The Dermatologic Nikolsky Sign: How Good is it?

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.

This article originally appeared in the May 2006 issue Internal Medicine Alert. It was reviewed by the physician editor, Stephen Brunton, MD, and peer reviewed by Gerald Roberts, MD.

Pv Nikolsky was a Russian dermatologist who published information about Pemphigus foliaceus in 1896. He was the first to describe an altered structural integrity of the epidermis in pemphigus. The Nikolsky Sign (also commonly spelled Nikolskiy) is performed by placing pressure upon skin adjacent to tissue involved with bullae. In pemphigus, because the attachments of the intraepidermal intercellular bridges are damaged, skin pressure will allow the bulla to dissect further within the epidermis, as the layers separate due to IgG-mediated attachment defects. Although at one time considered specific to pemphigus, Nikolsky Sign has been sometimes reported in association with other skin disorders, such as toxic epidermal necrolysis, mycosis fungoides, and epidermolysis bullosa.

To study the sensitivity and specificity of the Nikolsky Sign, patients (n = 127) with a variety of bullous lesions were tested. The sensitivity for diagnosis of pemphigus by Nikolsky sign was only 38%.1 Disorders other than pemphigus also manifest Nikolsky sign. A positive Nikolsky sign is useful to support the diagnosis of pemphigus, but is also seen in other disorders.

Reference

1. Uzun S, Durdu M. The Specificity of Sensitivity of Nikolskiy Sign in the Diagnosis of Pemphigus. J Am Acad Dermatol. 2006;54:411-415.