Vates Gamification 2023

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Interpret the information in the case study and answer questions to diagnose and manage the patient's condition. See how you score!

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Case	Case description	Completed
	A 50-year-old female is presenting with well-defined, erythematous plaques on both feet - can you help diagnose and treat her condition to improve her sleep and social life?

Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

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Case 1	0

Patient vignette and clinical history

Background: The patient is a 50-year-old female household domestic assistant.

Clinical presentation: The patient has presented with erythematous, well-defined plaques on both feet, with white scales, crust and excoriations. Plaques were associated with intense pruritus.

Duration and temporal pattern of symptoms and signals: The patient first noticed erythematous, pruritic plaques on both feet 3 years ago. She applied several OTC topical treatments, but these provided no relief; the plaques gradually increased in size and were intensely pruritic.

Recurrent disease (incidence, duration, causes, treatments used): No history was given; however, her condition was chronic at the time of consultation and she had not responded to previous OTC treatments.

Other information: No other relevant medical history, including allergies
and comorbidities.

Psychosocial impact: Intense pruritus had impacted her sleep. Her social interactions had also been affected.

OTC, over-the-counter.
Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

Physical examination

General physical examination: Nothing of significance.

Location of skin condition: Both feet and ankles.

Description of skin lesions: Multiple erythematous, well-defined plaques with white scales, crust and excoriations covering a large area of both feet.

Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).
1. Charifa A, et al. Lichen Simplex Chronicus. [Updated 2022]. In: StatPearls. Treasure Island [internet]: StatPearls Publishing; 2022.

Differential diagnosis (1/3)

Condition	Lichen planus	Localised plaque psoriasis
Cause	A T-cell-mediated autoimmune disorder, in which inflammatory cells attack an unknown protein within the skin and mucosal keratinocytes.¹	Wide range of causes including both genetic predisposition and triggers such as trauma, infection, drugs, metabolic factors, stress, alcohol, smoking and sunlight. This condition is an autoimmune disorder characterised by keratinocyte hyperplasia, altered T-cell function and angiogenesis.⁵
Location	The flexor surfaces of the wrists, forearms, and legs.²	Scalp, trunk, extensor body surface and buttocks.^5,6
Onset	Primarily middle-aged adults between the ages of 30 and 60, and is more likely to occur in women than men.^1,3,4	Can occur at any age, with two peaks of onset: between the ages of 20 and 30 years and between the ages of 50 and 60 years, with equal incidence in each sex.⁷
Signs/symptoms	Ranges from asymptomatic to intense pruritus.^1,2	Pruritus, erythema, Auspitz's sign (bleeding after the removal of a scale) and the Koebner phenomenon (lesions induced by trauma).^6,8
Lesion appearance and borders	Lesions are typically purple, pruritic, planar plaques/papules, that tend to heal with residual post-inflammatory hyperpigmentation. Lesions may be polygonal and often have a shiny surface covered in fine white lines (Wickham striae). The lesions may appear in a linear configuration, following the lines of trauma (Koebner phenomenon).²	Well-delimited, thick, erythematous plaques, covered by silvery white scales. These lesions can range from small erythematous, scaly papules to large, thick plaques.6,7 The plaques are typically >0.5 cm in diameter.⁹

Images used with permission from DermNet NZ and Danderm.
1. DermNet NZ. Lichen Planus. Available at https://dermnetnz.org/topics/lichen-planus (last accessed March 2023); 2. Usatine RP and Tinitigan M. Am Fam Physician 2011;84: 53–60; 3. Gorouhi F, et al. Sci World J 2014;742826. doi: 10.1155/2014/742826; 4. Askin O, et al. J Turk Acad Dermatol 2020;14:83–88; 5. Badri T, et al. Plaque Psoriasis. 2022. In: StatPearls [Internet]. Treasure Island, 2022; 6. Armstrong AW and Read C. JAMA Dermatol 2020;323:1945–1960; 7. Menter A. Am J Manag Care 2016;22(8 suppl):S216–224; 8. American Family Physician. Chronic Plaque Psoriasis. Available at https://www.aafp.org/pubs/afp/issues/2006/0215/p636.html (last accessed March 2023); 9. Whan KB, et al. Can Fam Physician 2017;4:278–285.

