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Dermatology
Image Interpretation
8 clinical cases with structured lesion descriptions, differentials, and management. Click the DermNet and NHS buttons to view real clinical photographs for each case.
8 cases
DermNet image links
NHS image links
Reveal answers
Year 2 / Finals
01
Dermatology
Inflammatory
Common
Chronic Plaque Psoriasis
45-year-old man · Bilateral elbow plaques · 10-year history
How to use this case: Read the clinical vignette and lesion description below, then click the image buttons to view real clinical photographs on DermNet and NHS. Work through the questions before revealing the answers.
Clinical vignette
A 45-year-old man presents to his GP with a 10-year history of a scaly rash on his elbows and knees. It is mildly itchy, worsens in winter, and improves in summer. His father had a similar condition. He has tried over-the-counter moisturisers with little benefit. He drinks 25 units of alcohol per week. Examination reveals bilateral symmetrical lesions on the extensor surfaces of both elbows and the knees, with some involvement of the scalp.
MorphologyPlaque
SurfaceSilvery-white scale
ColourWell-demarcated salmon-pink / erythematous
BorderSharp, well-defined
DistributionExtensor surfaces, symmetrical — elbows, knees, scalp, sacrum
Size2–8 cm plaques
Special signsAuspitz sign — pinpoint bleeding on scale removal
Koebner phenomenonNew lesions at sites of trauma
Clinical photographs — open in new tab
Images © DermNet / NHS — linked for educational use
Differentials to consider
1st Chronic plaque psoriasis
2nd Seborrhoeic dermatitis
3rd Lichen planus
4th Pityriasis rosea
5th Bowen's disease (if single plaque)
Interpretation questions — reveal when ready
Q1What three clinical features most strongly point to psoriasis over eczema?
Well-demarcated border (eczema is poorly defined), silvery-white scale on an erythematous base (eczema scales are yellow/golden if crusted), and extensor distribution (eczema is flexural in adults — antecubital and popliteal fossae). The Auspitz sign (pinpoint bleeding on scale removal) is pathognomonic.
Q2What is the Koebner phenomenon and which conditions demonstrate it?
New skin lesions developing at sites of skin trauma or injury in a patient with a pre-existing dermatosis. Seen in psoriasis, vitiligo, lichen planus, and warts. Clinically important — scratching or minor injury in a psoriasis patient will produce new plaques along the scratch line.
Q3What is the DLQI and why is it used in psoriasis?
The Dermatology Life Quality Index (DLQI) is a 10-item validated questionnaire measuring impact of skin disease on quality of life (0–30). In psoriasis, DLQI >10 indicates very large effect on life. It is used by NICE to gate access to biologic therapies — biologics require PASI ≥10 AND DLQI >10.
Q4Name the treatment ladder for psoriasis.
Step 1: Topical — emollients, topical corticosteroids, vitamin D analogues (calcipotriol), coal tar, dithranol. Step 2: Phototherapy — narrowband UVB (first-line), PUVA. Step 3: Systemic non-biologic — methotrexate, ciclosporin, acitretin. Step 4: Biologics — TNF-α inhibitors (adalimumab, etanercept), IL-17 inhibitors (secukinumab), IL-23 inhibitors (ustekinumab). This patient should also be counselled on alcohol reduction — alcohol is a major trigger and reduces treatment efficacy.
Exam tip — Psoriasis associations
Remember the associations: psoriatic arthritis (30% — nail pitting + DIP joint involvement), metabolic syndrome, cardiovascular disease, depression, and inflammatory bowel disease. A patient with psoriasis and new joint pain needs a rheumatology referral.
02
Dermatology
Inflammatory
Common
Atopic Eczema (Atopic Dermatitis)
8-month-old infant · Facial and flexural rash · Mother concerned
How to use: Read the vignette and lesion description, then open the image links to view real photos. Answer questions before revealing.
Clinical vignette
An 8-month-old infant is brought to the GP by her mother. She has had a red, itchy rash on her face and the insides of her elbows since she was 3 months old. She sleeps poorly due to scratching. Her mother has asthma. On examination, there are erythematous, weeping patches on the cheeks, with dry, scaly, lichenified plaques in the antecubital fossae bilaterally. No vesicles. No crusting to suggest superinfection. She is otherwise well and afebrile.
