Nikolsky's sign

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Nikolsky's sign

Nikolsky's sign is a sign in the skin, in which the top layer of skin comes off by applying pressure to intact skin in a person with a blistering skin disease such as pemphigus, staphylococcal scalded skin syndrome and toxic epidermal necrolysis.[1][2]

It is named after the Russian physician Pyotr Nikolsky (1858–1940).[2]

Signs and symptoms

The sign is present when slight rubbing of the skin results in exfoliation of the outermost layer.[3][4][5][6] A typical test would be to place the eraser of a pencil on the roof of a lesion and spin the pencil in a rolling motion between the thumb and forefinger. If the lesion is opened (i.e., skin sloughed off), then the Nikolsky's sign is present/positive.


Nikolsky's sign is almost always present in Stevens–Johnson syndrome/toxic epidermal necrolysis[7] and staphylococcal scalded skin syndrome, caused by the exfoliative toxin of Staphylococcus aureus.[3] It is also associated with pemphigus vulgaris and pemphigus foliaceus.[8][9] It is useful in differentiating between the diagnosis of pemphigus vulgaris or mucous membrane pemphigoid (where the sign is present) and bullous pemphigoid (where it is absent). The Nikolsky sign is dislodgement of intact superficial epidermis by a shearing force, indicating a plane of cleavage in the skin epidermal-epidermal junctions (e.g., desmosomes). The histological picture involves thinner, weaker attachments of the skin lesion itself to the normal skin – resulting in easier dislodgement.

The formation of new blisters upon slight pressure (direct Nikolsky) and shearing of the skin due to rubbing (indirect Nikolsky) is a sign of pemphigus vulgaris, albeit not a 100% reliable diagnosis.[10] In addition, another physical exam, the Asboe-Hansen signs, must be used to determine the absence of intracellular connections holding epidermal cells together.[11]

See also


  1. James, William D.; Elston, Dirk; Treat, James R.; Rosenbach, Misha A.; Neuhaus, Isaac (2020). "2. Cutaneous signs and diagnosis". Andrews' Diseases of the Skin: Clinical Dermatology (13th ed.). Edinburgh: Elsevier. p. 13. ISBN 978-0-323-54753-6. Archived from the original on 2022-04-17. Retrieved 2022-04-16.
  2. 2.0 2.1 Maity, Subhadeep; Banerjee, Ishita; Sinha, Rupam; Jha, Harshvardhan; Ghosh, Pritha; Mustafi, Subhasish (2020). "Nikolsky's sign: A pathognomic boon". Journal of Family Medicine and Primary Care. 9 (2): 526–530. doi:10.4103/jfmpc.jfmpc_889_19. ISSN 2249-4863. PMID 3231876. Archived from the original on 2022-04-20. Retrieved 2022-04-18.
  3. 3.0 3.1 Moss C, Gupta E (September 1998). "The Nikolsky sign in staphylococcal scalded skin syndrome". Arch. Dis. Child. 79 (3): 290. doi:10.1136/adc.79.3.290. PMC 1717681. PMID 9875032.
  4. "eMedicine - Pemphigus Foliaceus : Article by Robert A Schwartz". 2018-04-03. Archived from the original on 2008-10-25. Retrieved 2021-06-18. {{cite journal}}: Cite journal requires |journal= (help)
  5. Nikolski PV. Materiali K.uchenigu o pemphigus foliaceus [doctoral thesis]. Kiev. 1896.
  6. "MedilinePlus: Nikolsky's sign". Archived from the original on 2016-07-05. Retrieved 2021-06-18.
  7. Asz J, Asz D, Moushey R, Seigel J, Mallory SB, Foglia RP (December 2006). "Treatment of toxic epidermal necrolysis in a pediatric patient with a nanocrystalline silver dressing". J. Pediatr. Surg. 41 (12): e9–12. doi:10.1016/j.jpedsurg.2006.08.043. PMID 17161178.
  8. Ma, O. Emergency Medicine Manual. McGraw Hill. 2004.
  9. Beigi, Pooya Khan Mohammad (2018). "Background". A Clinician's Guide to Pemphigus Vulgaris. Springer, Cham. pp. 3–10. doi:10.1007/978-3-319-67759-0_1. ISBN 9783319677583.
  10. Venugopal, Supriya S.; Murrell, Dédée F. (July 2011). "Diagnosis and clinical features of pemphigus vulgaris". Dermatologic Clinics. 29 (3): 373–380, vii. doi:10.1016/j.det.2011.03.004. ISSN 1558-0520. PMID 21605802.
  11. Corwin, J (2016). "Pemphigus vulgaris. In: Ferri FF, editor". Ferri's Clinical Advisor: 945–6.