Facial Herpes Zoster With Hutchinson's Sign Complicated by Secondary Bacterial Superinfection: A Case Report

Herpes zoster ophthalmicus results from the reactivation of latent varicella zoster virus involving the ophthalmic branch of the trigeminal nerve and may lead to severe ocular complications. Hutchinson's sign, defined by vesicular or crusted lesions on the nasal tip, is a key predictor of ocular involvement.  We describe a 57-year-old woman with no relevant past medical history who presented with a 15-day history of pruritus and burning in the right eye. She was initially misdiagnosed with blepharitis and later periorbital cellulitis, receiving topical tobramycin and systemic antibiotics without improvement. On further evaluation, necrotic crusted lesions on the nasal tip and right frontal region were observed. The integration of clinical features, including dermatomal involvement, nasal tip lesions, and necrosis, established the diagnosis of herpes zoster with associated bacterial superinfection. Oral valaciclovir and clindamycin were initiated, resulting in a favorable clinical response with the progressive resolution of lesions and no ocular complications, underscoring the benefit of combined antiviral and timely antibiotic therapy. This case highlights the importance of early recognition of Hutchinson's sign and timely initiation of antiviral therapy to prevent visual sequelae while also emphasizing the need to identify and adequately manage bacterial superinfection in herpes zoster lesions, including the prompt initiation of appropriate antibiotic therapy when indicated.