MBBS OSCE · Dermatology / Emergency medicine / Critical care
OSCE — toxic epidermal necrolysis and red-flag skin emergencies: triage, SCORTEN and immediate care
An 8-minute OSCE station on recognising SJS/TEN and other dermatologic emergencies, calculating SCORTEN, stopping culprits, fluid/wound care, and differentiating DRESS, NF, meningococcaemia and SSSS.
8 min stationSource-verified ·
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Exam tags
NEET-PGINICETUSMLEPLABMRCP
Brief (to candidate)
A 60-year-old man developed painful dusky erythema and sheet-like epidermal detachment involving ~25% BSA with severe oral and ocular erosions 10 days after starting allopurinol and a sulphonamide antibiotic. He is febrile and tachycardic. You have 8 minutes to diagnose, score severity, resuscitate and disposition.[10][23][9]
Candidate instructions
- Recognise SJS/TEN spectrum and estimate BSA detachment.
- Calculate / list SCORTEN components.
- Immediate actions: stop drugs, fluids, wound/eye care, ICU/burns pathway.
- Differentiate key emergencies: DRESS, AGEP, SSSS, necrotising fasciitis, purpura fulminans.
- High-level specific therapies and what not to delay.
- Multidisciplinary communication (derm, ICU, ophth, plastics).[9][10][11]
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition SJS/TEN | Painful necrolysis, +Nikolsky, mucosal sites, recent high-risk drug; Bastuji-Garin 1993: SJS below 10%, overlap 10–30%, TEN with spots above 30% BSA; this case ~25% is overlap[23] |
| SCORTEN | Seven points: age above 40, malignancy, HR above 120, detachment above 10%, urea above 10 mmol/L, glucose above 14 mmol/L, bicarbonate below 20 mmol/L — TEN mortality about 30%; OR 3.45 per point[9] |
| Immediate care | Stop all culprit drugs; ABC, careful fluid resuscitation (not classic Parkland overfill), aseptic wound care, early ophthalmology, analgesia, infection surveillance, ICU/burns unit transfer; avoid unnecessary skin trauma[2][10] |
| Other emergencies | DRESS: delayed fever/rash/eos/organ injury; SSSS: paediatric, toxin-mediated, no full-thickness necrolysis of mucosa like TEN; NF: pain out of proportion, surgical emergency (LRINEC adjunct only); purpura fulminans/meningococcaemia: sepsis + purpura — antibiotics immediately; anaphylaxis: IM adrenaline[1][7][11][12] |
| Adjunct Rx | Supportive care is cornerstone for TEN; systemic immunomodulation controversial/specialist (e.g. ciclosporin, etanercept, IVIG protocols vary) — do not delay supportive/ICU care debating agents[10] |
| Disposition | Level 2/3 care; burn-unit-style nursing; document allergy; contact tracing of all recent drugs[10] |
| Communication | Clear family explanation of high mortality risk; urgent multi-specialty involvement[10][9] |
Model key actions
- Call TEN/SJS spectrum emergency; stop culprits; calculate SCORTEN; transfer to ICU/burns pathway with eye care.[9][10][2]
- Run a parallel emergency differential for NF, meningococcaemia, DRESS, SSSS when morphology/timeline differ.[1][11]
- Prioritise resuscitation and organ support over unproven mono-therapy debates.[10]
Common errors
- Treating TEN as "bad eczema" on the ward without ICU transfer.
- Forgetting ophthalmology and mucosal care.
- Massive fluid over-resuscitation as if thermal burn percentages alone dictate volume.
- Delaying antibiotics in purpura fulminans while arranging dermatology review.
- Using SCORTEN as a reason to withhold care rather than to escalate.[9][10][11]
References8ShowHide
- [1]Gruver JR, Kirkorian AY. Pediatric dermatologic emergencies. Current Opinion in Pediatrics, 2024.PMID 39400084
- [2]Usatine RP, Sandy N. Dermatologic emergencies. American Family Physician, 2010.PMID 20879700
- [7]Awad A, Goh MS, Trubiano JA Drug Reaction With Eosinophilia and Systemic Symptoms: A Systematic Review. Journal of Allergy and Clinical Immunology: In Practice, 2023.PMID 36893848
- [9]Bastuji-Garin S, Fouchard N, Bertocchi M, et al. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. Journal of Investigative Dermatology, 2000.PMID 10951229
- [10]Jacobsen A, Olabi B, Langley A, et al. Systemic interventions for treatment of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome Cochrane Database of Systematic Reviews, 2022.PMID 35274741
- [11]Fernando SM, Tran A, Cheng W, et al. Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging, and LRINEC score. Annals of Surgery, 2019.PMID 29672405
- [12]Tarricone A, Mata K, Gee A, et al. LRINEC score for the prediction of necrotizing fasciitis: a systematic review and meta-analysis. Journal of Foot and Ankle Surgery, 2022.PMID 34657810
- [23]Bastuji-Garin S, Rzany B, Stern RS, et al. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme Arch Dermatol, 1993.PMID 8420497