Differential diagnosis (2/3)

Condition	Prurigo nodularis	Venous stasis dermatitis
Cause	The interplay of pro-inflammatory and pruritogenic substances in addition to the itch-scratch cycle, which increases the concentration of cytokines and neuropeptides in skin lesions, resulting in altered nerve density and inflammation.^1,2 The itch-scratch cycle is often, but not always, the result of pre-existing dermatological conditions such as atopic dermatitis, infections or psychiatric disorders.³ Patients who are female and black are at higher risk of developing this condition.^3,4	Caused by chronic venous insufficiency and venous hypertension, resulting in the accumulation of dermal infiltrating cytokines, T-cells and macrophages in the affected skin.⁵
Location	Extensor surfaces and parts of the trunk accessible to scratching such as the upper back and abdomen.¹	Lower legs.⁵
Onset	The disease is more common in individuals who are >50 years old.⁴	Common in elderly female patients (>65 years old).^5,6
Signs/symptoms	Pruriginous lesions and pruritus.¹	Pruritus, swelling around the ankles.^5,6
Lesion appearance and borders	Multiple excoriated, hyperkeratotic, and pruritic dome-shaped nodules, papules, or plaques with a symmetrical distribution.³ The clinical presentation of this condition varies between different racial groups with hypo- or hyperpigmentation being more common in patients with darker skin and redness or erythema being more prevalent in patients with lighter skin. The size of the lesions ranges from a few millimeters to 2 cm in diameter. Increased hypervascularisation, epidermal hyperkeratosis and dermal fibrosis are common.²	Bulging varicose veins; scaley and thickened red or brown skin around the ankles; and hair loss around the ankles and shins.⁶ Venous ulcers can occur on the affected area and swelling can be uni- or bilateral.⁷

Images used with permission from DermNet NZ.
1. Kowalski EH, et al. Clin Cosmet Investig Dermatol 2019;12:163–172; 2. Bewley A, et al. Dermatol Ther (Heidelb) 2022;9:2039–2048; 3. Morgan CL, et al. Br J Dermatol 2022; 2:188–195; 4. American Academy of Dermatology Association. Available at https://www.aad.org/public/diseases/a-z/prurigo-nodularis-causes (last accessed March 2023); 5. Hashimoto T, et al. J Invest Dermatol 2020;140:850–859; 6. WebMD. Available at https://www.webmd.com/skin-problems-and-treatments/eczema/venous-stasis-dermatitis (last accessed March 2023); 7. National Eczema Association. Stasis Dermatitis. Available at https://nationaleczema.org/eczema/types-of-eczema/stasis-dermatitis/ (last accessed March 2023).

Differential diagnosis (3/3)

Condition	Lichen simplex chronicus
Cause	Unknown, but localised areas of the skin itch spontaneously, leading to an itch-scratch cycle that provokes lesions.¹
Location	Usually easy-to-reach areas, such as the head, neck, arms, hands, scalp, and genitals.¹
Onset	Middle-to-late adulthood, peaking at 30–50 years of age.¹
Signs/symptoms	Pruritus, erythema.¹
Lesion appearance and borders	Typically presents as single or multiple discoloured lesions with dry, patchy areas of skin that are scaly and thick. The lichenification of lesions may occur due to chronic scratching.¹

Images used with permission from GSK.
1. Charifa A, et al. Lichen Simplex Chronicus. [Updated 2022]. In: StatPearls. Treasure Island [internet]: StatPearls Publishing; 2022.

Question 1: Diagnosis

What would be your chosen diagnosis for this patient based on the options below? (Please select one option from the list below)

Lichen planus Prurigo nodularis Lichen simplex chronicus Localised plaque psoriasis Venus stasis dermatitis

Question 1: Correct diagnosis

Correct answer:

Lichen simplex chronicus

Click the buttons below to find out more:

Disease background Precipitating factors Diagnostic considerations

Disease background: Lichen simplex chronicus

Lichen simplex chronicus is a chronic itchy skin disorder characterised by well-demarcated, erythematous patches and plaques of thickened leathery skin.¹

Symptoms:

Chronic itch-scratch cycle¹
Rubbing which becomes an automatic and unconscious habit²
Pruritus which may also be paroxysmal²
Hyperexcitability of lichenified skin where itching is elicited by minor stimuli²

