OSCE Management Cases- Skin, Eye and Ear Conditions

Acne
What is acne?
For reasons no one completely understands, follicles (often called pores) become blocked and sebum that normally drains to the
surface gets blocked and bacteria begin to grow.
There are two types of acne inflammatory and non inflammatory
Non Inflammatory
Whiteheads
When the trapped sebum and bacteria stay below the skin surface, a whitehead is formed. Whiteheads may show up as tiny white
spots, or they may be so small that they are invisible to the naked eye.
Blackheads
A blackhead occurs when the pore opens to the surface, and the sebum, which contains the skin pigment melanin, oxidizes and
turns a brown/black color. It is not dirt and can not be washed away. Blackheads can last for a long time because the contents very
slowly drain to the surface.
A blackhead or whitehead can release its contents to the surface and heal. Or, the follicle wall can rupture and inflammatory acne
can ensue. This rupture can be caused by random occurrence or by picking or touching the skin. This is why it is important to
leave acne prone skin relatively untouched
Inflammatory
Papule
A papule occurs when there is a break in the follicular wall. White blood cells rush in and the pore becomes inflamed.
Pustule
A pustule forms several days later when white blood cells make their way to the surface of the skin. This is what people usually
refer to as a "zit" or a "pimple".
Nodule
When a follicle breaks along the bottom, total collapse can occur, causing a large, inflamed bump that can be sore to the touch
Cyst
Sometimes a severe inflammatory reaction can result in very large pus filled lesions
Why has it got worse? Will I grow out of it?
Acne onset generally begins at puberty. It may subside after puberty (late teens) and it usually will. However, it may be persistent
until the 50s.
Things that make it worse can include:
- Medication: hormonal (OCP), topical/ oral steroids
- Hormones
- Increased sebum production or abnormality in the hair follicle
Does it matter what I eat?
There are several myths regarding acne.
Diet
Diet has not been scientifically proven to be linked with acne. However, if you do find that your acne is improving/ clearer on a
certain diet, then you should certainly maintain that diet.
Cleanliness
Facial blemishes are not caused by dirt. Far from preventing acne, frequent washing may actually irritate pores and cause them to
become clogged. The best way is to wash gently with bare hands and only wash twice a day

OSCE Management Cases- Skin, Eye and Ear Conditions

Stress
Stress may have an effect on hormones and theoretically can promote acne. But this is difficult to control
Do I need tablets? Is there any problem with taking tablets?
Over the counter
Name of medication
Benzoyl Peroxide

Salicylic Acid
Sulfur
Resorcinol

Commonly used brand names

Neutrogena On-the-Spot,
Clearasil,
Oxy-10
Fostex,
Clear by Design,
Persa-Gel
Stri-dex,
Clearasil Clearstick,
Oxy Night Watch
Clearasil Adult Care
Clearasil Adult Care

Specific Treatment
Severity
Mild Topicals

Over the Counter

Benzoyl Peroxide
Morning

Moderate
Antibiotic +
Topicals

Moderate
Hormonal Therapy +
Topicals

Prescription
Adepalene (Differin) Night
Erythromycin/ Clindamycin as
needed
Doxycycline (100mg daily)
Minocycline (50mg bd)
Trimethoprim (300mg bd)
Erythromycin (500mg bd)* can be
used in pregnancy
Cephalexin (500mg tds)
Cyproterone acetate Diane ED or 50100mg 10 days/month
Spiranolactone 100-200mg daily
Anti androgens progesterone
Contraception required

Severe
Isotretinoin

Others
Comedones
Extraction Fine-wire diathermy, Followed by Adapalene gel (topical retinoid)
Depressed Scars
Punch excision or Laser
Hypertrophic Scars
Intralesional steroid injection (triamcinolone)

Usage
3-6 months to have an effect.
Apply all over face even when
clear of acne.
Ongoing (for years)
6 month course.
Use up to 1-2 years. Then topicals
for maintenance.
Tetracyclines contra-indicated in
children 12yo or younger

Dermatologist only.
6-8 month course.
Blood test potential liver toxicity
+ increased lipids.
Dryness
Photosensitivity
Myalgias
Hair Shedding
Teratogenic
Mood changes

