Derm Cases · Dermatology / Rheumatology / Ophthalmology
OSCE — recurrent oral and genital ulcers: diagnose Behçet disease and protect the eyes
An 8-minute OSCE station on ICBD 2014 classification of Behçet disease, mucocutaneous and pathergy features, sight-threatening uveitis red flags, vascular events, and EULAR-aligned stepwise therapy including apremilast for oral ulcers.
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NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on ICBD 2014 classification of Behçet disease, mucocutaneous and pathergy features, sight-threatening uveitis red flags, vascular events, and EULAR-aligned stepwise therapy including apremilast for oral ulcers.
Brief (to candidate)
A 29-year-old man from a Silk Road ancestry region has recurrent oral aphthae, scrotal ulcers, erythema nodosum–like lesions and pathergy at venepuncture sites. He now reports blurred vision and floaters. You have 8 minutes to classify Behçet disease, escalate ocular care, and outline organ-based therapy.
[10]Candidate instructions
- Define Behçet as a multisystem variable-vessel vasculitis.
- Apply ICBD 2014 scoring principles (threshold ≥4).
- List mucocutaneous, ocular, vascular, and neurologic red flags.
- Outline EULAR-aligned treatment by organ (mucocutaneous vs eye vs major vessel vs neuro).
- Differentiate recurrent aphthous stomatitis alone from Behçet.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Definition | Relapsing multisystem vasculitis of arteries and veins with classic oral + genital ulcers ± uveitis/skin/pathergy spectrum[3][5] |
| ICBD 2014 | Points-based classification: oral aphthosis and genital aphthosis heavily weighted; ocular lesions, skin, neuro, vascular, pathergy contribute; score ≥4 classifies Behçet; oral ulcers not mandatory unlike older ISG framework[7] |
| Mucocutaneous | Recurrent oral aphthae, genital ulcers (often scar), EN-like lesions, papulopustular lesions, positive pathergy |
| Eye emergency | Uveitis / retinal vasculitis is sight-threatening — urgent ophthalmology; high-dose steroids + steroid-sparing (e.g. azathioprine); escalate to biologics (anti-TNF/interferon pathways) per severity; do not delay for non-urgent tests[8] |
| Major organ | Arterial aneurysms, venous thrombosis (often without standard thrombophilia), neuro-Behçet (parenchymal vs vascular) — specialist immunosuppression, anticoagulation decisions nuanced in vasculitis-driven thrombosis[2] |
| Therapy ladder | Mucocutaneous: colchicine, topicals; apremilast evidence for oral ulcers; systemic steroids for flares; organ-threatening disease → azathioprine/anti-TNF etc. per EULAR 2018[8][9] |
| Differential | Simple RAS, HSV, fixed drug, SLE, reactive arthritis, Crohn — need multi-organ pattern not isolated mouth ulcers[4] |
Model key actions
- Classify with ICBD ≥4 using oral/genital/ocular/skin/pathergy features.[7]
- Treat ocular disease as an emergency with steroids + immunosuppression and same-day ophthalmology.[8]
- Use colchicine/apremilast pathways for mucocutaneous disease and escalate for major vessel/neuro disease.[3][9]
Common errors
- Diagnosing Behçet from isolated oral aphthae.
- Delaying ophthalmology for uveitic symptoms.
- Routine anticoagulation without addressing inflammatory vascular disease context.
- Missing pathergy history and genital scar examination.
- Using only topical mouth care when systemic criteria and organ risk are present.
References8ShowHide
- [2]Belfeki N, Ghriss N, Fourati M, et al. Neuro-Behçet's disease: A review. La Revue de médecine interne, 2024.PMID 38937151
- [3]Fazaa A, Makhlouf Y, Ben Massoud F, et al. Behçet disease: epidemiology, classification criteria and treatment modalities. Expert Review of Clinical Immunology, 2024.PMID 39101633
- [4]Manfredini M, Guida S, Giovani M, et al. Recurrent Aphthous Stomatitis: Treatment and Management. Dermatology Practical & Conceptual, 2021.PMID 34631263
- [5]Nelson CA, Stephen S, Ashchyan HJ, et al. Neutrophilic dermatoses: Pathogenesis, Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease. Journal of the American Academy of Dermatology, 2018.PMID 29653210
- [7]International Team for the Revision of the International Criteria for Behçet's Disease (ITR-ICBD). The International Criteria for Behçet's Disease (ICBD): a collaborative study of 27 countries on the sensitivity and specificity of the new criteria. Journal of the European Academy of Dermatology and Venereology, 2014.PMID 23441863
- [8]Hatemi G, Christensen R, Bang D, et al. 2018 update of the EULAR recommendations for the management of Behçet's syndrome. Annals of the Rheumatic Diseases, 2018.PMID 29625968
- [9]Hatemi G, Melikoglu M, Tunc R, et al. Apremilast for Behçet's syndrome—a phase 2 placebo-controlled study. New England Journal of Medicine, 2015.PMID 25875256
- [10]Pérez-Garza DM, Chavez-Alvarez S, Ocampo-Candiani J, et al. Erythema Nodosum: A Practical Approach and Diagnostic Algorithm Am J Clin Dermatol, 2021.PMID 33683567