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11/13/24, 8\:17 PM Guide | Explaining eczema

Explaining eczema

Table of contents

Introduction

Being able to share information in a clear and concise way is an essential skill in all
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
e
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.

Structure

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.
Explanation structure

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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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
structure)\:
What has brought the patient in to see you today?
What are their symptoms?
Are there any risk factors that can be identi
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\:
“ W h a t d o y o u t h i n k i s c a u s i n g y o u r s y m p t o m s ?”
“ W h a t d o y o u k n o w a b o u t e c z e m a ?”
“ W h a t h a s b e e n e x p l a i n e d t o y o u a b o u t e c z e m a s o f a r ?”
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 con
throughout by repeatedly ‘chunking and checking’
.
Tip\: Try using phrases such as\:
“ J u s t t o c h e c k t h a t I a m e x p l a i n i n g e c z e m a c l e a r l y , c a n y o u r e p e a t b a c k t o m e w h a t y o u
u n d e r s t a n d s o f a r ?”
. This is far better than only saying “ W h a t d o y o u u n d e r s t a n d s o f a r ?” 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 speci
The “ICE” (ideas, concerns and expectations) format, can provide a useful structure for exploring this area further.

ICE

Ideas\:
What does the patient think is causing their symptoms?
What is their understanding of the diagnosis?
Concerns\:
What are the patient’s concerns regarding their symptoms and diagnosis?
Expectations\:
What is the patient hoping to get out of the consultation today?
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Explanation

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.

Normal anatomy/physiology

“ T h e n o r m a l f u n c t i o n o f t h e s k i n i s t o a c t a s a b a r r i e r . W e c a n i m a g i n e t h e s k i n t o b e l a y e r s o f b r i c k s s t a c k e d o n t o p o f e a c h
o t h e r . I n n o r m a l s k i n , t h e m o r t a r b e t w e e n t h e b r i c k s p r e v e n t s i r r i t a n t s f r o m ge t t i n g i n a n d p r e v e n t s w a t e r f r o m ge t t i n g o u t w h i c h
s t o p s t h e s k i n f r o m d r y i n g o u t .
"

What the disease is

Eczema (a.k.a atopic dermatitis) is a chronic in
relapsing and remitting condition that presents with areas of red, itchy, dry skin on the body, face and/or scalp.
The most frequently a
Infants are predominantly a
Adults with new presentations are often a
Children and adults with chronic eczema are typically a
" I n e c z e m a , t h e ' b r i c k s' b e c o m e d r y a n d c r a c k e d , a n d t h e m o r t a r b e t w e e n t h e b r i c k s c a n b e l o s t , c o m p r o m i s i n g t h e
w a t e r p r o o
e x p o s u r e t o i r r i t a n t s w h i c h c a u s e s i t t o b e c o m e r e d , i n
s k i n c r e a s e s , s u c h a s t h e f r o n t o f t h e e l b o w s a n d w r i s t s , b a c k s o f t h e k n e e s a n d a r o u n d t h e n e c k .
"

Cause of the disease

“ E c z e m a i s a c o n d i t i o n t h a t m o s t l y a
t y p i c a l l y s e e e c z e m a c o m e a n d g o i n w h a t w e c a l l
a f t e r w h i c h i t m a y s e t t l e d o w n .
”
“ W e d o n’ t k n o w e x a c t l y w h a t c a u s e s e c z e m a , b u t w e d o k n o w t h a t i t c a n r u n i n f a m i l i e s . F a m i l y m e m b e r s c a n h a v e e c z e m a , h a y
f e v e r o r a s t h m a o r a c o m b i n a t i o n o f t h e s e c o n d i t i o n s . P e o p l e w h o s u
t o f o o d , c l o t h i n g , d y e s e t c . b u t e c z e m a i s n o t a n a l l e r g y i t s e l f . I t i s c a u s e d b y a c o m p l e x i m m u n e r e a c t i o n i n t h e s k i n .
”
“ E c z e m a i s n o r m a l l y d i a g n o s e d b y i n s p e c t i n g t h e a
a d d i t i o n a l t e s t s f o r e c z e m a . I t i s n o t c a u s e d b y a n a l l e r gy , s o a l l e r g y t e s t s d o n o t h e l p u s m a k e t h e d i a gn o s i s .
”

Problems/complications

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
Thickening of the skin a
Serious complications\:
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.
“ O n e o f t h e s e r i o u s c o m p l i c a t i o n s o f e c z e m a i s a n i n f e c t i o n o f t h e s k i n . T h e s i gn s t o l o o k o u t f o r a r e i f y o u r s k i n s t a r t s t o o o z e ,
c r u s t , y o u s e e c l u s t e r s o f b l i s t e r s o r i f y o u h a v e a n y o f t h e s e s y m p t o m s w i t h a f e v e r . I f a t a n y p o i n t y o u f e e l l i k e y o u r e c z e m a i s
i n f e c t e d o r i s g e t t i n g w o r s e q u i c k l y y o u s h o u l d s e e y o u r d o c t o r t h e s a m e d a y a n d a t t e n d A & E i f t h a t i s n o t p o s s i b l e .
”
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Management