OSCE Management Cases- Skin, Eye and Ear Conditions

Otitis Media
What is otitis media?
It is an infection and inflammation of the middle ear. The inflammation often begins with infections that cause sore throats, colds
or other respiratory problems. These can be viral or bacterial infections.
There are signs and symptoms of fluid in the middle ear and middle ear inflammation.
Presence of fluid in the ear:
- Bulging of ear drum
- Limited or absent mobility of ear drum
- Discharge from the ear
Inflammation
- Reddening of the ear drum
- Pain in the ears
With acute otitis media, usually you start with the symptoms of a common cold (runny nose, cough, fever). The symptoms of
otitis media develop soon after that.
Pain in the ear usually resolves over a few days.
Why does my child get this?
1 in 10 children suffer from otitis medial annually. It is one of the most common reasons for children below the age of 4 with a
fever visit a GP.
Children are more likely to suffer from otitis media than adults:
- Children have more trouble fighting infections because their immune systems are still developing
- The Eustachian tube (a small passageway that connects the upper part of the throat to the middle ear) is shorter and
straighter
o This tube can become plugged when a child has a respiratory infection, and fluid cannot drain and begins to
collect in the normally air filled middle ear
- Adenoids in children are larger than adults
o Adenoids are composed of cells that help fight infections
o They are located in the back of the upper part of the throat near the Eustachian tubes
o Enlarged adenoids can interfere with eustachan tube
o Adenoids themselves can become infected and this may spread to the Eustachian tube
- Bacteria can reach the middle ear through the Eustachian tube and can produce infection causes swelling of the lining
of the middle ear, blocking the Eustachian tube, causing fluid to accumulate.
Will her hearing be damaged?
Otitis media can interfere with hearing. As fluid accumulates in the middle ear, the eardrum and middle ear bones are unable to
move as freely as they should. This is only temporary however, and will resolve when the infection resolves.
Chronic or untreated otitis media can cause permanent hearing damage.
Sometimes, the eardrum may perforate and the fluid may drain out of the ear canal. Perforation of the ear drum is not a
catastrophic event since the drum can repair itself wuickly and easily
Can this be prevented?
There are things that can be done to try reduce the occurrence.
It is known that children in group settings (daycare) as well as children with adults who smoke have far more ear infections.
Infants who nurse froma bottle when lying down also develop otitis media more frequently, and breastfed children has fewer
episodes.
There are also more cases of otitis media in autumn/ winter months.
Does she need to have her tonsils removed?
Tonsil removal is only indicated if the child is having recurrent and frequent middle ear infections. It is usually somewhat of a last
resort treatment option.
Are antibiotics necessary?

OSCE Management Cases- Skin, Eye and Ear Conditions

Most people with otitis media respond well to pain relief and increased fluid intake.
Antibiotics have been shown to have little effect on the course of acute otitis media, and they are not used in all circumstances.
- In children without fever and vomiting, antibiotics are not given unless the childs symptoms have not resolved within 2
days or unless the child is less than 2 years of age
- In children with fever and vomiting, antibiotics are generally given. Amoxycillin is the antibioitic of choice.
If there is an effusion, a longer course of antibiotics is needed.
Once the infection clears, fluid may remain in the middle ear for several months. Middle ear fluid that is not infected often
disappears after 3-6 weeks. If the fluid persists for more than 3 months and is associated with loss of hearing, tubes are
recommended myringotomy operation. The tube normally stays in for 6-12 months after which it falls out. The tube ventilates
the middle ear and helps keep the air pressure in the middle ear equal to the air pressure in the environment.
If the child has enlarged or infected adenoids, these can also be removed, however, not in children under 4 years of age.
Hearing should be restored once the fluid is removed.
Is she allergic to Amoxil?
Roxithromycin.