MorphologyPatch / plaque with excoriation
SurfaceDry, scaly; weeping in acute phase
ColourErythematous; may be hyperpigmented in darker skin
BorderPoorly defined, indistinct
DistributionFlexural (antecubital, popliteal); face in infants
LichenificationSkin thickening from chronic scratching
AssociatedAtopic triad: asthma, allergic rhinitis, eczema
Dennie-Morgan foldExtra infraorbital skin fold — atopic marker
Clinical photographs — open in new tab
Differentials to consider
1st Atopic eczema
2nd Seborrhoeic dermatitis
3rd Contact dermatitis
4th Scabies (if widespread, itchy)
5th Psoriasis (in older children)
Interpretation questions — reveal when ready
Q1How do you clinically distinguish atopic eczema from seborrhoeic dermatitis in an infant?
Both affect the face and scalp in infants. Atopic eczema: itchy, poorly defined, red weeping patches, often worse at night, positive family history of atopy, flexural in older infants. Seborrhoeic dermatitis ("cradle cap"): greasy yellow scales on scalp and face, NOT itchy, appears in first 3 months, resolves spontaneously by age 1. Atopic eczema is rarely present before 2 months.
Q2What are the signs of secondary infection in eczema, and what is the first-line treatment?
Signs of secondary infection (usually Staphylococcus aureus): golden/honey-coloured crusting, weeping, pain, pustules, rapid worsening, fever. First-line: oral flucloxacillin (or erythromycin if penicillin allergic). Topical antibiotics (fusidic acid) for localised infection — but avoid long-term use due to resistance. Eczema herpeticum (HSV superinfection) is a dermatological emergency — punched-out erosions + systemic unwell → IV aciclovir.
Q3Explain the emollient-first approach and how topical steroids should be used safely.
Emollients are the cornerstone — applied liberally and frequently (at least twice daily), including as a soap substitute. They reduce water loss and barrier dysfunction. Topical corticosteroids used for flares only — use the lowest potency that is effective. Mild steroids (hydrocortisone 1%) for face and flexures; moderate (clobetasone butyrate) for body; potent (betamethasone) reserved for lichenified plaques in adults. Finger-tip unit (FTU) guides quantity. Avoid prolonged use — risk of skin atrophy, striae, adrenal suppression in children.
Eczema herpeticum — red flag
Widespread painful, punched-out erosions or vesicles in a child or adult with eczema = eczema herpeticum (HSV superinfection). This is a dermatological emergency. Admit and treat with IV aciclovir urgently. Do not confuse with bacterial impetiginisation.
03
Dermatology
Skin Cancer
Urgent 2WW
Superficial Spreading Melanoma
52-year-old woman · Changing mole on upper back · 6-month history
How to use: Read the vignette and lesion description, then open the image links to view real photos. Answer questions before revealing.
Clinical vignette
A 52-year-old woman presents to her GP reporting that a mole on her upper back has been changing over the last 6 months. Her partner noticed it has grown and darkened. She has a history of sunbed use in her 20s and several blistering sunburns. She is fair-skinned. Examination reveals a 14mm pigmented lesion on the upper back with irregular borders and variation in colour from tan to dark brown to black, with a small area of pink.
ABCDE criteria — this lesion
A — Asymmetry
Irregular, not symmetrical on any axis
B — Border
Irregular, notched, poorly defined edges
C — Colour
Multiple colours: tan, brown, black, pink within one lesion
D — Diameter
14mm — greater than 6mm (pencil eraser)
E — Evolution
Changing in size, shape, and colour over 6 months
MorphologyIrregular pigmented macule/plaque
Colour variationTan, brown, black, pink — variegated
BorderIrregular, notched, poorly defined
Size14mm — well above 6mm threshold
HistoryChanging over 6 months
Risk factorsSunbed use, sunburns, fair skin, back location
Clinical photographs — open in new tab
Differentials to consider
1st Superficial spreading melanoma
2nd Dysplastic naevus
3rd Seborrhoeic keratosis (stuck-on, matte)
4th Pigmented BCC
5th Lentigo maligna (on face in elderly)
Interpretation questions — reveal when ready
Q1This lesion meets 2-week-wait criteria. What happens at the referral?
Urgent 2WW referral to a dermatologist or plastic surgeon with a specialist interest in skin cancer. They will perform dermoscopy for detailed evaluation. If melanoma is suspected, an excision biopsy with 2mm margins is performed for histological diagnosis and Breslow thickness measurement. Wide local excision follows with margins determined by Breslow thickness (e.g. 0–1mm → 1cm margin; 1–2mm → 1–2cm; >2mm → 2–3cm).
Q2What is Breslow thickness and why does it matter?
