Skin sloughing and lip lesions after a recent foot procedure.

Volume 91, Number 2 www.aafp.org/afp American Family Physician 123 An 84-year-old woman presented with a one-week history of fever, blistering lips, and progressive skin sloughing. She had diffuse muscle aches and increased facial pigmentation and edema without recent sun exposure. Her history was significant for removal of a toenail by a podiatrist three weeks earlier. The podiatrist prescribed an antibiotic. Physical examination revealed a large area of epidermal skin sloughing on her left upper back and elbows (see accompanying figure). She had hemorrhagic crusting and erosions of the oral mucosa. There were also bullae on her left inner thigh. Nikolsky sign (exfoliation of skin with application of pressure) was present. Initial laboratory tests revealed new acute renal insufficiency with a creatinine level of 3.6 mg per dL (318 μmol per L); it was 0.8 mg per dL (71 μmol per L) at last check one year prior.