History
Sir Jonathan Hutchinson (1828–1913), a surgeon, pathologist, ophthalmologist, and dermatologist, earned the title of the world's most famous general practitioner because of the wide range of specialties in which he excelled [Figure 1].[1]
;)
Figure 1: Sir Jonathan Hutchinson, 1828–1913 (original source: Dermatological writings of Sir Jonathan Hutchinson)
In 1885, he described the Hutchinson's eye sign and in 1886, he described the Hutchinson's nail sign.[12]
His other contributions in dermatology include description of Hutchinson's teeth, Hutchinson–Gilford progeria, Hutchinson's summer prurigo, malignant freckles of Hutchinson, and lupus lymphaticus. In addition, he has also contributed to the aspects of temporal arteritis, leukoplakia, cheiropompholyx, and leprosy.
Hutchinson's Eye Sign
It is the presence of vesicles on the tip of the nose or nasal mucosa on the ipsilateral side of herpes zoster ophthalmicus (HZO) infection, which is indicative of involvement of the nasociliary branch of the ophthalmic division of the trigeminal nerve [Figure 2].[3]
Figure 2: Herpes zoster ophthalmicus with Hutchinson's sign positive
Distribution
The nasociliary nerve with its branches – infra-trochlear nerve and external nasal nerve – supplies the skin in the inner corner of the eye and the root and lateral aspect of the nose and the globe [Figure 3].[3]
Figure 3: Distribution of nasociliary nerve and its branches (original source: Pernkopf's atlas)
There is usually an overlap with the branches of the frontal nerve which supply the scalp, forehead, conjunctiva, and upper and central eyelids.[3]
Interpretation
A positive Hutchinson's sign is a strong predictor of acute ocular inflammation and corneal sensory denervation in HZO, especially if both branches of the nasociliary nerve are involved.[3]
The risk of ocular involvement is even higher in patients who are immunocompromised as in HIV-positive individuals.[4]
However, the negative predictive value of this sign is low as some patients can develop eye manifestations even without nasociliary involvement.[3] This could be attributed to:[3]
- Overlap between the frontal and ophthalmic branches of trigeminal nerve
- Absence of nasociliary skin lesions which do not rule out nasociliary nerve involvement (zoster sine herpete).
Ocular involvement
Risk factors for ocular involvement in HZO include:[34]
- Positive Hutchinson's sign
- Severe skin rash
- Lesions involving the upper eyelid
- Red eye.
Ocular manifestations include microdendritic corneal epithelial lesions, cellular reactions within the corneal stroma or anterior eye chamber, blepharitis, conjunctivitis, keratitis, iritis, scleritis, corneal anesthesia, and glaucoma.[3]
Presence of these factors warrants an urgent ophthalmologic reference and evaluation which should include:
- Test for corneal sensation with a fine cotton wisp
- Slit-lamp examination of the anterior chamber to look for stromal opacities and corneal vascularization. Also, staining of the cornea with fluorescein dye can be done to look for corneal ulcers
- Dilatation and fundoscopy to evaluate lens, macula, retina, optic nerve, and vitreous humor.
Follow-up
- Depending on the ocular findings and severity, the patient should be monitored every 1–7 days during the acute episode
- Monitoring every 3–12 months afterward may be helpful to monitor for delayed sequelae such as ocular hypertension, cataract, and corneal scarring.
Treatment
Treatment includes oral antivirals such as acyclovir, famciclovir, and valacyclovir.
Famciclovir (500 mg 3 times a day) and valacyclovir (1 g 3 times a day) have been shown to be as effective as acyclovir (800 mg 5 times a day), in the treatment of herpes zoster as well as in the reduction of complications. The simpler dosing regimen of famciclovir and valacyclovir improves patient compliance.[5]
Intravenous acyclovir (5–10 mg/kg, three times daily) is recommended in immunocompromised hosts, especially to prevent disseminated disease such as encephalitis.
The standard duration of antiviral therapy is 7–10 days. However in more severe cases and in immunocompromised patients, antivirals need to be continued for a longer duration.
The use of oral corticosteroids (0.5 mg/kg) reduces the duration of pain during the acute phase of the disease and improves cutaneous healing. However, it has not been shown to decrease the incidence of postherpetic neuralgia.
Corticosteroids are recommended for HZO only for use in combination with antiviral agents.
Topical steroids alone do not reactivate the virus but may exacerbate recurrences. Steroid eyedrops may be beneficial for stromal keratitis, uveitis, and scleritis/episcleritis, but can worsen epithelial diseases leading to ulcerations and perforations. Thus, ophthalmologic consultation is mandatory before initiating ocular steroid therapy.[6]
Hutchinson's Nail Sign
In 1886, Hutchinson described the nail sign to differentiate between benign and malignant longitudinal melanonychia (LM) [Figure 4].[7]
Figure 4: Longitudinal melanonychia
LM is defined as a longitudinally oriented band of brown-black pigment in the nail plate.[7]
Hutchinson's sign is the periungual extension of brown-black pigment from the nail bed and nail matrix onto the surrounding tissues, which usually occurs during the radial growth phase of subungual melanoma [Figures 5-7].[8]
Figure 5: Positive Hutchinson's sign with dystrophic changes in subungual melanoma (photograph courtesy: Dr. Tanumay Raychowdhury)
Figure 6: Positive Hutchinson's sign in subungual melanoma (photograph courtesy: Dr. Tanumay Raychowdhury)
Figure 7: Dermatoscopy of longitudinal melanonychia with negative Hutchinson's sign
Micro-Hutchinson's sign is defined as true pigmentation of the cuticle, invisible to the unaided eye, but can be seen with the help of a dermatoscope. It is observed in melanoma and rarely in nevi.[8]
Pseudo Hutchinson's sign is due to periungual hyperpigmentation and pigmentation of the nail bed and matrix, which may reflect through the transparent nail folds simulating Hutchinson's sign.[9]
Interpretation
Although a positive Hutchinson's sign should alert the clinician to the likelihood of a subungual melanoma, it is neither pathognomonic nor its absence precludes the diagnosis of melanoma.
Conditions associated with a positive Hutchinson's nail sign [8]
various conditions are as follows:[8]
- Subungual melanoma
- Bowen's disease
- Benign – Racial melanonychia, Laugier–Hunziker syndrome, Peutz–Jeghers syndrome, radiation therapy, malnutrition, minocycline-induced dyschromia, AIDS, congenital nevus, chronic trauma, and subungual hematoma
- Illusionary – Pigmentation of nail bed seen through the transparency of the cuticle
- A positive Hutchinson's nail sign warrants a thorough examination of the nail for other features indicative of subungual melanoma which include:[10]
- Width of LM >6 mm
- Proximal width > distal width
- Heterogeneous pigment (multicolored)
- Blurred or jagged borders
- Associated nail-plate dystrophy
- Ulceration and bleeding
- High-risk digit involved (thumb, index finger, and great toe).
Role of dermatoscopy
Dermatoscopy is very useful in differentiating benign and malignant LM as shown in [Table 1 and Figure 7].[7]
Table 1: Dermatoscopy is very useful in differentiating benign and malignant longitudinal melanonychia as follows
Conclusion
Hutchinson described several conditions in the field of dermatology and others. In this article, we have discussed in detail Hutchinson's eye sign and Hutchinson's nail sign.
The eye sign is important to identify and prevent the several complications of HZO in the eye, and the nail sign would be of great importance to diagnose invasive melanoma of the nail unit.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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10. Jellinek N. Nail matrix biopsy of longitudinal melanonychia: Diagnostic algorithm including the matrix shave biopsy J Am Acad Dermatol. 2007;56:803–10