The vertical depth of melanoma invasion in millimetres, measured from the top of the granular layer to the deepest tumour cell on histology. It is the single most important prognostic factor — the thicker the melanoma, the worse the prognosis and the wider the excision margin required. It also determines need for sentinel lymph node biopsy (offered if Breslow >1mm).
Q3What is the 7-point weighted checklist used in UK primary care?
The Glasgow 7-point checklist: Major features (2 points each): change in size, irregular border, irregular colour. Minor features (1 point each): largest diameter >7mm, inflammation, oozing/crusting, altered sensation. A score ≥3 warrants urgent referral. This lesion scores at least 6 (size change + irregular border + irregular colour + diameter >7mm).
Never shave biopsy a suspected melanoma
Shave biopsy of a suspicious pigmented lesion is contraindicated — it destroys the architecture needed to measure Breslow thickness. Always perform excision biopsy with 2mm margins as the primary diagnostic procedure.
04
Dermatology
Infection
Assess urgency
Cellulitis — Lower Leg
68-year-old woman · Right lower leg · 2-day history · Diabetic
How to use: Read the vignette and lesion description, then open the image links. Answer questions before revealing.
Clinical vignette
A 68-year-old woman with type 2 diabetes attends the ED with a 2-day history of increasing redness, warmth, swelling, and pain in her right lower leg. She has a small cut on her right foot from gardening 5 days ago. She feels generally unwell with a temperature of 38.4°C and heart rate of 104 bpm. Examination reveals a spreading area of erythema, warmth, and oedema extending from the foot to mid-calf, with a clearly marked border. She has no bullae or skin necrosis. CRP 142, WCC 14.2.
MorphologyDiffuse erythema, oedema, warmth, tenderness
BorderSpreading — mark border to monitor progression
DistributionUnilateral lower leg (bilateral = unlikely cellulitis)
Systemic featuresFever 38.4°C, HR 104, CRP 142, WCC raised
Portal of entryFoot laceration 5 days prior
Bullae / necrosisAbsent — reassuring against necrotising fasciitis
Risk factorsDiabetes, skin breach, oedema
Causative organismsStrep. pyogenes (most common), Staph. aureus
Clinical photographs — open in new tab
Differentials — including dangerous mimics
1st Cellulitis
Dangerous Necrotising fasciitis
2nd DVT (unilateral swelling)
3rd Lipodermatosclerosis
4th Venous eczema
5th Erysipelas (more superficial, raised border)
Interpretation questions — reveal when ready
Q1How do you distinguish cellulitis from necrotising fasciitis clinically?
NF features: pain disproportionate to appearance (early), skin that appears normal despite severe systemic upset, rapid progression, skin necrosis, bullae, crepitus (gas in tissues — late), woody hard texture on palpation. LRINEC score (Laboratory Risk Indicator for Necrotising Fasciitis) uses CRP, WCC, Hb, sodium, creatinine, glucose — ≥6 = high risk. When in doubt, urgent surgical review and consider MRI or surgical exploration. NF has a mortality of >20% — never delay.
Q2Using the Eron classification, what class is this patient and what does it mean for management?
Eron Class III — systemic features (fever, tachycardia) but no sepsis or significant comorbidity threatening life (Class IV). Management: hospital admission, IV antibiotics. First-line IV: flucloxacillin (covers both Strep and Staph). In penicillin allergy: clarithromycin or clindamycin. Mark the border with a skin marker pen and review in 24–48 hours. Elevate the limb. Check blood glucose.
Q3Why is bilateral lower leg cellulitis almost always a misdiagnosis?
Bacteria do not infect both legs simultaneously. Bilateral "cellulitis" is most commonly bilateral venous eczema / gravitational dermatitis — a common mimic. Other bilateral causes: lipodermatosclerosis, bilateral DVT (rare), dependent oedema with secondary skin change. Treatment with antibiotics will fail. This is one of the most common dermatological misdiagnoses in UK emergency medicine — approximately 30% of admitted "cellulitis" patients have another diagnosis.
Necrotising fasciitis — never miss
Severe pain out of proportion to skin findings + rapid systemic deterioration = necrotising fasciitis until proven otherwise. This is a surgical emergency. Call the surgeons immediately — do not wait for imaging if clinical suspicion is high.
05
Dermatology
Viral Infection
VZV reactivation
Herpes Zoster (Shingles)
71-year-old man · Right-sided chest pain and rash · 4-day history
How to use: Read the vignette and lesion description, then open the image links. Answer questions before revealing.
