Generalized exfoliation associated with Staphylococcus aureus infection.

A 67-year-old man presented with a rash that was refractory to systemic corticosteroid therapy. Physical examination revealed sloughing skin on his hands, soles, and lower extremities. Stroking involved and uninvolved skin produced Nikolsky's sign. Skin biopsies revealed the plane of cleavage to be in the basal epidermal layer. Cultures of the patient's skin, blood, nose, and throat grew Staphylococcus aureus. These isolates produced an epidermal toxin that caused Nikolsky's sign in neonatal mice. The toxin caused cleavage in the basal epidermal layer of neonatal mice, was heat labile, and was not neutralized by exfoliatin antitoxin.