DR13.2 | Nikolsky Sign and Bulla Spread Sign — Summary & Reflection

KEY TAKEAWAYS

Nikolsky's sign and the Bulla-spread (Asboe-Hansen) sign are free, equipment-light bedside tests of epidermal adhesion that begin the primary-management pathway required by DR13.2. Nikolsky's sign is elicited by firm, gentle tangential pressure on perilesional normal skin: it is POSITIVE in pemphigus vulgaris (intra-epidermal, anti-desmoglein 3/1 — the epidermis shears) and NEGATIVE in bullous pemphigoid (sub-epidermal, anti-BP180/BP230 — the epidermis holds). The Bulla-spread sign is positive when downward pressure makes an intact bulla extend laterally, supporting an intra-epidermal plane. A positive Nikolsky's sign is not specific — it also occurs in SJS/TEN and staphylococcal scalded skin syndrome — so the signs triage and raise suspicion but do not replace biopsy and DIF. Once a serious blistering disease is recognised, primary management before referral is supportive: non-adherent wound care (never adhesive tape), fluid/electrolyte monitoring and replacement for burn-like fluid loss, analgesic oral care and nutritional support, vigilant infection surveillance, and a short bridging course of prednisolone (~1 mg/kg/day) — followed by early, well-documented referral to dermatology, urgent when erosions are extensive or oral intake fails.

REFLECT

Imagine you are the only doctor on duty when a severely blistered patient arrives, and a dermatologist is hours away. How confident are you, right now, that you could both elicit Nikolsky's sign correctly and deliver the full primary management without forgetting the unglamorous essentials — fluid, nutrition, infection watch, gentle dressings? Which half of this competency is your weaker side: the bedside procedure, or the supportive care that actually keeps the patient alive? Picture yourself explaining to an anxious family why their relative needs urgent transfer, and what you are doing in the meantime to protect them. Commit to one concrete habit — perhaps a mental checklist of 'sign, fluid, skin, mouth, infection, refer' — that you will carry into your first posting so that neither half of this duty is left undone.