Clinical vignette
A 71-year-old man presents to the GP with a 4-day history of burning pain and a rash on the right side of his chest. He noticed the pain 2 days before the rash appeared. He had chickenpox aged 7. He is on methotrexate for rheumatoid arthritis. Examination reveals a unilateral band of erythema with grouped vesicles on an erythematous base running from the right mid-back to the right lateral chest wall in a dermatomal distribution (T5–6). He has no eye involvement. Temperature 37.6°C.
MorphologyGrouped vesicles on erythematous base
DistributionUnilateral, dermatomal — does NOT cross midline
DermatomeT5–T6 (mid-thoracic)
ProdromePain 2 days before rash — burning/stabbing
StagesErythema → vesicles → pustules → crusting → healing
ImmunosuppressionMethotrexate — increased severity risk
Eye involvementNone — but Hutchinson's sign must be checked
Contagious?Yes — vesicle fluid causes chickenpox in non-immune contacts
Clinical photographs — open in new tab
Differentials to consider
1st Herpes zoster (shingles)
2nd Herpes simplex (localised)
3rd Contact dermatitis (bilateral, not dermatomal)
Rare Zosteriform herpes simplex
Interpretation questions — reveal when ready
Q1Does this patient need antiviral therapy and if so, when is it effective?
Yes — antivirals are indicated because he is: (1) immunosuppressed (methotrexate), (2) aged >50, and (3) has moderate-severe pain. Aciclovir 800mg 5× daily for 7 days (or valaciclovir 1g TDS) — most effective if started within 72 hours of rash onset. Reduces severity, duration, and risk of postherpetic neuralgia (PHN). Can be started up to 7 days if new vesicles are still forming or if immunosuppressed.
Q2What is Hutchinson's sign and why does it matter?
Vesicles on the tip or side of the nose (nasociliary branch of V1) — indicates ophthalmic branch involvement and predicts herpes zoster ophthalmicus (HZO). HZO can cause corneal scarring, uveitis, and blindness. Any zoster affecting the V1 dermatome (forehead, nose, periorbital skin) or Hutchinson's sign positive = same-day ophthalmology referral.
Q3What is postherpetic neuralgia and how is it managed?
Persistent neuropathic pain lasting >3 months after resolution of the shingles rash. Affects 10–15% of patients overall; up to 50% in those aged >70. Management: first-line: amitriptyline or gabapentin / pregabalin. Second-line: duloxetine or capsaicin cream. Topical lidocaine patches for localised pain. Refer to pain clinic if refractory. Early antiviral treatment reduces but does not eliminate PHN risk.
Shingles vaccination — NHS routine schedule
The NHS offers a Shingrix (recombinant zoster vaccine) to all adults aged 70–79 and immunosuppressed adults from age 50. Two doses, 2 months apart. ~90% efficacy against shingles and significantly reduces PHN risk. Ask every patient with shingles if they have been vaccinated.
06
Dermatology
Inflammatory
Common
Acne Vulgaris — Moderate Inflammatory
17-year-old · Face and upper back · Psychological impact
How to use: Read the vignette and lesion description, then open the image links. Answer questions before revealing.
Clinical vignette
A 17-year-old girl attends her GP with an 18-month history of spots on her face and upper back. She has tried washing her face frequently with soap. She has become increasingly self-conscious and is avoiding social situations. Examination reveals multiple open comedones (blackheads), closed comedones (whiteheads), inflammatory papules and pustules across the forehead, cheeks, chin, and upper back. There are no nodules or cysts. No scarring is visible. She is not on any contraception.
Non-inflammatoryOpen comedones (blackheads), closed comedones (whiteheads)
InflammatoryPapules, pustules — moderate
Severe lesionsNone — no nodules, cysts, or abscesses
DistributionFace (forehead, cheeks, chin), upper back — sebaceous sites
ScarringNone visible yet — intervention before scarring occurs is key
GradeModerate inflammatory acne (Grade III)
Psychosocial impactSocial avoidance — must be explored and documented
PathogenesisSebum↑, Cutibacterium acnes, follicular hyperkeratinisation, inflammation
Clinical photographs — open in new tab
Differentials to consider
1st Acne vulgaris (moderate)
2nd Rosacea (older patients, flushing, no comedones)
3rd Perioral dermatitis
4th Milia (tiny white cysts, no inflammation)
Interpretation questions — reveal when ready
Q1What is the appropriate treatment for moderate inflammatory acne in this patient?
