Derm Cases · Dermatology / Oral Medicine / General Medicine
OSCE — assessment of cutaneous and mucosal lichen planus with hepatitis C screening
An 8-minute OSCE station assessing recognition of the 6 Ps and Wickham striae, oral/nail/scalp examination, hepatitis C association, and stepwise management of cutaneous and oral lichen planus per European guidance.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station assessing recognition of the 6 Ps and Wickham striae, oral/nail/scalp examination, hepatitis C association, and stepwise management of cutaneous and oral lichen planus per European guidance.
Brief (to candidate)
A 48-year-old man has intensely itchy, flat-topped violaceous papules on the flexor wrists and shins for 4 months, white lacy streaks in the buccal mucosa, and recent longitudinal nail ridging with one pterygium. You have 8 minutes to confirm the diagnosis, examine all key sites, screen associations, and outline management.
Candidate instructions
- Describe classic cutaneous morphology (the 6 Ps) and Wickham striae.
- Examine/state need to examine oral cavity, nails, scalp/genital mucosa.
- Discuss hepatitis C screening rationale and other associations (drugs, dental amalgam debate for oral disease).
- Outline topical and systemic treatment by site and severity.
- Counsel on chronicity, malignant risk in chronic erosive oral LP, and follow-up.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Pruritic, purple, polygonal, planar, papules/plaques (6 Ps) ± Wickham striae; flexor wrists, shins, sacral area classic; Koebner phenomenon may be noted[2] |
| Site survey | Oral (reticular Wickham network, erosive forms), nails (thinning, ridging, pterygium, anonychia risk), scalp (lichen planopilaris → scarring alopecia), genitalia if indicated[5] |
| Associations | Screens for HCV (especially oral LP / endemic regions); drug-induced lichenoid eruptions; autoimmune thyroid disease sometimes coexists; biopsy if atypical[7] |
| Cutaneous Rx | Potent/superpotent topical corticosteroids first-line; occlusion for hypertrophic LP; phototherapy or systemic (e.g. oral corticosteroids short course, other immunosuppressants) for extensive disease per guidelines[1] |
| Oral / nail Rx | Oral: topical corticosteroid gels/pastes or TCI; dental review; systemic therapy for severe erosive disease; nail LP needs early aggressive therapy to prevent irreversible dystrophy[1][5] |
| Safety & malignancy | Chronic erosive oral LP → monitor for SCC; stop culprit drugs if lichenoid drug eruption; explain itch control and pigmented sequelae (PIH) |
| Communication | Sets expectations (months course; post-inflammatory hyperpigmentation common in skin of colour); clear review plan |
Model key actions
- Diagnose classic cutaneous LP with oral and nail involvement; name Wickham striae and the 6 Ps.[2]
- Order HCV serology when appropriate; examine all mucosae/nails/scalp.[7]
- Start potent topical steroids for skin; site-specific oral/nail plans; escalate per European S1 guidance if extensive/erosive.[1]
Common errors
- Examining only skin and missing oral / nail / scarring scalp disease.
- Omitting HCV consideration in oral LP.
- Under-treating nail LP until permanent dystrophy.
- Ignoring erosive oral LP cancer surveillance.
- Misdiagnosing as psoriasis without noting violaceous flat-topped morphology and mucosal findings.
References5ShowHide
- [1]Ioannides D, Vakirlis E, Kemeny L, et al. European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology. Journal of the European Academy of Dermatology and Venereology, 2020.PMID 32678513
- [2]Le Cleach L, Chosidow O. Clinical practice. Lichen planus. New England Journal of Medicine, 2012.PMID 22356325
- [5]Gupta MK, Lipner SR. Review of Nail Lichen Planus: Epidemiology, Pathogenesis, Diagnosis, and Treatment. Dermatologic Clinics, 2021.PMID 33745635
- [7]García-Pola M, Rodríguez-Fonseca L, Suárez-Fernández C, et al. Bidirectional Association between Lichen Planus and Hepatitis C-An Update Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 2023.PMID 37762719
- [8]Atzmony L, Reiter O, Hodak E, Gdalevich M, Mimouni D. Treatments for Cutaneous Lichen Planus: A Systematic Review and Meta-Analysis Am J Clin Dermatol, 2016.PMID 26507510