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 e
treatments in patients that do not respond to
ladder, so do the side e
immunomodulators, then phototherapy, and
this causes problems with sleeping.
Emollient therapy
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
growth (to help prevent folliculitis).
Ointments\:
para
oily/greasy, thick
can stain clothing
the most e
Creams\:
water-based
soak in and disappear
Lotions\:
water-based
replacement for soaps and shampoos
not used as an emollient alone
Topical corticosteroids
Topical steroids are typically used to manage eczema
di
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
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-e
suppressing T-lymphocyte response (i.e. reducing the immune system's in
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
“ E c z e m a c a n r e a l l y a
”
a n d i t c a n a l s o a
“ T h e m a i n s t a y o f m a n a g e m e n t f o r e c z e m a i s w h a t w e c a l l e m o l l i e n t t h e r a p y . E m o l l i e n t s w o r k b y
d r y b r i c k s , w h i c h s t o p s i r r i t a n t s g e t t i n g i n a n d p r e v e n t s w a t e r f r o m e s c a p i n g , w h i c h h e l p s t o m o i s t u r i s e t h e s k i n . T h i s c a n a l s o
r e d u c e t h e n u m b e r o f
s o w e c a n p i c k o n e s t h a t a r e m o s t e
b e g i n n i n g . I c a n g i v e y o u s o m e s a m p l e s o f t h e d i
t h e m t o d a y i f y o u w o u l d l i k e ?”
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“ D u r i n g a
b e s t w a y t o d o t h i s i n e c z e m a i s t o r u b i t d i r e c t l y o n t o t h e i n
h o u r s a f t e r y o u r s k i n i m p r o v e s , t o h e l p p r e v e n t i t
s h o u l d n o t b e u s e d o n t h e f a c e a s t h e y c a n c a u s e t h i n n i n g o f t h e s k i n a n d o t h e r s e r i o u s s i d e e
y o u r h a n d s a f t e r a p p l y i n g s t e r o i d c r e a m s .
”
“ I n m o s t p e o p l e , t h e t r e a t m e n t s w e h a v e d i s c u s s e d w i l l c o n t r o l y o u r e c z e m a e x t r e m e l y w e l l . H o w e v e r , w e d o h a v e o t h e r
o p t i o n s f o r t r e a t m e n t i f t h e s e a r e n o t s u c c e s s f u l a n d w e c a n d i s c u s s t h o s e i f i t b e c o m e s a p p r o p r i a t e .
”

Closing the consultation

Summarise the key points back to the patient.
“ I n s u m m a r y , e c z e m a i s a v e r y c o m m o n s k i n c o n d i t i o n w h i c h o f t e n ge t s b e t t e r w i t h a ge . W e h a v e l o t s o f t r e a t m e n t o p t i o n s
a v a i l a b l e t o m a n a g e y o u r e c z e m a , a n d w e u s u a l l y s t a r t w i t h e m o l l i e n t t h e r a p y a n d a d d i n o t h e r t h i n gs i f t h e y a r e n e e d e d . I f y o u r
e c z e m a g e t s w o r s e q u i c k l y o r y o u h a v e a n y c o n c e r n s a b o u t i t b e i n g i n f e c t e d , y o u s h o u l d s e e a d o c t o r t h e s a m e d a y . Y o u a r e
g o i n g t o m e e t t h e s p e c i a l i s t n u r s e t o d a y t o t a l k a b o u t t h e e m o l l i e n t s w h i c h w i l l s u i t y o u b e s t , a n d t h e n w e c a n m e e t a g a i n i n a
f e w w e e k s t o s e e h o w t h i n g s a r e g o i n g.”
Ask the patient if they have any questions or concerns that have not been addressed.
" I s t h e r e a n y t h i n g I h a v e e x p l a i n e d t h a t y o u’ d l i k e m e t o g o o v e r a ga i n ?"
" D o y o u h a v e a n y o t h e r q u e s t i o n s b e f o r e w e
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.
“ W e h a v e d i s c u s s e d w h a t e c z e m a i s , a n d h o w i t i s t r e a t e d . Y o u a r e g o i n g t o m e e t w i t h a s p e c i a l i s t n u r s e w h o c a n t a l k t o y o u i n
m o r e d e t a i l a b o u t t h e d i
y o u h a v e b e e n f o l l o w i n g t h i s t r e a t m e n t f o r a f e w w e e k s y o u w i l l h a v e n o t i c e d s o m e i m p r o v e m e n t , b u t i t w o u l d b e a g o o d i d e a
t o s e e y o u a g a i n i n 2-4 w e e k s .
”
O
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.

References

1. NICE. Eczema - atopic CKS. Available from\: [LINK].
2. NICE. Atopic eczema in under 12s. Available from\: [LINK].
Source\: geekymedics.com
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