NICE/BAD guidance for moderate acne: topical combination therapy — topical retinoid (adapalene) + topical antibiotic (clindamycin) or benzoyl peroxide. Use benzoyl peroxide alongside or alternating with topical antibiotic to reduce antibiotic resistance. If insufficient response after 12 weeks, add oral antibiotic — lymecycline or doxycycline for up to 3–6 months. Do not use topical and oral antibiotics simultaneously. If she were on COCP, co-cyprindiol (Dianette) is an option for females.
Q2When is isotretinoin indicated and what are the main risks?
Isotretinoin is reserved for: severe nodulo-cystic acne, moderate acne resistant to ≥2 adequate antibiotic courses, acne causing significant psychological distress, or scarring acne. Prescribed only by dermatologists. Key risks: teratogenicity (Category X — mandatory pregnancy prevention programme, 2 methods of contraception), depression/suicidality (screen at each visit), dry skin/lips/eyes, raised triglycerides and LFTs. Monthly monitoring required.
Q3This patient is socially withdrawing. How should you address the psychological impact?
Acne causes significant psychological morbidity — depression, anxiety, social isolation, and reduced quality of life, often disproportionate to clinical severity. You should: (1) explicitly acknowledge the impact on her daily life, (2) screen for depression (PHQ-2/PHQ-9), (3) reassure that treatment works and set realistic timelines (improvement over 3–6 months), (4) consider IAPT referral for CBT if distress is significant, (5) do not minimise — "everyone gets spots" is unhelpful and harmful.
Exam tip — Acne vs Rosacea
Key distinguishing feature: comedones are present in acne and absent in rosacea. Rosacea: flushing, background erythema, telangiectasia, rhinophyma, affects middle age. Acne: comedones, occurs in adolescence, sebaceous distribution. If a patient has rosacea and you prescribe a topical steroid — it will worsen it (steroid rosacea).
07
Dermatology
Skin Cancer
Most common skin cancer
Nodular Basal Cell Carcinoma
74-year-old man · Pearly nodule on nose · Slow-growing 2 years
How to use: Read the vignette and lesion description, then open the image links. Answer questions before revealing.
Clinical vignette
A 74-year-old retired farmer presents with a slowly enlarging lesion on the left side of his nose, present for approximately 2 years. It occasionally bleeds when he washes his face. He spent most of his working life outdoors and has fair skin. Examination reveals a 9mm translucent, pearly papule with rolled (everted) edges and surface telangiectasia. The centre shows a small area of ulceration. There are no regional lymphadenopathy and no other suspicious lesions on examination.
MorphologyPearly / translucent papule / nodule
SurfaceRolled (everted) edges — classic BCC feature
VesselsTelangiectasia (arborising vessels on dermoscopy)
UlcerationCentral ulceration — "rodent ulcer"
ColourSkin-coloured, pearly white, may be pigmented
LocationH-zone of face (nose, periorbital, ears) — high risk site
GrowthSlow — months to years; locally invasive
MetastasisExtremely rare (<0.1%) — locally destructive
Clinical photographs — open in new tab
Differentials to consider
1st Nodular BCC
2nd Squamous cell carcinoma (indurated, keratotic)
3rd Melanoma (pigmented BCC mimic)
4th Intradermal naevus (no telangiectasia)
5th Sebaceous hyperplasia (multiple lobules, central dell)
Interpretation questions — reveal when ready
Q1What are the four main subtypes of BCC and how do they differ clinically?
Nodular BCC (most common) — pearly nodule, rolled edges, telangiectasia, central ulceration ("rodent ulcer"). Superficial BCC — flat, scaly, erythematous plaque with thread-like raised edge; found on trunk; can mimic eczema. Morphoeic/sclerosing BCC — scar-like, ivory/waxy plaque with ill-defined margins; most aggressive subtype, difficult to excise. Pigmented BCC — blue/brown/black pigmentation; can mimic melanoma.
Q2Why is the location of this BCC on the nose particularly important for management?
The nose is in the H-zone (high-risk facial area: nose, inner canthi, periorbital, ears, temples, lips). BCCs in this zone are more likely to have ill-defined margins, deeper invasion, and recurrence after standard excision. Mohs micrographic surgery is the treatment of choice for H-zone BCCs — it achieves the highest cure rates (99%) by excising the tumour in horizontal layers with immediate margin analysis, thereby sparing maximum normal tissue in a cosmetically critical area.
