2. • INTRODUCTION
• Clinical signs to elicit characteristics of blisters are a
crucial part of the examination of patients with
vesiculobullous disorders.
4. Nikolsky’s sign
• History
• In 1894, Russian dermatologist Pyotr V Nikolskiy,
reported a mechanical phenomenon that would later be
internationally recognized by the eponym crediting his
name–the Nikolsky sign.
• In 1896, his thesis on pemphigus foliaceus described the
clinical finding, and his later work suggested that the
underlying pathologic process was acantholysis occurring
in affected areas as well as in areas with intact, normal-
appearing skin.
5. • Definition: Nikolsky's sign refers to the ability to
induce peripheral extension of a blister as a
consequence of applying lateral pressure to the
border of an intact blister.
• Indication to perform
oTo differentiate intraepidermal from subepidermal
blister.
6. PATHOPHYSIOLOGY
• The mechanism of Nikolsky’s sign most likely reflects
the underlying pathologic disease process.
• The primary histologic finding in patients with
pemphigus is acantholysis with the occurrence of
suprabasal epidermal/intraepidermal splits these
events presumably contribute to the epidermal
separation characteristic of a positive Nikolsky’s sign.
7. • Method to elicit:
• The sign is best elicited by applying lateral pressure
with the thumb or finger pad on skin over a bony
prominence.
• This results in a shearing force that dislodges the
upper layers of epidermis from the lower epidermis.
• The sign is said to be positive if the upper epidermis
separates from the lower.
8.
9. Variants of nikolsky’s sign
• Marginal nikolsky:
nikolsky sign elicited over
the normal looking skin of
a pemphigus patient close
to existing lesions.
10. • Direct nikolsky sign:
nikolsky sign elicited
over the normal looking
skin at a distant site.
• Positive direct nikolsky
sign indicates severe
activity of the disease in
pemphigus.
11. • Modified nikosky’s sign: it is the peripheral
extension of blisters on applying pressure to their
surface.
• This is helpful in patients in whom a new vesicle or
bulla is not available for biopsy.
• The advantage here is that artificially extended
blister does not show epithelial regeneration, which
may some times be seen in floor of older
subepidermal blisters making them appear as
intraepidermal
12. • Sheklakov sign/ false-nikolsky sign:
• This is positive in sub epidermal blistering disorders
like
1. Bullous pemphigoid,
2. Cicatricial pemphigoid,
3. Pemphigoid gestationis,
4. Dermatitis herpetiformis,
5. Linear IgA bullous dermatosis,
6. Epidermolysis bullosa acquisita,
7. Junctional & dystrophic epidermolysis bullosa,
8. Porphyrias and
9. Bullous SLE.
13. • This is elicited by pulling the peripheral remnant of a
roof of a ruptured blister, thereby extending the
erosion on the surrounding normal skin.
• It is called false nikolsky because it is a subepidermal
cleavage occuring in the perilesional skin.
14. • Pseudo nikolsky sign/epidermal peeling sign:
• This is positive in
1. Steven johnson syndrome
2. Toxic epidermal necrolysis
3. Burns
4. Bullous icthyosiform erythroderma.
15. • The method of eliciting is same as that for nikolsky
sign.
• It can be elicited only on the involved or
erythematous skin.
• Here the underlying mechanism is necrosis of
epidermal cells and not acantholysis as in true
nikolsky.
16. • “Wet” nikolsky’s sign: in which a moist, glistening
base of eroded skin is seen after pressure is exerted
on the skin.
• “Dry” nikolsky’s sign: in which a dry base of eroded
skin is seen after pressure is exerted on the skin.
17. Implications of nikolsky’s sign
oDiagnostic value of Nikolsky’s sign
• Nikolsky’s sign is moderately sensitive & highly
specific in the diagnosis of pemphigus.
• Marginal Nikolsky’s sign is more sensitive (69%).
• Direct Nikolsky’s sign is more specific (100%).
18. oPrognostic value of Nikolsky’s sign
• The nikolsky’s sign is positive in the active or
progressive stage of pemphigus.
• It becomes negative when a patient receives
immunosuppressive therapy & it indicates the end of
acute stage of the disease.
19. • In patients with active pemphigus vulgaris, a wet
nikolsky’s sign is expected,
• Whereas the presence of the dry nikolsky’s sign may
indicate reepithelialization beneath a pemphigus
blister, which could signify healing and thus be a
favorable finding.
20. • Nikolsky phenomenon
• It is the term applied when the superficial layers of
the epidermis is felt to move over the deeper layer,
instead of forming an erosion as in nikolsky’s sign, a
blister develops after some time.
21. • Bulla spread sign/ lutz sign
• Method: the margin of an intact bulla is marked by a
pen. Slow careful and unidirectional pressure applied
by a finger to the bulla causes peripheral extension
of the bulla beyond the marked margin.
• In pemphigus vulgaris the bulla thus extended has an
irregular angulated border.
• In subepidermal bullous disorders it has a regular
and rounded border.
22. Bulla spread sign/ asboe-hansen sign
Modified bulla spread sign where pressure is applied
to the centre of the lesion.
