Derm Cases · Dermatology / Infectious Diseases / Sexual Health
OSCE — clustered vesicles on erythematous base: herpes simplex management
An 8-minute OSCE station on HSV recognition, first-episode versus episodic versus suppressive antivirals with doses, eczema herpeticum and ocular red flags, pregnancy/neonatal issues, and patient counselling.
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Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on HSV recognition, first-episode versus episodic versus suppressive antivirals with doses, eczema herpeticum and ocular red flags, pregnancy/neonatal issues, and patient counselling.
Brief (to candidate)
A 26-year-old woman presents on day 2 of painful grouped vesicles on an erythematous base at the vermilion border after a tingling prodrome; she reports 4–5 similar episodes yearly. She is otherwise well, not pregnant, and has mild atopic eczema. You have 8 minutes to confirm the diagnosis, choose antiviral strategy, screen red flags, and counsel on transmission and recurrence.
Candidate instructions
- Recognise recurrent herpes labialis morphology and prodrome.
- Outline diagnostic options (clinical ± PCR).
- Prescribe episodic therapy correctly; state when suppressive therapy is indicated.
- Screen eczema herpeticum, keratitis, encephalitis, neonatal risk.
- Counsel transmission, triggers, and sexual health if genital disease discussed.
- Give clear disposition and safety-net.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Clustered vesicles on erythematous base after prodromal tingling = HSV; lifelong latency in sensory ganglia; HSV-1/2 both can be oro-labial or genital[1][2] |
| Diagnosis | Clinical diagnosis often sufficient for classic labialis; HSV PCR from vesicle fluid is gold standard when atypical, severe, pregnant, or genital first episode |
| Episodic Rx | Start at prodrome: valaciclovir 500 mg BD × 3 days (or aciclovir 400 mg TDS × 5 days; labialis single-day high-dose valaciclovir options); oral > topical cream efficacy[3] |
| Suppressive Rx | Offer if ≥6 genital recurrences/year, severe episodes, HSV-triggered EM, immunocompromise, or transmission reduction: e.g. valaciclovir 500 mg OD (or aciclovir 400 mg BD)[3][4] |
| Red flags | Eczema herpeticum (monomorphic punched-out erosions + fever in atopic skin) → systemic/IV aciclovir; dendritic keratitis → urgent ophthalmology; encephalitis → IV aciclovir 10 mg/kg q8h empirically; neonatal HSV risk counselling if relevant |
| Pregnancy notes | Primary genital HSV near delivery → caesarean consideration; recurrent genital HSV → suppressive aciclovir/valaciclovir from 36 weeks |
| Communication | Stigma-sensitive explanation; triggers (UV, fever, stress); not curable but controllable; return if eye pain, widespread facial/atopic dissemination, or neurological symptoms |
Model key actions
- Diagnose recurrent herpes labialis; start valaciclovir 500 mg BD × 3 days at prodrome.[2][3]
- Discuss suppressive therapy given frequent recurrences; safety-net eczema herpeticum given atopic history.[4]
- Do not promise sterilising cure; explain latency and shedding.
Common errors
- Incising herpetic whitlow or treating as bacterial abscess.
- Topical steroid without antiviral on facial vesicles in atopic patient.
- Missing ocular HSV (pain, photophobia, dendritic ulcer).
- Wrong zoster-level dosing for simple labialis (or under-dosing first-episode genital disease).
- No advice on starting treatment at prodrome.
References4ShowHide
- [1]Zhu S, Viejo-Borbolla A. Pathogenesis and virulence of herpes simplex virus. Virulence, 2021.PMID 34676800
- [2]Groves MJ. Genital Herpes: A Review. American Family Physician, 2016.PMID 27281837
- [3]Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR. Recommendations and reports, 2021.PMID 34292926
- [4]Van Wagoner N, Qushair F, Johnston C. Genital Herpes Infection: Progress and Problems. Infectious disease clinics of North America, 2023.PMID 37105647