MBBS OSCE · Dermatology / Respiratory / Ophthalmology
OSCE — non-caseating granulomas on skin and Löfgren: diagnose cutaneous sarcoidosis
An 8-minute OSCE station on specific vs non-specific cutaneous sarcoidosis, lupus pernio and scar sarcoid, Löfgren syndrome, systemic work-up, and stepwise therapy from topical steroids to systemic agents per ERS framing.
8 min stationVerification in progress
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Exam tags
NEET-PGINICETUSMLEPLABMRCP
Brief (to candidate)
A 34-year-old woman presents with tender red pretibial nodules, bilateral ankle arthritis and bilateral hilar lymphadenopathy on CXR. A second patient has violaceous plaques on the nose and cheeks (lupus pernio) with chronic cough. You have 8 minutes to classify cutaneous sarcoidosis, complete systemic staging, and outline treatment intensity.
Candidate instructions
- Define sarcoidosis histologically and list major organ targets.
- Separate specific (granulomatous) cutaneous forms from non-specific EN/Löfgren.
- Recognise lupus pernio, scar sarcoid, and red-flag organ disease.
- Plan work-up (CXR/HRCT, eyes, ECG/cardiac, calcium, ACE with caveats).
- Outline therapy ladder from observation/topicals to systemic agents.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Definition | Multisystem disease with non-caseating ("naked") granulomas; lungs ~90%, skin 25–30%, eyes, nodes, heart, CNS possible[1] |
| Specific skin | Maculopapular, plaque, nodular, lupus pernio (chronic disfiguring centrofacial), scar/tattoo infiltration — biopsy shows sarcoidal granulomas[3][4] |
| Non-specific / Löfgren | Erythema nodosum + bilateral hilar lymphadenopathy ± migratory polyarthritis/fever = Löfgren syndrome — acute sarcoid phenotype with good prognosis; EN itself is not granulomatous skin sarcoid[5] |
| Diagnosis | Compatible clinicoradiology + non-caseating granulomas on tissue when needed + exclusion of TB/fungi/foreign body; CXR stages; serum calcium; eye exam; ECG/cardiac symptoms pathway |
| Red flags | Cardiac sarcoid (block, VT, sudden death risk); neurosarcoid; hypercalcaemia; chronic fibrotic lung disease; treatment-resistant lupus pernio signalling chronic systemic disease |
| Therapy | Limited skin: potent topicals/intralesional steroids; systemic disease/disfiguring skin: oral corticosteroids first-line systemic; steroid-sparing (MTX, etc.) and advanced agents per organ severity — align with ERS treatment principles[2] |
| Communication | Explain EN/Löfgren often self-limited vs chronic plaque/lupus pernio needing long-term care |
Model key actions
- Diagnose Löfgren from EN + bilateral hilar adenopathy ± arthritis and recognise excellent prognosis.[1][5]
- Label lupus pernio as chronic specific cutaneous sarcoid needing systemic staging and often systemic therapy.[3]
- Screen eyes, heart, calcium, lungs before assuming "skin-only" disease.[2]
Common errors
- Treating EN as infection without looking for sarcoid/TB/strep/IBD triggers.
- Missing cardiac screening in systemic sarcoidosis.
- Assuming ACE level alone diagnoses sarcoidosis.
- Biopsying classic complete Löfgren unnecessarily when clinical diagnosis is clear, or conversely failing to biopsy atypical chronic plaques.
- Ignoring ocular sarcoid risk (uveitis).
References5ShowHide
- [1]Sève P, Pacheco Y, Durupt F, et al. Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis. Cells, 2021.PMID 33807303
- [2]Baughman RP, Valeyre D, Korsten P, et al. ERS clinical practice guidelines on treatment of sarcoidosis. The European respiratory journal, 2021.PMID 34140301
- [3]Ezeh N, Caplan A, Rosenbach M, et al. Cutaneous Sarcoidosis. Dermatologic Clinics, 2023.PMID 37236714
- [4]Abdelghaffar M, Hwang E, Damsky W. Cutaneous Sarcoidosis. Clinics in chest medicine, 2024.PMID 38245372
- [5]Pérez-Garza DM, Chavez-Alvarez S, Ocampo-Candiani J, et al. Erythema Nodosum: A Practical Approach and Diagnostic Algorithm. American Journal of Clinical Dermatology, 2021.PMID 33683567