Clinical presentation:

Lichen simplex chronicus presents as dry, patchy, lichenified areas of skin where the chronic itch-scratch cycle has caused epidermal hypertrophy³
- The hyperkeratotic plaque encompasses perivascular and interstitial inflammation with an abundance of immune cells including lymphocytes and eosinophils³
Commonly affected areas include regions of the body that are easily accessible for the individual to scratch, such as the scalp, head, neck, hands, arms and genitals³
Post-inflammatory hyperpigmentation is also common¹

1. DermNet NZ. Lichen simplex chronicus. Available at https://dermnetnz.org/topics/lichen-simplex (last accessed March 2023); 2. Saavedra A, et al. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 7^th ed. McGraw Hill Medical; 2008; 3. Charifa A, et al. Lichen Simplex Chronicus. [Updated 2022]. In: StatPearls. Treasure Island [internet]: StatPearls Publishing; 2022.

Diagnosis is typically based on history and clinical presentation³

Intrinsic precipitating factors for lichen simplex chronicus

The inciting stimulus for the itch causing LSC can be due to a variety of intrinsic factors:¹

Primary or secondary
lichen simplex¹
This can develop on normal skin, and can develop as a result of an underlying itchy dermatosis such as atopic dermatitis, psoriasis or scabies

Neural-mediated stimulus
that triggers an itch¹
Brachioradial pruritus
or radiculopathy

Systemic disease associated with pruritus¹
Uraemia, polycythaemia vera
or malignancy

Psychological comorbidities²
Anxiety, depression, OCD, or other emotional stressors

Sex²
Women between the ages of
35 and 50 are at higher risk
of developing LSC

LSC, lichen simplex chronicus; OCD, obsessive-compulsive disorder.

1. DermNet NZ. Lichen simplex chronicus. Available at https://dermnetnz.org/topics/lichen-simplex (last accessed March 2023); 2. Charifa A, et al. Lichen Simplex Chronicus. [Updated 2022]. In: StatPearls. Treasure Island [internet]: StatPearls Publishing; 2022.

Extrinsic precipitating factors for lichen simplex chronicus

The inciting stimulus for the itch causing LSC can be due to a variety of extrinsic, environmental factors:¹

Heat and sweat^1,2
Which triggers the initial itch

Chemical irritants^1,2
Such as being exposed to lots of traffic exhaust pollution

Insect bites^1,3
This initiates continued rubbing and scratching

LSC, lichen simplex chronicus.

1. DermNet NZ. Lichen simplex chronicus. Available at https://dermnetnz.org/topics/lichen-simplex (last accessed March 2023); 2. Ludmann P. Eczema types: Neurodermatitis causes. Available at https://www.aad.org/public/diseases/eczema/types/neurodermatitis/causes (last accessed March 2023); 3. Vun Y. Lichen Simplex Chronicus. Available at https://www.dermcoll.edu.au/atoz/lichen-simplex-chronicus/#:~:text=In%20others%2C%20there%20is%20an%20associated%20skin%20condition,in%20a%20heightened%20 sensitivity%20to%20the%20itch%20sensation (last accessed March 2023).

Diagnostic considerations and final diagnosis

Diagnosis: The following methods can be used to differentiate lichen simplex chronicus from other similar dermatoses:

Skin biopsy to identify histopathological change¹

Patch testing to exclude allergic contact dermatitis¹

Fungal culture to investigate underlying dermatophyte or candida infection¹

Differential diagnoses: Tinea corporis was excluded following a negative potassium hydroxide test and allergic/irritant contact dermatitis was excluded due to no identifiable contact with any allergens or irritants.