Q3What non-surgical treatments are available for BCC and when are they used?
Imiquimod cream (immune response modifier) — for superficial BCCs, especially in low-risk sites. Photodynamic therapy (PDT) — for superficial BCCs, particularly in elderly patients unsuitable for surgery. Radiotherapy — for patients unfit for surgery or with large/inoperable tumours. Vismodegib/sonidegib (hedgehog pathway inhibitors) — for locally advanced or metastatic BCC not amenable to surgery or radiotherapy. Standard treatment for most BCCs is surgical excision with 4–5mm margins.
BCC vs SCC vs Melanoma — exam summary
BCC: most common, locally invasive, rarely metastasises, pearly nodule/rolled edge. SCC: second most common, risk of metastasis (especially lips/ears), indurated keratotic nodule, arises from actinic keratosis. Melanoma: highest mortality, ABCDE criteria, Breslow thickness determines prognosis. All three → urgent 2WW referral if suspected.
08
Dermatology
Allergic / Mast cell
Anaphylaxis risk
Acute Urticaria (Hives)
28-year-old woman · Widespread wheals · Developed after ibuprofen · No airway compromise
How to use: Read the vignette and lesion description, then open the image links. Answer questions before revealing.
Clinical vignette
A 28-year-old woman presents to the ED with a 90-minute history of an intensely itchy rash that appeared 30 minutes after taking ibuprofen for a headache. She has no previous history of urticaria. She has no swelling of the lips, tongue, or throat, no difficulty breathing, and feels generally well. Her observations are normal. Examination reveals multiple erythematous, raised, blanchable wheals of varying sizes scattered across the trunk and upper arms. Each individual wheal is migrating — the ones she noticed first have already faded.
MorphologyWheals (hives) — raised, erythematous, blanchable
Key featureIndividual wheals last <24h and migrate
ItchIntensely itchy — mast cell mediator release
DistributionTrunk, arms — can be anywhere
TriggerIbuprofen (NSAID) — common drug trigger
Angioedema?Absent — no lip/tongue/throat swelling
Anaphylaxis featuresNone — airway intact, obs normal
DurationAcute (<6 weeks) — most resolve within days
Clinical photographs — open in new tab
Differentials to consider
1st Acute urticaria — drug-induced (NSAID)
2nd Urticarial vasculitis (wheals persist >24h, bruise)
3rd Erythema multiforme (target lesions, fixed)
4th Anaphylaxis (if systemic features present)
5th Bullous pemphigoid — urticarial prodrome
Interpretation questions — reveal when ready
Q1What is the single most useful clinical feature that distinguishes urticaria from other rashes?
Individual wheals that disappear within 24 hours and migrate. This transient nature is pathognomonic — eczema, psoriasis, and contact dermatitis all stay in the same place. If a patient says "the spots keep moving" or "they come and go", urticaria should be your first thought. Wheals that persist beyond 24–48 hours should raise the suspicion of urticarial vasculitis — biopsy would show vessel wall inflammation, and they often bruise as they resolve.
Q2When does urticaria become an emergency and what is the management?
Urticaria becomes an emergency when it occurs alongside features of anaphylaxis: airway compromise (throat swelling, stridor), bronchospasm, hypotension, or collapse. Management: IM adrenaline 0.5mg (1:1000) into the anterolateral thigh — first-line. Then IV antihistamines, IV hydrocortisone, oxygen, IV fluids if hypotensive. Observe for at least 6 hours (biphasic reaction risk). Prescribe an AAI (adrenaline auto-injector — EpiPen) on discharge and refer to an allergy clinic.
Q3What is chronic urticaria and how is it managed differently?
Chronic urticaria = wheals occurring on most days for >6 weeks. Usually idiopathic (no identifiable trigger in 80–90%). Investigation: FBC, TFTs, ESR/CRP, ANA (to exclude systemic cause). Management: non-sedating oral antihistamines (cetirizine, loratadine) as first-line — up to 4× the standard dose is licenced. If inadequate: add montelukast or H2 antagonist. Refractory: omalizumab (anti-IgE biologic) — highly effective, NICE approved. Avoid triggers (NSAIDs, ASA, heat, tight clothing).
Always assess for anaphylaxis in acute urticaria
Every patient with acute urticaria must be assessed for airway swelling, breathing difficulty, and circulatory compromise. Urticaria alone is not anaphylaxis — but it can be the skin manifestation of a developing anaphylactic reaction. Take observations, check the throat, and ask about difficulty swallowing or breathing.