The correct answer is:

This finding doubles the patient’s risk of possible vision loss.

Educational Objective:

Discuss the association of a rash on the nose with the risk of possible vision loss.

Key Point:

This patient’s presentation is most consistent with herpes zoster (shingles), which is due to the reactivation of latent Varicella infection.

Explanation:

The lifetime risk of any reactivation (anywhere in the body) is approximately 10% to 20%. Nearly 1 in 3 Americans will develop shingles in their lifetime.

This 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 long-term ocular inflammation. The rest will have an outbreak limited to the skin around the eye while the eye itself is spared.

Among patients with herpes zoster ophthalmicus, some will also have a herpes lesion on the tip of their nose. This signifies involvement of the nasociliary branch (innervates the tip of the nose) and is known as the 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 long-term 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.

Compared with acyclovir, famciclovir and valacyclovir have fewer adverse events and offer a more convenient dosing schedule. Timely diagnosis and management of herpes zoster ophthalmicus, with referral to an ophthalmologist when ophthalmic involvement is present, are critical in limiting visual morbidity.

The 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 shingles affects the facial nerve proximal to the ear. In addition to a painful shingles rash, Ramsay-Hunt syndrome can cause facial paralysis and hearing loss in the affected ear.

The Hutchinson sign is not associated with herpes zoster oticus; thus, a specialized ear examination is unnecessary in patients with the Hutchinson sign.

References:

Walls R, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2017.

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

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