OSCE Management Cases- Skin, Eye and Ear Conditions

Eczema
What is eczema?
Eczema (also called atopic dermatitis) is a recurring, non infectious, inflammatory skin condition affecting one in three
Australians at some stage in their lives. The condition is most common in people with a family history of atopy (asthma and
hayfever).
The skin becomes red, dry, itchy and scaly and in severe cases may weep, bleed and crust over, causing discomfort. Sometimes
the skin may become infected, which in this case, requires further treatment.
Eczema affects all ages usually appears in early childhood and disappears around 6 years of age. Most children grow out of the
condition but a small percentage may experience severe eczema in adulthood.
What are the symptoms of eczema?
- Moderate to severely itching skin
- Recurring rash (red, dry, patchy or cracked skin)
o Infants/ toddlers rash appears on face, elbows or knees
o Older children/ adults rash more commonly on hands, neck, inner elbow, back of knees/ ankles
- Skin weeping watery fluid
- Rough, leathery thick skin
- Lesions may become secondarily infected by bacteria or viruses
What causes it?
The exact cause of eczema is unknown, but there are a variety of triggers.
Internal
- Family history of eczema, asthma or hayfever
- Particular food and alcohol
- Stress
External
- Irritants tobacco smoke, chemicals, weather (hot or humid/ cold or dry), airconditioning or overheating
- Allergens house dust mites, moulds, grasses, pollens, foods, pets, clothing
How long does it last?
Eczema symptoms tend to become less severe over time. However, sufferers may always suffer from dry, sensitive skin.
How do I control it?
Although eczema is not a life threatening disease, it can affect the sufferer and the familys quality of life. Night time itching can
cause sleepless nights for sufferers and their families. Flare ups may lead to work/school absence.
How do I avoid an outbreak?
Many things can be done to avoid an eczema outbreak.
Most importantly, the skin should be kept moist by using a daily moisturizer.
Other methods:
- Wearing 100% cotton or soft fabrics avoiding rough, scratchy fibres and tight clothing
- Using rubber gloves with cotton liners
- Lukewarm baths using non soap cleanser or hyopallergic bath oil
- Gently pat the area with soft towel
- Avoiding allergens/triggers
- Reducing daily stress
Is there a cure?
There is no cure, but there are methods for symptom control.
Treatment Options?
General rules:
- Avoid dryness

OSCE Management Cases- Skin, Eye and Ear Conditions

- Avoid overheating
- Avoid irritation
- Use wet dressings to sooth the skin, reduce itchiness and help heal leasions
Topical Corticosteroids
- Help reduce inflammation and itchiness.
- Ointments (greasy) instead of creams are preferred as they also moisturize the skin (however they may cause folliculitis
on hairy skin)
- Side effects skin atrophy, glaucoma, cataracts
Infected eczema
- Soak off the crusts with water or saline
- Antibiotic/ Antiviral treatment (oral)
Other
- Phototherapy
- Oral steroids/ Cyclosporin/ Azathioprine
- Stress management
- Dietician for diet assistance
- Allergy testing (prick/ blood tests) to establish trigger factors
- Probiotics may improve skin
Complications?
Eczema skin is often broken and it places the sufferer at risk of contracting skin infections.
An eczema sufferer is also at risk of developing Herpes Simplex Type 1 (Cold Sores) which can spread.

OSCE Management Cases- Skin, Eye and Ear Conditions

Nappy Rash
What is it?
Nappy rash commonly happens when a babys skin is exposed to wet or dirty nappies for too long. Urine is sterile (so there are no
germs in urine) but the germs on the babys skin and in the nappy can change chemicals in urine to other chemicals (including
ammonia, which can be very irritating to skin). Leaving a wet nappy on a baby for long periods of time can make the rash worse.
Some babies get nappy rash no matter how well they are cared for. Others dont get nappy rash, even when they are not changed
very often. Some babies have very sensitive skin and therefore are more prone to rashes. Some babies only get nappy rashes when
they have a cold or some other viral illness.
Most cases of nappy rash can be treated at home. If the rash looks severe, is hurting the baby or does not clear up within a few
days, it is good to see the doctor.
What are the signs?
- Inflamed skin: skin around the genital area and anus looks red and moist
- Blistering: the skin may blister and then peel, leaving raw patches (ulcers)
- Spreading: the rash can spread onto the tummy and buttocks
- Ulcers: small ulcers can sometimes form on healthy skin near the area of the rash
All of this damage to the skin is very sore and the baby can be very unsettled, especially when they pass urine that comes in
contact with the rash. Many babies with nappy rash dont sleep well, waking often due to pain.
What are the causes?
Common causes include:
- Sensitive skin
o Babies that have rashes on other parts of their bodies (such as cradle cap or eczema on the face or under the
chin) are more prone to nappy rash this tendency is often inherited
- A trigger factor or agent
o Ammonia chemicals in urine that may be changed to ammonia which burns the skin
o Thrush (candida) thrush exists in the faeces normally but the levels rise sometimes without obvious causes.
This can occur when a baby needs antibiotics for another infection. Thrush can make nappy rash much redder
and more painful
o Chemical exposure laundry detergents, fabric softners can irritate the skin of very sensitive babies. Some baby
wipes can also cause irritation. Use products that are hypoallergic
o Plastic pants may keep the babys clothes clean and dry but they prevent airflow. Babys skin is kept wet and
this predisposes to nappy rash
o Friction or rubbing rough nappies can rub and chafe at the babys sensitive skin
How do I prevent it/ treat it?
- Change the baby more frequently
- Use disposable nappies that absorb urine quickly and leave the nappy surface dry
- Only use soaps/ baby wipes with no alcohol in them
- Clean babys bottom with plain water at nappy changes
- Use a barrier cream zinc and cod liver oil to keep wetness away from babys skin
- Give pain relief if necessary
o Paracetamol