Final diagnosis: Lichen simplex chronicus

The repetitive, self-perpetuating itch-scratch cycle spanning several years results in the exacerbation of plaques¹
Intense pruritus has affected the patient's sleep and social interactions, which may have had a negative psychological impact on the patient. Low mood and anxiety are known to exacerbate the itch, which can worsen the disease prognosis and the patient's quality of life²
Common differential diagnoses include psoriasis, atopic dermatitis, lichen planus, contact dermatitis, mycosis fungoides, fungal infections and squamous cell carcinoma³
The patient has not responded to previous OTC treatments, suggesting that her condition may be recalcitrant and require higher potency treatments^1,3,4

OTC, over the counter.
Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

1. DermNet NZ. Lichen simplex chronicus. Available at https://dermnetnz.org/topics/lichen-simplex (last accessed March 2023); 2. Sanders KM, et al. Neurosci Biobehav Rev 2018;87:17–26; 3. Charifa A, et al. Lichen Simplex Chronicus. [Updated 2022]. In: StatPearls. Treasure Island [internet]: StatPearls Publishing; 2022; 4.Dermovate cream prescribing information based on UK V11; Dermovate oinment prescribing information based on UK V11; Dermovate scalp application prescribing information based on UK V11.

Question 2: Diagnostic tests

The diagnosis of LSC is largely clinical, based on history and physical examination, and can often be determined at presentation. Which of the below diagnostic tests could you use to exclude other differential diagnoses if the clinical presentation is not clear?
(Select all that apply)

Fungal culture KOH testing Skin biopsy Patch testing

KOH, potassium hydroxide; LSC, lichen simplex chronicus.

Question 2: Correct diagnostic tests

Correct answer:

Skin biopsy

Skin biopsies and histological findings can be used for clarification when diagnosing steroid-responsive dermatoses, if necessary^1,2

KOH testing

Testing with potassium hydroxide can be used to exclude tinea corporis³

Patch testing

Patch testing can be used to exclude allergic contact dermatitis²

Fungal culture

Fungal cultures can be used to investigate underlying dermatophyte or candida infection²

KOH, potassium hydroxide.
1. Gisondi P, et al. J Clin Med 2020;9:3594; 2. DermNet NZ. Lichen simplex chronicus. Available at https://dermnetnz.org/topics/lichen-simplex (last accessed March 2023); 3. Shukla S, et al. Medscape. Available at https://emedicine.medscape.com/article/1091473-workup#:~:text=A%20potassium%20hydroxide%20(KOH)%20examination,10% 20scalpel%20blade (last accessed March 2023).

Question 3: Risk factors

Please select the risk factors for lichen simplex chronicus:

Psychological comorbidities Primary lichen simplex Neural-mediated stimulus that triggers an itch Diet Being a woman between the ages of 35 and 50 The overuse of TCS Being an adolescent Dehydration Systemic disease associated with pruritus Environmental triggers Being a woman between the ages of 60 and 85 Secondary lichen simplex

TCS, topical corticosteroids.

Question 3: Correct risk factors

Correct answer:

Psychological comorbidities

Environmental triggers

Primary lichen simplex

Being a woman between the ages of 35 and 50

Neural-mediated stimulus that triggers an itch

Systemic disease associated with pruritus

Secondary lichen simplex

Therapeutic management

Treatment options
Non-steroidal topicals^1–3 e.g., calcineurin inhibitors³
Highly potent topical corticosteroids, such as clobetasol propionate, for the treatment of thick, well-established lesions which have previously not responded to lower-potency treatments^1–3
- Clobetasol propionate should be used once or twice a day, with overnight occlusion to enhance TCS penetration for more resistant lesions, for a maximum of 4 weeks²
- TCS potency should then be reduced progressively to minimise the risk of side effects such as steroid atrophy²
Intralesional steroid injections^1,3

Psychological interventions
Educating patients about the effect of scratching may encourage the patient to avoid scratching¹
Psychiatric medication can reduce anxiety⁴
Counselling or CBT may benefit some patients³

Pruritus relief
Treatment with antihistamines^1,3

CBT, cognitive behavioural therapy; TCS, topical corticosteroids.
1. MSD Manual. Lichen simplex chronicus. 2022. Available at https://www.msdmanuals.com/en-gb/professional/dermatologic-disorders/dermatitis/lichen-simplex-chronicus (last accessed March 2023); 2. Dermovate cream prescribing information based on UK V11; Dermovate oinment prescribing information based on UK V11; Dermovate scalp application prescribing information based on UK V11; 3. National Eczema Association. Neurodermatitis. Available at https://nationaleczema.org/eczema/types-of-eczema/neurodermatitis/ (last accessed March 2023); 4. Sagar VV, et al. Int J Res Med Sci 2017;5:3261–3263.

