Derm Cases · Dermatology / Rheumatology / Respiratory
OSCE — Raynaud, skin thickening and SSc classification: diagnose and screen for organ crisis
An 8-minute OSCE station on recognising limited vs diffuse systemic sclerosis, applying 2013 ACR/EULAR classification, nailfold capillaroscopy and autoantibody patterns, and escalating for ILD, PAH and scleroderma renal crisis.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on recognising limited vs diffuse systemic sclerosis, applying 2013 ACR/EULAR classification, nailfold capillaroscopy and autoantibody patterns, and escalating for ILD, PAH and scleroderma renal crisis.
Brief (to candidate)
A 48-year-old woman has progressive Raynaud phenomenon for 3 years, puffy fingers, facial skin tightening and new dyspnoea on exertion. Blood pressure is normal today. A second card describes malignant hypertension with rising creatinine in a patient with diffuse skin thickening. You have 8 minutes to classify systemic sclerosis, organise autoantibody and organ screening, and manage renal crisis vs ILD/PAH pathways.
[1]Candidate instructions
- Define the pathophysiological triad and clinical gateway of SSc.
- Distinguish limited (lcSSc) vs diffuse (dcSSc) cutaneous subsets and typical antibody links.
- Apply 2013 ACR/EULAR classification framework and role of nailfold capillaroscopy.
- List organ-screening priorities (ILD, PAH, GI, renal).
- State emergency management of scleroderma renal crisis and steroid caution.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Definition / triad | SSc = autoimmune CTD with microvascular vasculopathy, tissue fibrosis, and autoimmunity; Raynaud is the clinical gateway[1][2] |
| Subsets | lcSSc: distal skin (face, neck, distal limbs distal to elbows/knees), CREST pattern, anti-centromere, late PAH risk. dcSSc: proximal trunk/limb involvement early, anti-Scl-70/RNA pol III, higher ILD and renal-crisis risk |
| Classification | ACR/EULAR 2013 weighted criteria (skin thickening of fingers, fingertip lesions, telangiectasia, abnormal nailfold capillaries, lung disease, Raynaud, SSc-related antibodies) — score ≥9 classifies SSc[5] |
| Capillaroscopy / Abs | Scleroderma pattern on nailfold capillaroscopy (giant capillaries, haemorrhage, avascular areas, ramified capillaries); Abs: anti-centromere, anti-topo I (Scl-70), anti-RNA polymerase III[6] |
| Organ screen | HRCT + PFTs for ILD; echo ± right-heart catheter pathway for PAH; GI symptoms; BP and renal function; skin score/mRSS when used |
| Renal crisis | New malignant HTN + AKI in SSc → start ACE inhibitor immediately (captopril classically); do not stop ACEI solely for rising creatinine; avoid high-dose steroids that may precipitate crisis |
| Therapy framing | Organ-based: mycophenolate/other immunosuppression and antifibrotics for progressive ILD as specialist care; vasodilators for Raynaud/PAH; EULAR 2023-aligned multidisciplinary care[7][8] |
Model key actions
- Diagnose SSc using skin thickening + Raynaud + capillaroscopy/antibodies within ACR/EULAR framework.[5]
- Screen for ILD and PAH as major modern mortality drivers.[8]
- Treat renal crisis with ACE inhibitors immediately; warn against injudicious high-dose steroids.[7]
Common errors
- Confusing morphea (localised scleroderma) with systemic sclerosis.
- Missing PAH/ILD screening in longstanding limited disease with dyspnoea.
- Stopping ACEI in renal crisis because creatinine rises.
- Using high-dose steroids without awareness of renal-crisis risk.
- No nailfold capillaroscopy or autoantibody panel when diagnosing early disease.
References6ShowHide
- [1]Di Battista M, Lepri G, Codullo V, et al. Systemic sclerosis: one year in review 2025. Clinical and experimental rheumatology, 2025.PMID 40737082
- [2]Jerjen R, Nikpour M, Krieg T, et al. Systemic sclerosis in adults. Part I: Clinical features and pathogenesis. Journal of the American Academy of Dermatology, 2022.PMID 35131402
- [5]van den Hoogen F, Khanna D, Fransen J, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative. Annals of the rheumatic diseases, 2013.PMID 24092682
- [6]Smith V, Ickinger C, Hysa E, et al. Nailfold capillaroscopy. Best practice & research. Clinical rheumatology, 2023.PMID 37419757
- [7]Del Galdo F, Lescoat A, Conaghan PG, et al. EULAR recommendations for the treatment of systemic sclerosis: 2023 update. Annals of the rheumatic diseases, 2025.PMID 39874231
- [8]Maher TM. Interstitial Lung Disease: A Review. JAMA, 2024.PMID 38648021