Nikolsky's sign

What is Nikolsky’s sign?

Using Nikolsky’s original definition strictly, his eponymous sign is the physical splitting of the epidermis creating an erosion (partial loss of the epidermis) following the application of a shearing force to the surface of the skin seen in pemphigus foliaceus.

However, with time the use of the sign has broadened to include other intraepidermal disorders including pemphigus vulgaris and it has been used to differentiate them from subepidermal disorders. Historically it was a useful clinical sign, but it is now superseded by modern immunohistochemistry and specific antibody testing as knowledge of skin disease has grown since the first description.

The term “pseudo Nikolsky” sign or “Nikolsky’s test” has been applied to Stevens-Johnson syndrome/toxic epidermal necrolysis where the full epidermis is involved but a shearing force propagates the blister.

Who was Pyotr Vasilyevich Nikolsky?

Pyotr Vasilyevich Nikolskiy (1858-1940) was born in Usman, Russia. He was Professor of Dermatology at Warsaw University, Poland, and later head of Department of Dermatology and Venereology at North-Caucasian University, Rostov-on-Don, Russia.

Dr. Pyotr Nikolsky 

His doctoral thesis published in 1896 reported that when rubbing the skin of patients with pemphigus foliaceus “the skin shows a weakening relationship and contact among its layers… on all surfaces even in places between lesions (blisters and excoriations) on the seemingly unaffected skin”. He strongly emphasised a distinction between pemphigus foliaceus and pemphigus vulgaris. Nikolskiy stated that the level of the split was unique to pemphigus foliaceus and that only this disease elicits a positive sign.

He credits his teacher, Professor Mikhail Ivanovich Stoukavenkow of the University of Kyiv, for first recognising the sign.

His name was spelt Nikolskiy but the term Nikolsky is commonly used.

How do you elicit Nikolsky’s sign?

There are three methods to elicit Nikolsky’s sign:

• Apply firm pressure using the thumb or finger to an unaffected, intact area of skin. If present, the stratum corneum will be displaced, revealing the underlying granular surface. This is best elicited if conducted over a bony prominence.
• Pull on the residual roof of a ruptured blister which will be withdrawn over long distances of normal appearing skin.
• Apply lateral pressure to an intact lesion, resulting in peripheral extension on visibly normal skin.

What conditions are associated with a positive Nikolsky’s sign?

• Pemphigus foliaceus
• Pemphigus vulgaris
• Staphylococcal scalded skin syndrome
• Epidermolysis bullosa (some subtypes)
• Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (“Pseudo” Nikolsky sign or “test”)