A 45-year-old lady sought dermatology consultation for severely tender erythematous vesicles and bullae over back, chest and arms.

These were sudden in onset associated with fever, nausea and malaise.

Along with this she also complained of pain in upper abdomen.

There was no history of receiving any drugs prior to the onset of lesions.

She did not report any significant weight loss or loss of appetite.

On physical examination, her temperature was 38°C, pulse rate was 100/min and blood pressure was 126/72 mm Hg.

There were multiple coalescing vesicles and bullae over upper back, chest and arms distributed symmetrically showing areas of pustulation and necrosis.

Surrounding them were multiple pseudovesicular satellite papule (figure 1A,B).

On per abdominal examination mild tenderness was present in the right hypochondrium.

Patient's initial laboratory investigations showed a total leucocyte count of 12 000 cells/mm3 with 75% neutrophils.

The haemoglobin level was 14.3 gm% and erythrocyte sedimentation rate was 30 mm/h.

Liver function test, kidney function test and C reactive protein levels were within normal limits.

Gram stain from purulent exudates showed only neutrophils without any organisms and culture did not show any growth after 72 h of incubation.

A lesional skin biopsy taken from the satellite papule showed neutrophilic infiltration in dermis with papillary dermal oedema and spongiosis (figure 2A,B).

Abdominal ultrasonography revealed intraluminal gall bladder mass suggestive of malignancy.

On the basis of these findings a final diagnosis of SS associated with gall bladder malignancy was made.

She was started on oral prednisolone in dose of 40 mg daily along with symptomatic treatment.

Her cutaneous lesions responded dramatically and subsided completely after 1 week of treatment (figure 3A,B).

Dose of prednisolone was tapered and an open cholecystectomy was performed.

Histopathology of excised tissue confirmed it to be well-differentiated gall bladder adenocarcinoma forming glands and papillae infiltrating the muscularis propria superficially.

Cystic duct cut margins were free of tumour (figure 2C,D).

Patient's postoperative period was uneventful and she was discharged on tapering doses of prednisolone with advice to follow-up periodically.