SCA practice case · Video consultation
“I keep getting these itchy raised welts all over that come and go within hours — it’s been months and I can’t find a trigger”
Video consultation
Adult patient
Straightforward
New & undifferentiated presentationsLong-term conditions & cancer
The candidate brief
This is what you would read in the 3-minute window before the patient connects. Read it once, note two or three hypotheses and one thing you must not miss, then stop.
Patient
Sofia Larkin · 34 years · female
Setting
Video consultation, with the skin examined face to face if the weals cannot be seen clearly on camera or photographs — recurrent itchy weals.
Past history
- Nil recorded
Medication
- Nil recorded
Allergies
NKDA
Recent notes
No previous consultations about a rash.
Reason for contact
“Itchy raised welts for months, can’t find a trigger. What’s causing it?”
Practise this case
The full case is in the Hot Seat with the Gold plan. You get a 12-minute timer, a role-player script with facts released only when asked, examiner checkpoints by the three RCGP domains, a model consultation and the guidance behind it.
What this case tests
Show the learning points (spoiler: read after you have practised)
CHRONIC SPONTANEOUS URTICARIA is recurrent itchy WEALS (hives) occurring most days for MORE THAN 6 WEEKS, with each individual weal coming and going within 24 hours and leaving NO mark, often with ANGIOEDEMA (lip/eyelid/soft-tissue swelling) and frequently NO identifiable trigger (often idiopathic/autoimmune). If individual weals last LONGER than 24 hours, are painful/burning, or leave bruising/pigmentation, consider URTICARIAL VASCULITIS (refer dermatology for assessment/biopsy). Reassure that chronic spontaneous urticaria is usually NOT a dangerous food allergy and that extensive allergy testing is generally unrewarding — avoid fruitless elimination diets/allergy tests — while identifying aggravating (not causative) factors where relevant (NSAIDs/aspirin, opiates, heat, pressure, alcohol, stress, infection). Manage STEPWISE: regular (not just PRN) non-sedating ANTIHISTAMINES are first-line (BSACI 2015), up-titrated after 2–4 weeks to up to four times the standard dose if not controlled (international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline 2026; off-label above the licensed dose, so explain it; ask about pregnancy and breastfeeding first); limit tests to FBC and CRP or ESR; for refractory cases, refer to dermatology/immunology for add-on options (omalizumab preferred — NICE TA339 for severe disease with UAS7 of 28 or more despite antihistamine-based treatment — then ciclosporin; consider a montelukast add-on first if up-dosed antihistamine fails — BAD 2021, and a leukotriene receptor antagonist trial is required before omalizumab under TA339 — with an MHRA April 2024 neuropsychiatric warning), with short oral steroid courses only for severe flares (not long-term). Crucially counsel the angioedema/anaphylaxis safety-net — seek emergency help (999) for tongue/throat swelling or difficulty breathing/swallowing — and consider ACE-inhibitor-induced angioedema (stop the ACE inhibitor) and hereditary angioedema (C1-esterase inhibitor deficiency) in recurrent isolated angioedema without weals. The skill is recognising chronic urticaria, reassuring and stopping the trigger-hunt, starting regular up-titrated antihistamines, referring if refractory/vasculitis, and giving the angioedema red-flag advice.
The guidance behind it
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