Effective communication is a key skill in medicine, from simple explanations like why a blood test is necessary to more complex explanations for a new diagnosis. Although often done naturally in a consultation, providing clinical information can be its own primary focus. To communicate effectively in this situation, it is important to have a structured format.
Eczema is a common dermatological condition in both the paediatric and adult population. This guide will provide an overview of the steps for explaining the diagnosis and management of eczema to a patient in an OSCE setting.
Explaining a diagnosis needs structure and a good knowledge of the disease. For communicating information about a procedure, medication, or in this case, a disease, the BUCES structure can be used. This structure is shown below.
Wash hands and put on PPE if appropriate.
Introduce yourself to the patient, including your name and role.
When providing information to a patient, it is essential to start with a common point of reference. Establishing rapport with the patient and creating an open environment where they can express concerns and ask questions is essential to understanding and treating their problem. BUCES is a method for structuring this initial conversation:
For example, when a patient presents with eczema, itching of the skin may be their primary symptom. Other risk factors such as pre-existing atopy and family history of eczema may also be present.
Tip: Practicing the timing for taking a brief history is important for successful OSCEs. Aim to keep the introduction and history taking within 1-2 minutes.
Once a brief history is taken, it is pertinent to assess the patient's knowledge of their condition. Some may have a comprehensive understanding while others may only be familiar with basic information. As such, open questions allow you to begin this assessment. Examples include:
Focusing on listening to the patient and giving positive feedback where applicable will help you to determine the most appropriate level of explanation. Additionally, "chunking and checking" can be used throughout the consultation to make sure the patient fully understands.
Asking the patient about their concerns prior to beginning your explanation is important. This allows you to provide the most relevant information to the patient. The ICE format (ideas, concerns and expectations) is useful in structuring this conversation. Ideas include what the patient believes is causing their symptoms, as well as their understanding of the diagnosis. Concerns should be voiced by the patient and addressed accordingly. Finally, expectations cover what the patient hopes to achieve from the consultation.
After determining the patient's current level of understanding and concerns, you should be able to explain their condition clearly. Avoid medical jargon to prevent confusing the patient.
Firstly, provide the patient with an indication of what to expect by signposting your explanation.
Tip: Remember “NWCPM” when explaining a disease. This stands for “Normally We Can Probably Manage”.
The skin's role is to act as a barrier. Imagine it as layers of bricks stacked on top of each other. In healthy skin, the mortar between the bricks keeps out irritants and prevents moisture from evaporating, which helps keep the skin from becoming dry.
Eczema, or atopic dermatitis, is a chronic inflammatory skin condition that can affect people of all ages. It is a relapsing and remitting condition, typically presenting with red, itchy and dry skin on the body, face and/or scalp.
The parts of the body most commonly affected include the flexor surfaces of the elbows, backs of the knees, wrists and neck. In infants, it appears mostly on the face and extensor surfaces of the limbs. Adults with new presentations are often affected on the hands due to exposure to irritants. Those with chronic eczema typically experience it on the flexor surfaces.
The exact cause of eczema is unknown. It is more likely to occur in families with a history of eczema, hay fever and/or asthma. People with eczema may get allergic reactions to food, clothing, dyes, etc., but eczema itself is not an allergy. It is caused by a complex immune reaction in the skin.
Diagnosis is typically done by inspecting the affected skin for signs of the disease. No additional tests are usually needed and allergy tests do not help make the diagnosis.
Explain potential complications of eczema to the patient, so they can identify problems early and seek medical help. Being aware of common problems will also promote adherence to treatment.
Reassure the patient that potential complications are outlined to make them aware, rather than to frighten them. Highlight that working together to reduce potential risks will help achieve the best outcomes.
Common complications of eczema can include:
Serious complications may include:
Signs of an infected eczema are oozing, crusting, clusters of blisters, or a fever. If any of these symptoms occur, it is important to seek medical advice immediately and attend a hospital emergency department if necessary.
It is important to emphasise to the patient that successful management of eczema requires collaboration between patient and doctor. Patients should be encouraged to avoid any potential triggers, such as perfumed soaps, detergents, wool, and pets.
The aim of treating eczema is to achieve sufficient symptom control with minimal side effects. Treatment involves a stepwise approach, increasing in strength and effectiveness with each step. Emollients are the foundation of treatment, followed by topical steroids and immunomodulators, then phototherapy, and finally systemic treatments. Antihistamines are used to reduce itching when this causes sleep disruption.
Emollients should be applied regularly, up to 8 times a day, regardless of how well-controlled the eczema is. Regular use of emollients has been associated with fewer flares. When applying emollients, patients should be made aware to do so gently in the same direction of hair growth to reduce the risk of folliculitis.
Ointments:
Creams:
Lotions:
Topical steroids are used to manage eczema flares and not to prevent flare-ups. The strength of the steroid varies depending on the area of skin affected. Treatment should be discontinued after 48 hours when the skin has returned to normal. Overuse of topical steroids can cause the skin to become thin and weak.
Emollient use should continue when treating acute eczema flares with topical steroids. There should be a 30 minute gap between applying emollients and steroids.
Tacrolimus and pimecrolimus are topical calcineurin inhibitors used for cases of moderate to severe eczema that have not responded to other treatments, or to reduce the side-effects of long-term topical corticosteroid use. These medications suppress T-lymphocyte response, reduce the immune system's inflammatory response, and can be used as maintenance therapy.
When initially used, these medications can cause stinging, but this usually decreases with regular use. The long-term safety of topical calcineurin inhibitors is still unknown.
“Eczema can have a significant impact on people’s confidence and sleep, so it is important to get symptoms under control. The mainstay of management for eczema is emollient therapy. Emollients help to fill the cracks between the dry skin, preventing irritants from entering and moisture from escaping. This, in turn, helps to moisturise the skin and reduce flare-ups. There are various types of emollients such as creams, ointments, and gels, so we can choose the most effective option for you.”
Finding the right emollient to manage your eczema may require some trial and error. I can provide you with samples of the different types of emollients and if you would like, you can have a conversation with a specialist nurse about them today.
During a flare, we suggest using a topical steroid cream. Steroids reduce inflammation and the best way to do this for eczema is by rubbing it on the inflamed skin. We recommend continuing this for 48 hours after your skin improves to prevent it from flaring up again, but we do not advise using it after that. Steroids should not be used on the face as they can cause skin thinning and other serious side effects. You should always wash your hands after applying steroid creams.
Most people will be able to effectively control their eczema with the treatments discussed, but if these are unsuccessful, we have other options available which we can discuss if necessary.
Summarize the key points back to the patient.
"In summary, eczema is a very common skin condition which often improves with age. We have a range of treatment options to manage your eczema, and we usually start with emollient therapy and add in other treatments if needed. If your eczema gets worse quickly or if you suspect it to be infected, you should visit the doctor the same day. You will be meeting the specialist nurse today to talk about the emollients which are suitable for you and we can meet again in a few weeks to review your progress."
Ask the patient if they have any questions or concerns that have not been addressed.
Arrange follow-up to discuss their eczema further, acknowledging that you have discussed a lot of information and they are unlikely to remember everything.
"We have discussed what eczema is, and how it is treated. The specialist nurse can provide more detail on the different types of emollients available during their appointment. We expect that after following the treatment for a few weeks you will have noticed some improvement, but it is a good idea to see you again within 2-4 weeks."
Offer the patient some leaflets on eczema and its management, and direct them to reliable websites with additional information.
Thank the patient for their time, dispose of PPE appropriately and wash your hands.
