-effects of long-term topical corticosteroids. They work by suppressing T-lymphocyte response (i.e. reducing the immune system’s inflammatory response) and can be used as maintenance therapy. Topical calcineurin inhibitors are typically initiated by a dermatologist.
This type of treatment can sting on application but this typically stops with regular use. The long-term safety of topical calcineurin inhibitors remains unknown.
Example of how you might explain the management of eczema
“Eczema can really affect people’s confidence, particularly when it is visible, and it can also affect sleep if it becomes severe, so we know that it’s important to get the symptoms under control.”
“The mainstay of management for eczema is what we call emollient therapy. Emollients work by filling the cracks between the dry bricks, which stops irritants getting in and prevents water from escaping, which helps to moisturise the skin. This can also reduce the number of flare-ups of eczema. There are lots of different types of emollients such as creams, ointments, and gels, so we can pick ones that are most effective and work best for you. This can sometimes be a case of trial and error at the beginning. I can give you some samples of the different types of emollients, and ask a specialist nurse to speak to you about them today if you would like?”
“During a flare, we suggest that you use a topical steroid cream. Steroids work by reducing inflammation, and we know that the best way to do this in eczema is to rub it directly onto the inflamed skin. We recommend that you continue to use this for 48 hours after your skin improves, to help prevent it flaring up again, but we don’t suggest continuing to use it after that. Steroids should not be used on the face as they can cause thinning of the skin and other serious side effects. You should always wash your hands after applying steroid creams.”
“In most people, the treatments we have discussed will control your eczema extremely well. However, we do have other options for treatment if these are not successful and we can discuss those if it becomes appropriate.”
Closing the consultation
Summarise the key points back to the patient.
“In summary, eczema is a very common skin condition which often gets better with age. We have lots of treatment options available to manage your eczema, and we usually start with emollient therapy and add in other things if they are needed. If your eczema gets worse quickly or you have any concerns about it being infected, you should see a doctor the same day. You are going to meet the specialist nurse today to talk about the emollients which will suit you best, and then we can meet again in a few weeks to see how things are going.”
Ask the patient if they have any questions or concerns that have not been addressed.
“Is there anything I have explained that you’d like me to go over again?”
“Do you have any other questions before we finish?”
Arrange appropriate follow-up to discuss their eczema further. Acknowledge that you have discussed a large amount of information and it is unlikely that they will remember everything.
“We have discussed what eczema is, and how it is treated. You are going to meet with a specialist nurse who can talk to you in more detail about the different types of emollients available, as we don’t have time during this appointment. Hopefully, once you have been following this treatment for a few weeks you will have noticed some improvement, but it would be a good idea to see you again in 2-4 weeks.”
Offer the patient some leaflets on eczema and its management, and direct them to some reliable websites which they can use to gather more information (examples include patient.info and NHS Choices).
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
- NICE. Eczema – atopic CKS. Available from: [LINK].
- NICE. Atopic eczema in under 12s. Available from: [LINK].