Derm Cases · Dermatology / Therapeutics / Immunology
OSCE — starting a dermatologic biologic or JAK inhibitor: class choice and safety screen
An 8-minute OSCE station on matching cytokine targets to disease (psoriasis, AD, HS, alopecia areata, CSU, pemphigus), pre-treatment infection screening, class-specific contraindications (IL-17 and IBD; JAK and VTE), and live-vaccine/pregnancy counselling.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on matching cytokine targets to disease (psoriasis, AD, HS, alopecia areata, CSU, pemphigus), pre-treatment infection screening, class-specific contraindications (IL-17 and IBD; JAK and VTE), and live-vaccine/pregnancy counselling.
Brief (to candidate)
A 34-year-old with severe plaque psoriasis (PASI 18) failed methotrexate and phototherapy. He has a history of treated latent TB 2 years ago, intermittent diarrhoea under investigation, and plans pregnancy with his partner next year. A second card offers alternative diseases (severe AD, extensive alopecia areata). You have 8 minutes to choose an appropriate advanced therapy class, complete the pre-treatment bundle, and counsel on class-specific risks.
[3]Candidate instructions
- Map disease → cytokine/pathway target (IL-17/IL-23/TNF for psoriasis; IL-4/13 for AD; JAK for AA; etc.).
- List the pre-biologic / pre-JAK screening bundle.
- State major class contraindications and red-flag AEs.
- Address TB reactivation, vaccines, pregnancy, and monitoring.
- Avoid unsafe combinations and live vaccines while immunosuppressed.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Class matching | Psoriasis: anti-IL-17 or anti-IL-23 highly effective (TNF alternatives; consider PsA); AD: dupilumab / IL-13 first-line advanced; AA: JAK inhibitors; CSU: omalizumab; pemphigus: rituximab[1][2][3] |
| Screening bundle | IGRA/Quantiferon + CXR, HBsAg/anti-HBc/anti-HBs, HCV, HIV as indicated, FBC/LFTs/lipids as class requires, infection history, malignancy history, pregnancy test when relevant |
| Class-specific CI | IL-17 inhibitors: avoid/caution in active IBD (can worsen Crohn/UC); candidiasis risk; JAK inhibitors: infection, zoster, VTE/MACE/malignancy boxed warnings — VTE risk assessment; TNF: TB reactivation, demyelination, heart failure cautions[1][6] |
| TB pathway | Never start anti-TNF (or most biologics) with untreated latent TB; complete/ensure adequate latent TB treatment and specialist input before initiation |
| Vaccines | Update inactivated vaccines (including recombinant zoster, pneumococcal, influenza) ideally before therapy; avoid live vaccines while on significant immunosuppression |
| Pregnancy notes | Prefer agents with better pregnancy data when relevant (e.g. certolizumab among anti-TNF because minimal Fc-mediated placental transfer); counsel shared decision-making for other classes |
| Monitoring & safety-net | Infection red flags, zoster, bloods for JAKs, when to hold drug peri-operatively/infection; clear follow-up |
Model key actions
- Choose a psoriasis pathway inhibitor (IL-17 or IL-23) after methotrexate failure, unless IBD symptoms push away from IL-17.[1][6]
- Complete TB/hepatitis screening before any advanced systemic immunomodulator.
- Counsel class-specific risks (IBD with IL-17; VTE/zoster with JAK; TB with TNF) and vaccine rules.[2][3]
Common errors
- Starting anti-TNF/biologic without latent TB screen.
- Prescribing IL-17 inhibitor despite active IBD symptoms.
- Starting a JAK inhibitor without VTE/CV risk discussion.
- Giving live vaccines after immunosuppression starts.
- Picking a random biologic without linking target to disease biology.
References4ShowHide
- [1]Armstrong AW, Read C. Pathophysiology, Clinical Presentation, and Treatment of Psoriasis: A Review. JAMA, 2020.PMID 32427307
- [2]Chu DK, Schneider L, Asiniwasis RN, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Annals of Allergy, Asthma & Immunology, 2024.PMID 38108679
- [3]Mateos-Haro M, Novoa-Candia M, Sánchez Vanegas G, et al. Treatments for alopecia areata: a network meta-analysis. Cochrane Database of Systematic Reviews, 2023.PMID 37870096
- [6]Azuaga AB, Ramírez J, Cañete JD. Psoriatic Arthritis: Pathogenesis and Targeted Therapies. International Journal of Molecular Sciences, 2023.PMID 36902329