Question 4: Treatment

Which of the below first-line treatment options would be appropriate for this patient who has been diagnosed with lichen simplex chronicus? (Please select one from the following)

Dermovate (clobetasol propionate) ointment + emollient Betnovate (betamethasone valerate) ointment + emollient Cutivate (fluticasone propionate) ointment + emollient Oral corticosteroids

Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

Question 4: Correct treatment

Correct answer:

Dermovate (clobetasol propionate) ointment

To be applied twice a day and emollients 2-3 times a
day to clear plaques and reduce inflammation

Continue through the next slides to see the rationale for treatment selection and outcomes for this patient…

Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

Treatment selection

Objective: Reduction or resolution of the itch-scratch cycle, rapid and effective response to treatment, reduction/resolution of inflammation and resolution of skin appearance.

Treatment chosen: Dermovate (clobetasol propionate) ointment to be applied twice a day for an initial period of 3 weeks with plastic occlusion overnight, as well as emollients 2–3 times a day, to clear plaques and reduce inflammation. Daily oral antihistamines were also prescribed to further reduce pruritus and improve sleep.

Patient education: The patient was educated on treatment adherence, the benefits of emollients and/or moisturiser use, and the importance of avoiding scratching.

Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

Guideline-based rationale for treatment decision

Guidelines		Treatment decisions
“Thick, well-established lesions usually require a high-potency topical corticosteroid (e.g., clobetasol ointment). Efficacy can be further increased by using the topical corticosteroid under occlusion, for example, by covering the treated area with plastic wrap and leaving it on overnight.”¹		The patient was prescribed a very potent topical corticosteroid for 3 weeks (clobetasol propionate), to be applied twice a day with overnight plastic occlusion, in order to treat her well-defined lesions that had increased in size over the course of 3 years
“Oral H1-blocking antihistamines, emollients, and topical capsaicin cream may also be helpful.”¹		Oral antihistamine daily was prescribed to further reduce pruritus and improve sleep, as well as the use of emollients 2-3 times a day
“If a cause of the initial itch can be identified (e.g., radiculopathy, ill-fitting shoes, atopy), it should be treated or addressed. Otherwise, the primary treatment of lichen simplex chronicus is patient education about the effects of scratching and rubbing.”¹		The patient was educated on treatment adherence and the benefits of emollients and/or moisturiser use, as well as the importance of avoiding scratching

1. MSD Manual 2022. Available at https://www.msdmanuals.com/en-gb/professional/dermatologic-disorders/dermatitis/lichen-simplex-chronicus#v961651 (last accessed March 2023).

Question 5: Treatment

What would be a reasonable course of action for the first 3 weeks of treatment for this patient? (Please select one from the following)

Application of a very potent TCS for 3 weeks (clobetasol propionate), once a day without overnight plastic occlusion Application of a moderately potent TCS for 2 weeks (clobetasol propionate), twice a day with overnight plastic occlusion Application of a very potent TCS for 3 weeks (clobetasol propionate), twice a day with overnight plastic occlusion Application of an emollient twice daily

TCS, topical corticosteroid.
Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

Question 5: Correct treatment

Correct answer:

Application of a very potent TCS for 3 weeks (clobetasol propionate), twice a day with overnight plastic occlusion

TCS, topical corticosteroid.
Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

Outcome following treatment with Dermovate (clobetasol propionate) ointment

Follow-up period: 2 weeks.

Response: Partial.

Course of action: The patient was advised to continue using Dermovate (clobetasol propionate) ointment + emollient twice a day with plastic occlusion overnight for a further week.

Rationale: There was a 30% improvement in lesions at follow-up, indicating a positive response to treatment.

Next steps: Following 3 weeks of Dermovate use, the patient was advised to reduce the frequency of Dermovate application to once a day for 1 week. TCS potency would then be reduced to Betnovate or Cutivate twice a day for 2 more weeks, with subsequent progressive reduction in the frequency of application until all lesions are resolved.
The patient was further advised to continue using emollient and to avoid potential triggers, such as environmental factors.

TCS, topical corticosteroid.
Images and case study provided by Dr Sheila Chua, Philippines (board-certified dermatologist).

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