Derm Cases · Dermatology / Infectious Diseases / Geriatrics / Ophthalmology
OSCE — painful unilateral dermatomal vesicles: herpes zoster care
An 8-minute OSCE station on herpes zoster recognition, 72-hour antiviral windows with correct doses, ophthalmic and Ramsay Hunt red flags, pain control, PHN risk, and vaccination counselling.
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Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on herpes zoster recognition, 72-hour antiviral windows with correct doses, ophthalmic and Ramsay Hunt red flags, pain control, PHN risk, and vaccination counselling.
Brief (to candidate)
A 68-year-old man has 36 hours of burning pain in a unilateral thoracic band followed by grouped vesicles on an erythematous base that stop at the midline. He is immunocompetent, afebrile, and has no facial or eye involvement. You have 8 minutes to diagnose, start antivirals, assess complications, manage pain, and counsel on contagion and prevention.
Candidate instructions
- Confirm herpes zoster and differentiate from HSV and other vesicular rashes.
- Start first-line antiviral with correct dose and the 72-hour rationale.
- Screen HZO (Hutchinson sign), Ramsay Hunt, disseminated zoster.
- Address acute pain and post-herpetic neuralgia risk.
- Counsel contagion (varicella-naive contacts) and vaccination.
- Disposition and safety-net.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Unilateral dermatomal painful vesicles after sensory prodrome; does not cross midline; VZV reactivation from dorsal root ganglion latency[1][2] |
| Antiviral Rx | Ideally within 72 h of rash onset: valaciclovir 1 g TDS × 7 days or famciclovir 500 mg TDS × 7 days or aciclovir 800 mg five times daily × 7 days; still treat if new lesions forming or immunocompromise beyond 72 h[3] |
| Red flags | HZO / Hutchinson sign (nasal tip) → urgent ophthalmology + antivirals; Ramsay Hunt (ear vesicles + facial palsy) → antivirals ± prednisolone 1 mg/kg; disseminated (>20 vesicles outside dermatome / visceral) → IV aciclovir 10 mg/kg q8h |
| Pain & PHN | Analgesia ladder; PHN risk rises with age; neuropathic agents (e.g. gabapentinoids/TCA) if needed; antivirals reduce acute severity — counsel realistic PHN risk in elderly[4] |
| Isolation advice | Infectious via direct contact with vesicle fluid until crusted; avoid pregnant non-immune, neonates, immunocompromised; cover lesions |
| Prevention | Discuss recombinant zoster vaccine (e.g. Shingrix) for older adults/eligible immunocompromised per local schedule — reduces zoster and PHN |
| Disposition | Outpatient if limited thoracic zoster, stable, can take oral Rx; admit/IV if ocular, neurological, disseminated, severe pain, or high-risk host |
Model key actions
- Diagnose thoracic herpes zoster and start valaciclovir 1 g TDS × 7 days within 72 h.[2][3]
- Explicitly exclude ophthalmic and disseminated disease; counsel contacts and vaccine.[1][4]
- Provide analgesia and PHN safety-net.
Common errors
- Using HSV labialis doses (too low) for zoster.
- Delaying antivirals when still within window / new vesicles appearing.
- Missing Hutchinson sign / HZO eye review.
- No advice on infectious risk to varicella-naive contacts.
- Ignoring vaccine counselling in eligible older adults.
References4ShowHide
- [1]Gershon AA, Breuer J, Cohen JI, et al. Varicella zoster virus infection. Nature Reviews Disease Primers, 2015.PMID 27188665
- [2]Schmader K. Herpes Zoster. Annals of Internal Medicine, 2018.PMID 30083718
- [3]Patil A, Goldust M, Wollina U. Herpes zoster: A Review of Clinical Manifestations and Management. Viruses, 2022.PMID 35215786
- [4]Lim DZJ, Tey HL, Salada BMA, et al. Herpes Zoster and Post-Herpetic Neuralgia-Diagnosis, Treatment, and Vaccination Strategies. Pathogens, 2024.PMID 39057822