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Hutchinson’s Signs in Dermatology

History and corneal sensory denervation in Manjyot Gautam,
HZO, especially if both branches of the Palak Sheth
Sir Jonathan Hutchinson (1828–1913),
nasociliary nerve are involved.[3]
a surgeon, pathologist, ophthalmologist, Department of Dermatology,
and dermatologist, earned the title of the The risk of ocular involvement is Dr. DY Patil Medical College,
Mumbai, Maharashtra, India
world’s most famous general practitioner even higher in patients who are
because of the wide range of specialties in immunocompromised as in HIV‑positive
which he excelled [Figure 1].[1] individuals.[4]
In 1885, he described the Hutchinson’s However, the negative predictive value
eye sign and in 1886, he described the of this sign is low as some patients can
Hutchinson’s nail sign.[1,2] develop eye manifestations even without
nasociliary involvement.[3] This could be
His other contributions in dermatology
attributed to:[3]
include description of Hutchinson’s teeth,
1. Overlap between the frontal and
Hutchinson–Gilford progeria, Hutchinson’s
ophthalmic branches of trigeminal nerve
summer prurigo, malignant freckles of
2. Absence of nasociliary skin lesions
Hutchinson, and lupus lymphaticus. In
which do not rule out nasociliary nerve
addition, he has also contributed to the
involvement (zoster sine herpete).
aspects of temporal arteritis, leukoplakia,
cheiropompholyx, and leprosy. Ocular involvement

Hutchinson’s Eye Sign Risk factors for ocular involvement in HZO

include:[3,4]
It is the presence of vesicles on the tip of • Positive Hutchinson’s sign
the nose or nasal mucosa on the ipsilateral • Severe skin rash
side of herpes zoster ophthalmicus (HZO) • Lesions involving the upper eyelid
infection, which is indicative of involvement • Red eye.
of the nasociliary branch of the ophthalmic
division of the trigeminal nerve [Figure 2].[3] Ocular manifestations include
microdendritic corneal epithelial lesions,
Distribution cellular reactions within the corneal stroma
The nasociliary nerve with its or anterior eye chamber, blepharitis,
branches – infra‑trochlear nerve and conjunctivitis, keratitis, iritis, scleritis,
external nasal nerve – supplies the skin in corneal anesthesia, and glaucoma.[3]
the inner corner of the eye and the root Presence of these factors warrants an urgent
and lateral aspect of the nose and the globe Address for correspondence:
ophthalmologic reference and evaluation Dr. Manjyot Gautam,
[Figure 3].[3] which should include: Department of Dermatology,
There is usually an overlap with the • Test for corneal sensation with a fine Dr. DY Patil Medical
College, Nerul, Navi
branches of the frontal nerve which supply cotton wisp Mumbai, Maharashtra, India.
the scalp, forehead, conjunctiva, and upper • Slit‑lamp examination of the anterior E‑mail: manjyotgautam@gmail.
and central eyelids.[3] chamber to look for stromal opacities com
and corneal vascularization. Also,
Interpretation
staining of the cornea with fluorescein
Access this article online
A positive Hutchinson’s sign is a strong dye can be done to look for corneal
predictor of acute ocular inflammation ulcers Website: www.ijpd.in
• Dilatation and fundoscopy to evaluate DOI: 10.4103/ijpd.IJPD_99_18

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lens, macula, retina, optic nerve, and Quick Response Code:
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Attribution‑NonCommercial‑ShareAlike 4.0 License, which
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new creations are licensed under the identical terms. How to cite this article: Gautam M, Sheth P.
Hutchinson's signs in dermatology. Indian J Paediatr
For reprints contact: reprints@medknow.com Dermatol 2018;19:371-4.

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Gautam and Sheth: Hutchinson's sign in Dermatology

Figure 1: Sir Jonathan Hutchinson, 1828–1913 (original source: Figure 2: Herpes zoster ophthalmicus with Hutchinson’s sign positive
Dermatological writings of Sir Jonathan Hutchinson)

Figure 4: Longitudinal melanonychia

Figure 3: Distribution of nasociliary nerve and its branches (original source:

Pernkopf’s atlas)

Figure 6: Positive Hutchinson’s sign in subungual melanoma (photograph

courtesy: Dr. Tanumay Raychowdhury)
Figure 5: Positive Hutchinson’s sign with dystrophic changes in subungual
melanoma (photograph courtesy: Dr. Tanumay Raychowdhury) helpful to monitor for delayed sequelae such as ocular
hypertension, cataract, and corneal scarring.
Follow‑up
Treatment
• Depending on the ocular findings and severity, the patient
should be monitored every 1–7 days during the acute episode Treatment includes oral antivirals such as acyclovir,
• Monitoring every 3–12  months afterward may be famciclovir, and valacyclovir.
372 Indian Journal of Paediatric Dermatology | Volume 19 | Issue 4 | October-December 2018
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Gautam and Sheth: Hutchinson's sign in Dermatology

