Research Article

Positive nikolsky sign and “pinpoint lake of pus” in acute generalized exanthematous pustulosis: a case report

Ketut Alit Pinidha Savitri , Ketut Suteja Wibawa, Komang Harry Supradnyan

Ketut Alit Pinidha Savitri
General Practitioner, Singaraja Regional Hospital, Buleleng, Bali-Indonesia. Email:

Ketut Suteja Wibawa
Dermatology and Venereology Department, Singaraja Regional Hospital, Buleleng, Bali-Indonesia

Komang Harry Supradnyan
Dermatology and Venereology Department, Singaraja Regional Hospital, Buleleng, Bali-Indonesia
Online First: March 03, 2020 | Cite this Article
Savitri, K., Wibawa, K., Supradnyan, K. 2020. Positive nikolsky sign and “pinpoint lake of pus” in acute generalized exanthematous pustulosis: a case report. Intisari Sains Medis 11(1): 97-99. DOI:10.15562/ism.v11i1.579

Introduction: Acute generalized exanthematous pustulosis (AGEP) is a severe, usually drug-related reaction, characterized by an acute onset of mainly small non-follicular pustules on an erythematous base and spontaneous resolution usually within two weeks. Current report aims to present management of AGEP in our center at Singaraja Regional Hospital, Bali-Indonesia.

Case: A 78 years old woman with a history of acute coronary syndrome, was reported to have a severe allergic drug reaction. Patients reported taking cefixime medication for the past 2 days because of acute bronchitis. The patient was hospitalized because of the complaint, and diffuse miliary pustules were found above the base of erythematous skin. On examination of lesions, the Nikolsky sign was positive on lesions in the back and abdomen without any tenderness. Histopathological examination was suitable for the diagnosis of acute generalized exanthema pustulosis (AGEP). Systemic intravenous corticosteroid with oral antihistamines was choosen as a primary treatment for this patient.

Conclusion: Treatment is based on the removal of the causative drug, supportive care, infection prevention and use of potent topical or systemic steroids


Christina Y, Wong M, Steven D, Billings M, Christine W. Positif Nikolsky Sign and Pinpoint Lake of Pus. The National Society for Cutaneous Medicine. 2017; 1(2):86-9.

Gaud C, Florence A, Christian C, Tristan F. Acute Generalised Exanthematous Pustulosis due to Prisyinamycin. BMJ Case Report. 2013; 10(11): 1-4.

Michael M, Nektaria S, Fani G. Acute Generalized Exanthematous Pustulosis (AGEP) Triggered by a Spider Bite. Journal of Allergology International. 2009; 58(2): 301-03.

Kumutnart H. Five Year Retrospective Review of Acute Generalized Exanthema Pustulosis. Dermatology Research and Practice. 2015;8(1): 1-6.

Mohammed H, Salhamooud A, Abdel G, Nabeel N. Acute Generalized Exanthematous Pustulosis: An Unusual Side Effect of Meropenem. Indian Journal Dermatology. 2010; 55(2): 176-77.

Siew C, Yi S, Nai L, Evelyn S, Xiao Y, Nalini N, Madhavan. Clinical Characteristics, Culprit Drugs and Outcome of Patients with Acute Generalised Exanthematous Pustulosis seen in Hospital Sultanah Aminah, Johor Bahru. Medical Journal Malaysia. 2018; 73(4): 220-24.

Mindy M, Sampson, Olga K, Julie V, Beata C. A Plethora of Pustules: Acute Generalized Exanthematous Pustulosis. The American Journal of Medicine. 2018; 131(6): 639-41.

Oscar M, Rosario C, Elena S, Luis B. Acute Generalized Exanthematous Pustulosis Simulating Stevens-Johnson Syndrome/ Toxic Epidermal Necrolysis Associated with use of Vismodegib. JAAD Case Report. 2018; 4(1): 123-25.

No Supplementary Material available for this article.
Article Views      : 211
PDF Downloads : 111