Initial management of an itchy skin rash

30 May 2019

A middle-aged woman, Mrs Y, presented to GP Dr U with a ten-day history of an itchy rash over her arms and chest, which was forming blisters. The distribution of the rash was on sun-exposed areas of skin, and the blisters were not forming scabs. Mrs Y felt the rash started after she took buscopan.

She had had chickenpox in the past. Dr U considered dermatitis herpetiformis, and arranged blood tests including full blood count, erythrocyte sedimentation rate, thyroid tests and a coeliac screen. All blood tests were normal, and the patient was given reassurance and advice.

At review with a different GP two weeks later, the rash was subsiding, but was leaving areas with a bruised appearance, which the patient was concerned about. A routine dermatology referral was planned, but unfortunately was not made for eight weeks, due to the referral task being closed in error before the referral was made.

In the dermatology clinic a few months on, the skin changes were thought to be post-inflammatory pigmentation. Mrs Y was reassured that the appearance of the patches should settle over the following months, and she was prescribed mometasone cream to assist. Unfortunately, the mometasone was not effective, and Mrs Y was referred for camouflage cosmetics to disguise them.

Mrs Y made a claim against Dr U.

Summary of allegations

It was alleged by Mrs Y’s solicitors that Dr U ought to have prescribed a “strong steroid cream” at the initial appointment and also made a referral to dermatology at that point.

It was alleged that had she done so, the rash would have settled sooner and the skin pigmentation requiring camouflage make up would not have occurred.

Expert opinion

Medical Protection did not obtain an opinion from a GP expert, being confident in basing our letter of response denying breach of duty on the facts of Dr U’s reasonable management at the initial consultation.

The claim was not pursued against Dr U following our letter of response denying liability. A co-defendant’s medical defence organisation went on to settle the claim in full on behalf of their member, who had mistakenly completed the dermatology referral task without making a dermatology referral.

Learning points

In primary care, when a claim involves an administrative error, such as a delayed referral, if the individual responsible is not identifiable, then the claim falls to the responsibility of the practice partners. In this case, however, the practice was able to provide Medical Protection with an audit trail showing which staff member had marked the dermatology referral task ‘complete’ in error. It was therefore possible for Medical Protection to relay this audit information to the relevant individual’s legal representatives to encourage them to settle the claim without involving the practice partners.

At Medical Protection we will ask members for their comments on the events in question when we are investigating a claim and preparing our response. In this case, we worked closely with the member to advance a robust letter of response, setting out her reasonable management at the consultation in question.

Blistering rashes can have many causes, including sunburn, extremes of cold or heat, friction, viruses (eg chickenpox, shingles, herpes simplex), chemical irritants, dermatitis herpetiformis, pemphigus, pompholyx, insect bites, and skin infections such as folliculitis. The precise diagnosis may not be obvious, especially early in the clinical course. 

We were able to demonstrate Dr U’s reasonable management of this case through her simple reassurance and advice, followed by blood investigations, and later a dermatology referral when patient concerns persisted.