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.
Figure 7: Dermatoscopy of longitudinal melanonychia with negative
Hutchinson’s sign Conditions associated with a positive Hutchinson’s nail
sign[8]
Famciclovir (500 mg 3 times a day) and valacyclovir
(1 g 3 times a day) have been shown to be as effective various conditions are as follows:[8]
as acyclovir (800 mg 5 times a day), in the treatment of • Subungual melanoma
herpes zoster as well as in the reduction of complications. • Bowen’s disease
The simpler dosing regimen of famciclovir and valacyclovir • Benign  –  Racial melanonychia, Laugier–Hunziker
improves patient compliance.[5] syndrome, Peutz–Jeghers syndrome, radiation therapy,
malnutrition, minocycline‑induced dyschromia, AIDS,
Intravenous acyclovir (5–10 mg/kg, three times daily) is congenital nevus, chronic trauma, and subungual
recommended in immunocompromised hosts, especially to hematoma
prevent disseminated disease such as encephalitis. • Illusionary  –  Pigmentation of nail bed seen through the
The standard duration of antiviral therapy is 7–10 days. transparency of the cuticle
However in more severe cases and in immunocompromised • A positive Hutchinson’s nail sign warrants a thorough
patients, antivirals need to be continued for a longer duration. examination of the nail for other features indicative of
subungual melanoma which include:[10]
The use of oral corticosteroids (0.5 mg/kg) reduces the • Width of LM >6 mm
duration of pain during the acute phase of the disease and • Proximal width > distal width
improves cutaneous healing. However, it has not been • Heterogeneous pigment (multicolored)
shown to decrease the incidence of postherpetic neuralgia. • Blurred or jagged borders
Corticosteroids are recommended for HZO only for use in • Associated nail‑plate dystrophy
combination with antiviral agents. • Ulceration and bleeding
• High‑risk digit involved  (thumb, index finger, and
Topical steroids alone do not reactivate the virus but may
great toe).
exacerbate recurrences. Steroid eyedrops may be beneficial
for stromal keratitis, uveitis, and scleritis/episcleritis, Role of dermatoscopy
but can worsen epithelial diseases leading to ulcerations Dermatoscopy is very useful in differentiating benign and
and perforations. Thus, ophthalmologic consultation is
malignant LM as shown in [Table 1 and Figure 7].[7]
mandatory before initiating ocular steroid therapy.[6]
Conclusion
Hutchinson’s Nail Sign
Hutchinson described several conditions in the field of
In 1886, Hutchinson described the nail sign to
dermatology and others. In this article, we have discussed
differentiate between benign and malignant longitudinal
in detail Hutchinson’s eye sign and Hutchinson’s nail sign.
melanonychia (LM) [Figure 4].[7]
The eye sign is important to identify and prevent the several
LM is defined as a longitudinally oriented band of
complications of HZO in the eye, and the nail sign would be of
brown‑black pigment in the nail plate.[7]
great importance to diagnose invasive melanoma of the nail unit.
Hutchinson’s sign is the periungual extension of
Declaration of patient consent
brown‑black pigment from the nail bed and nail matrix
onto the surrounding tissues, which usually occurs The authors certify that they have obtained all appropriate
during the radial growth phase of subungual melanoma patient consent forms. In the form the patient(s) has/have
[Figures 5-7].[8] given his/her/their consent for his/her/their images and
Indian Journal of Paediatric Dermatology | Volume 19 | Issue 4 | October-December 2018 373
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Gautam and Sheth: Hutchinson's sign in Dermatology

Table 1: Dermatoscopy is very useful in differentiating References

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follows 2. Mccleary JE, Farber EM. Dermatological writings of
Dermatoscopic Malignant lesion Benign lesion Sir Jonathan Hutchinson. AMA Arch Derm Syphilol
finding 1952;65:130‑6.
Pattern Diffuse haphazard Linear brushy pattern 3. Zaal  MJ, Völker‑Dieben  HJ, D’Amaro  J. Prognostic value of
pattern Hutchinson’s sign in acute herpes zoster ophthalmicus. Graefes
Width >2/3rd of the nail plate <1/3rd of the nail plate Arch Clin Exp Ophthalmol 2003;241:187‑91.
Color Gray/black Brown 4. Van Dyk M, Meyer D. Hutchinson’s sign as a marker of
Lines Irregular in parallelism Regularly thick and ocular involvement in HIV‑positive patients with herpes zoster
and thickness parallel ophthalmicus. S Afr Med J 2010;100:172‑4.
Micro‑Hutchinson’s Present Rarely present 5. Johnson JL, Amzat R, Martin N. Herpes zoster ophthalmicus.
Prim Care 2015;42:285‑303.
sign
6. Vrcek I, Choudhury E, Durairaj V. Herpes zoster ophthalmicus:
Nail dystrophy 3 times more common Less common
A Review for the internist. Am J Med 2017;130:21‑6.
Granular Present Rarely present
7. Benati E, Ribero S, Longo C, Piana S, Puig S, Carrera C, et al.
pigmentation
Clinical and dermoscopic clues to differentiate pigmented nail
bands: An International Dermoscopy Society study. J Eur Acad
other clinical information to be reported in the journal. The Dermatol Venereol 2017;31:732‑6.
patients understand that their names and initials will not 8. Baran LR, Ruben BS, Kechijian P, Thomas L. Non‑melanoma
be published and due efforts will be made to conceal their Hutchinson’s sign: A reappraisal of this important, remarkable
melanoma simulant. J Eur Acad Dermatol Venereol
identity, but anonymity cannot be guaranteed.
2018;32:495‑501.
Financial support and sponsorship 9. Kudur MH, Hulmani M. “Pseudo” conditions in dermatology:
Need to know both real and unreal. Indian J Dermatol Venereol
Nil. Leprol 2012;78:763‑73.
Conflicts of interest 10. Jellinek N. Nail matrix biopsy of longitudinal melanonychia:
Diagnostic algorithm including the matrix shave biopsy. J Am
There are no conflicts of interest. Acad Dermatol 2007;56:803‑10.

374 Indian Journal of Paediatric Dermatology | Volume 19 | Issue 4 | October-December 2018