Nasal Vestibulitis

Nasal vestibulitis is an infection and inflammation of the skin of the nasal vestibule. The vestibule is the most anterior part of the nasal cavity, lined with keratinising squamous epithelium and hair follicles (vibrissae), and is limited posteriorly by the limen nasi.

Acute nasal vestibulitis (or folliculitis) is most commonly caused by Staphylococcus aureus (including methicillin resistant strains, MRSA) and Streptococcus pyogenes.

It results from trauma to the vestibule:

• nose picking
• nasal hair plucking or clipping
• nasal piercing
• repeated nose blowing in rhinorrhoea (during an upper respiratory tract infection or allergy)
• nasal discharge
• topical medicines
• nasal cannulae or tubes
• cocaine use

Risk factors: nasal carriage of S. aureus (30 percent of the population), diabetes mellitus, immunosuppression, atopic dermatitis, and chronic nasal discharge.

Chronic vestibulitis occurs with chronic nasal discharge, chronic rhinitis, or from irritant exposure (dry air, nasal sprays). It also occurs in association with eczema and seborrhoeic dermatitis.

Complications:

• furuncle of the nasal tip
• nasal vestibular abscess
• perichondritis and chondritis of the nasal alar and septal cartilages
• facial cellulitis
• cavernous sinus thrombosis, the most serious, via the angular and ophthalmic veins, which have valveless connections to the cavernous sinus, in the "danger triangle" of the face; mortality is about 20 to 30 percent when untreated

• Pain, tenderness, redness, swelling and crusting of the nasal vestibule and the tip of the nose, with a burning feeling; often with a fissure at the nasal ala.
• Purulent crusts, pustules, erythema at the hair follicles, and weeping.
• Nasal obstruction (from swelling), discomfort when touching or blowing the nose, and occasional epistaxis when crusts are removed.
• A furuncle (boil) presents as a painful red, firm nodule that points and discharges pus.
• Systemic features: fever and malaise (in cellulitis or abscess).
• Cavernous sinus thrombosis: severe headache, fever, periorbital oedema, chemosis, proptosis, ophthalmoplegia (sixth nerve palsy first), and vision loss, which needs urgent care.
• Chronic form: persistent crusting, scaling and fissuring of the vestibule with recurrent episodes of flares.

• Clinical diagnosis by anterior rhinoscopy: erythematous, swollen, crusted vestibular skin, with folliculitis and pustules, sometimes ulceration; examination of the face for cellulitis, nasal tip, and the cartilage.
• Swab culture of the lesions (with sensitivity) in recurrent or severe cases, and screening for nasal carriage of MRSA (nasal swab).
• Blood glucose or HbA1c in recurrent cases, and full blood count; blood cultures if systemic features.
• Imaging (CT with contrast of the face and orbit) if a deep abscess, orbital extension or cavernous sinus thrombosis is suspected.
• Consider biopsy for chronic non-healing lesions (to exclude squamous cell carcinoma, granulomatosis with polyangiitis, lupus, sarcoidosis and cutaneous tuberculosis) and a nasal vestibular carcinoma.

• Mild localised folliculitis: topical mupirocin 2 percent ointment applied to the nasal vestibule with a cotton bud three times daily for 5 to 7 days (or fusidic acid 2 percent cream three times daily, or retapamulin 1 percent ointment twice daily); warm compresses; gentle cleaning with saline to remove crusts; avoid picking and plucking hairs.
• Moderate to severe vestibulitis or facial cellulitis, with spreading erythema, fever, or involvement of the face: oral antibiotics for 7 to 10 days covering S. aureus and streptococci.
  • flucloxacillin 500 mg four times daily (children 12.5 to 25 mg/kg four times daily), or cefalexin 500 mg four times daily
  • clindamycin 300 to 450 mg three to four times daily for penicillin allergy or in areas with a high prevalence of MRSA
  • trimethoprim-sulfamethoxazole 160/800 mg twice daily or doxycycline 100 mg twice daily for community acquired MRSA
  • vancomycin 15 to 20 mg/kg intravenously every 8 to 12 hours for severe or suspected MRSA infection
• Admission and intravenous antibiotics (flucloxacillin 1 to 2 g intravenously every 6 hours, or ceftriaxone, with vancomycin if MRSA is likely) in extensive cellulitis, immunosuppression, or suspected intracranial extension.
• Cavernous sinus thrombosis: broad spectrum intravenous antibiotics (vancomycin plus ceftriaxone 2 g every 12 hours plus metronidazole 500 mg every 8 hours) for 3 to 4 weeks or more. Anticoagulation is considered (low-molecular-weight heparin, e.g. enoxaparin 1 mg/kg twice daily). Neurosurgical, ophthalmology and ENT review.
• Abscess: incision and drainage, with culture of pus; warm soaks.
• Avoid squeezing the lesion or manipulation of boils in the danger triangle.
• Recurrent vestibulitis: decolonisation of S. aureus carriage (mupirocin 2 percent nasal ointment twice daily for 5 days, plus chlorhexidine 4 percent body wash for 5 days, and treat household contacts in some cases). Address the risk factors (nose picking, hair removal, diabetes control, treatment of rhinitis, and avoid irritants).
• Use an emollient (petroleum jelly or an emollient) regularly inside the vestibule to prevent drying and crusting.
• Chronic vestibulitis or eczema: topical corticosteroid (hydrocortisone 1 percent ointment twice daily for 1 to 2 weeks) combined with antibiotics, and tacrolimus 0.03 to 0.1 percent for refractory cases; biopsy and workup of persistent lesions.
• Follow up in 48 to 72 hours for those on treatment, with escalation if there is no improvement or worsening.
• Prognosis: excellent with early treatment; recurrences are common without risk factor control.