83-year-old man presents to you with new-onset vesicular rash

This finding doubles the patient’s risk of developing chronic ocular inflammation with possible vision loss.

This patient’s presentation is most consistent with herpes zoster (shingles), which is due to reactivation of latent Varicella infection. The lifetime risk of any reactivation (anywhere in the body) is about 10% to 20%. About 1 in 3 Americans will develop shingles in their lifetime. The risk increases with age, as does the risk of postherpetic neuralgia. This risk is increased in people aged 50 years or older, and 10% to 25% of these cases specifically involve the ophthalmic division of the trigeminal nerve (herpes zoster ophthalmicus). Despite its name, only one-third of patients with herpes zoster ophthalmicus will have ocular involvement (conjunctivitis, keratitis, uveitis), which can lead to blindness, corneal denervation, and chronic ocular inflammation.

Among patients with herpes zoster ophthalmicus, some will also have a herpes lesion on the tip of their nose. This signifies an involvement of the nasociliary branch (innervates the tip of the nose) and is known as a Hutchinson sign. Patients with herpes zoster ophthalmicus and a Hutchinson sign have twice the incidence of ocular involvement as those without a Hutchinson sign.

Permanent sequelae of ophthalmic zoster infection with eye involvement may include chronic ocular inflammation, loss of vision, and debilitating pain. Antiviral medications, such as acyclovir, valacyclovir, and famciclovir, are the mainstay of therapy and are most effective in preventing ocular involvement when started within 72 hours after the onset of rash. Famciclovir and valacyclovir have fewer adverse events and offer a more convenient dosing schedule than acyclovir. Timely diagnosis and management of herpes zoster ophthalmicus, with referral to an ophthalmologist when ophthalmic involvement is present, are critical in limiting visual morbidity.

Hutchinson sign is not associated with oral lesions and is not an independent predictor of autoimmune disorders.

Ramsay Hunt syndrome (herpes zoster oticus) occurs when a shingles infection affects the facial nerve near an ear. In addition to a painful shingles rash, Ramsay Hunt syndrome can cause facial paralysis and hearing loss in the affected ear. Hutchinson sign is not associated with herpes zoster oticus, thus a specialized ear examination is not necessary in patients with Hutchinson sign.

References:

Bell A. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2011;83(12):1432-1437.

Carlislie R. Differential diagnosis of a swollen red eyelid. Am Fam Physician. 2015;92(2):106-112.

Haile-Mariam T, May L. Viral illnesses. In: Marx JA, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed., 2014:1718-1741.

Johnson JL, Amzat R, Martin N. Herpes zoster ophthalmicus. Prim Care. 2015;42(3):285-303.