OSCE Management Cases- Skin, Eye and Ear Conditions

Umbilical Hernia
What is this lump?
Umbilical hernias are very common in children. It appears as a small lump near the naval. It usually cases no problems and goes
away as the child grows.
A hernia is the lump that appears when part of the body pushes through an opening of weak spot in the muscle wall.
This happens most around the tummy area.
An umbilical hernia happens when the muscles around the belly button have a gap between them, so part of the gut or other
tissues in the abdomen can poke through. Umbilical hernias are common in young children when the muscles are relatively weak,
but are less common and people age because the muscles become stronger, closing off the gap.
What problems can occur with this?
Umbilical hernias in babies rarely cause problems and are best left alone.
Parts of the bowel can push through some umbilical hernias, particularly when pressure in the tummy rises (such as when the
child cries or coughs). This can be pushed easily back into the tummy. Some hernias but rarely umbilical ones can cause
problems when part of the bowel gets caught in the hernia. This requires operation.
What treatment is required?
It is recommended that nothing is done and most will close by themselves.
As the child grows older, their tummy wall muscles get stronger and the gap will usually close and the bulge goes away. If it does
not close by itself, the gap can be closed by operation if the appearance causes distress to the child. This is a simple operation but
it is not recommended until the child is old enough to understand what is going on (around 6 years old).
If the umbilical hernia does cause problems (becomes painful and cannot gently be pushed back into the tummy) the child needs
to be urgently checked by the doctor.

OSCE Management Cases- Skin, Eye and Ear Conditions

Skin Cancer
What is it?
Basal Cell
Carcinoma

Keratoacanthom
a

Squamous Cell
Carcinoma

Malignant
Melanoma

Risk Factors: fair skin, sunlight exposure, >40years,

previous BCC, Arsenic, basal cell naevus syndrome.
Most common and least dangerous. Eventually invates
the dermis (slow growing) but does not metastasise.
Characteristics: Pearly nodule + Rolled edge +
Telangiectasia
Common sites: head and neck, trunk, limbs
Known clinically as rodent ulcer
Risk Factors: Males, >50yo, sun exposure, fair skin
There is a keratin plug with a rim once the plug is
excluded, it heals (but most people get the lesion
removed before this as it appears like SCC)
Clinical Features: Rapid evolution nodule over weeks.
Central keratotic plug, firm, fleshy. Skin coloured or red.
Risk Factors: Fair skin, sun, >60yo, Actinic Keratoses
(many of them)
High risk: Immunosuppression, arsenic, lower lip, scalp,
burn and radiation scars
Clinical signs: crusty, scaly tender nodule. Inflamed and
may bleed. Grows over weeks/ months. Poorly defined
Arises from keratinocytes. Can metastasise to lymph
nodes if left untreated.
Ddx: Keratoacanthoma
Solar Keratosis SCC in situ (Bowens Disease)
Invasive SCC Mets
Most deadly due to its ability to metastasise (anywhere).
Arises from melanocytes (that rest on the epidermal
basal layer. Contain melanosomes that produce melanin
transferred to keratinocytes where it lies above the
nucleus to shield from solar radiation).
Majority arise in normal skin, some from pre-existing
molves.
Melanoma does not necessarily occur at site of exposure.
ABCDE criteria change is most important feature.
Lesion NOT smooth, regular and well demarcated.
Subtypes
Radial growth (flat patch)
- Superficial spreading malignant melanoma
- Lentigo maligna melanoma
- Acral lentiginous malignant melanoma
Vertical growtn
- Nodular malignant melanoma
Dx biopsy (excisional, punch, curettage)
Staging Inx:
- Sentinel LN biopsy
- LN resection
- Imaging Xray, CT/ MRI (>4mm thickness)

