Nasal Furunculosis

Nasal furunculosis is a staphylococcal infection of hair follicles in the nasal vestibule, forming a painful boil. Staphylococcus aureus, including MRSA, is the usual organism and nasal carriage is common.

• Nose picking, nasal hair plucking, trauma and chronic rhinitis are triggers.
• Venous drainage of the nasal area passes through the facial and ophthalmic veins to the cavernous sinus, so infection here can spread intracranially.
• Diabetes and HIV increase risk and recurrence.

Painful red swelling of the nasal tip or vestibule, crusting, tenderness on touch, and sometimes a visible pustule or fluctuance.

• Facial cellulitis, fever and swollen upper lip may follow.
• Differential diagnosis: nasal vestibulitis, herpes simplex, impetigo, erysipelas, nasal vestibular carcinoma, lupus vulgaris, rosacea, nasal foreign body.
• Complications: facial cellulitis, upper lip abscess, cavernous sinus thrombosis, septal abscess, bacteraemia, recurrent boils.

Clinical diagnosis, with culture to guide treatment in recurrent cases.

• Swab of pus and of the anterior nares for culture and MRSA.
• Blood glucose or HbA1c and HIV test in recurrent disease.
• CT or MRI with venography if cavernous sinus thrombosis is suspected.

Treat early and avoid squeezing or manipulating the lesion.

• Supportive: warm compresses for 10 minutes four times daily, no picking or squeezing, analgesia, stop plucking nasal hairs.
• Pharmacological: mupirocin 2 percent ointment inside the nostril three times daily for 5 to 7 days; oral flucloxacillin 500 mg four times daily for 7 days (children 12.5 to 25 mg/kg four times daily); clindamycin 300 to 450 mg three times daily if penicillin allergic or MRSA is suspected. For spreading cellulitis or systemic illness: flucloxacillin 1 to 2 g IV every 6 hours, or vancomycin 15 to 20 mg/kg IV every 8 to 12 hours for MRSA. Decolonisation in recurrent disease: mupirocin nasal ointment twice daily for 5 days with chlorhexidine 4 percent body wash daily for 5 days.
• Procedures: incision and drainage of a fluctuant furuncle by an experienced clinician.
• Special groups: diabetes, tight glucose control and early IV therapy; pregnancy, mupirocin and flucloxacillin; children, weight based dosing and discouragement of nose picking.
• Red flags: swelling of the eyelids, proptosis, double vision, severe headache, high fever, rapidly spreading redness of the face.
• Follow-up: review in 48 hours; screen household contacts for carriage in recurrent disease.