How sure are you that this is a skin cancer?

On appearance, it appears that it could be a cancer.
Other supporting evidence:
- Leathery, sun damaged skin
- Nicotine stained fingers risk factor for cancer.
- Solar keratoses
- Similar lesions

Shave biopsy (not punch)

Excision (3mm margin)
Radiotherapy used in elderly
as it increases risk of radiation
induced carcinoma by 15x.
Cryotherapy (liquid nitrogen) +
Curettage for non critical sites
Self resolving

Total excision
Radiotherapy
Imiquimod

Surgical
0.5cm margin in situ
1cm - <2mm thick
2cm - >2mm thick
Adjuvant
Stage - none
Stage 3 Interferon
Stage 4 single agent
chemotherapy
Prognostic Factors
Breslow thickness
Clarkes level
Site (head, neck, trunk = poor)
Age
Amelanotic melanoma
Ulceration

OSCE Management Cases- Skin, Eye and Ear Conditions

- Enlarged lymphnodes
- On sun exposed areas
However, there is a need for confirmation. We can confirm what this is via a variety of methods which are all variants of a biopsy.
There is a scrape biopsy, punch biopsy and excision biopsy.
Scrape biopsy
Only scrapes the surface of the lesion. We may not obtain the cancerous cells in the sample and therefore it is not very accurate in
diagnosing.
Punch biopsy
Taking a sample of the lesion to examine it. This is accurate as it samples a considerable amount of the lesion. However, if it is
malignant, there is a need to go back and completely excise the lesion.
Excision biopsy
This removes the entire lesion for examination.
Pro The entire lesion is removed and if it is malignant there may not be a need for re-exicision (however this is dependant if the
margins are clear)
Cons Removal of lesion that is completely benign. Unnecessary scarring.
What caused it?
Anyone can develop skin cancer, but there are certain factors that increase the chances of it developing:
- UV radiation exposure, tanning and sunburn extensive sunlight exposure/ Solarium tanning
o Skin cells at the top layer of the skin (epidermis) produce a pigment called melanin that gives the skin its natural
colour. When the skin is exposed to UV radiation, more melanin is produced causing skin to darken (tan). A tan
is a sign that the skin is getting UV radiation damage.
o Tanning can contribute to DNA damage, premature skin ageing and skin cancer. Every time the skin is exposed
to the sun or solarium, the total lifetime dose of UV radiation is increased. Over time, this damage adds up, even
when no sunburn is experienced.
o All types of sunburn (whether serious or mild) can cause permanent and irreversible skin damage and can lay
the groundwork for skin cancer to develop.
- Hereditary Factors
o Increased incidence Caucasians
o Rare inherited condition xeroderma pigmentosum (have a defect in enzyme system that is responsible for
repair of UV damaged DNA). As a result they develop signs of skin damage at a very young age and develop
skin cancer before the age of 10.
- Skin type
o People with fair skin are at higher risk than people with naturally dark skin
o The melanin in naturally dark skin offers some protection against the damaging effects of UV radiation and the
risk of skin cancer is lower. However, when skin cancer is detected in people with naturally dark skin, it is often
found at a later, more dangerous stage
- Moles and Freckles
o The greater the number of moles/ freckles, the greater the risk of cancer
Is it really that serious?
It may be serious. Therefore it is best to investigate it and find out what it is. If it is serious and we catch it early, it may be
treatable. Even if it isnt serious, at least you will have peace of mind regarding it.