What are the causes of a red nose?

Causes of a Red Nose

A red nose is most commonly caused by rosacea with telangiectasias, chronic UV exposure, rhinophyma, drug-induced vasodilation, or infectious/inflammatory rhinitis, though serious systemic diseases and malignancies must be excluded in persistent cases. 1, 2

Common Dermatologic and Vascular Causes

Rosacea and Telangiectasias

• Rosacea is the leading cause of persistent nasal erythema in adults, characterized by visible telangiectatic blood vessels that create the red appearance 1, 3
• Chronic UV light exposure damages superficial nasal vessels, leading to persistent telangiectasias and erythema 1
• Topically applied corticosteroids can induce telangiectatic changes and persistent redness 1
• Post-rhinoplasty vascular changes may result in persistent nasal erythema from surgical trauma to superficial vessels 1, 3

Drug-Induced Causes

• ACE inhibitors, phosphodiesterase-5 inhibitors (e.g., sildenafil), phentolamine, and alpha-receptor antagonists cause nasal vasodilation and erythema 4
• Rhinitis medicamentosa from overuse of topical decongestants (oxymetazoline) or cocaine causes rebound congestion with visible erythema 4
• Alcohol ingestion triggers vagally-mediated nasal vasodilation, producing transient redness 4

Infectious and Inflammatory Rhinitis

Acute Infectious Causes

• Viral upper respiratory infections account for 98% of acute infectious rhinitis, presenting with nasal congestion, clear rhinorrhea, and visible nasal erythema 4, 5
• Secondary bacterial rhinosinusitis may develop, characterized by mucopurulent discharge, facial pain, and inflamed nasal mucosa 4

Chronic Inflammatory Conditions

• Allergic rhinitis affects 30-60 million Americans annually and presents with nasal congestion, clear rhinorrhea, and pale/bluish swollen mucosa (though erythema can occur) 4, 6
• Vasomotor (idiopathic) rhinitis causes chronic nasal symptoms with visible mucosal inflammation not due to IgE-mediated mechanisms 4
• Occupational rhinitis from workplace irritants (fumes, chemicals, smoke) produces nasal erythema and congestion 4, 7
• Environmental pollutants including cigarette smoke, ozone, and particulate matter induce sinonasal mucosal irritation and erythema 7

Serious Systemic and Granulomatous Diseases

Granulomatous Conditions

• Wegener granulomatosis, sarcoidosis, relapsing polychondritis, and midline granuloma produce ulcerative nasal lesions with surrounding erythema, often before systemic symptoms appear 8
• Infectious granulomas from tuberculosis, syphilis, leprosy, and deep fungal infections (sporotrichosis, blastomycosis, histoplasmosis) cause nasal inflammation and redness 8
• Rhinoscleroma (Klebsiella rhinoscleromatis) presents as polypoid masses with epistaxis in endemic tropical regions 8

Malignancy

• Nasal malignancies cause unilateral obstruction, bleeding, and visible erythema, particularly with rapidly growing tumors 8
• Prolonged occupational exposure to nickel and chrome increases nasal carcinoma risk 8

Critical Diagnostic Approach

When to Pursue Aggressive Workup

• Any nasal erythema or ulceration persisting >2 weeks or not responding to 1-2 weeks of treatment requires tissue biopsy and comprehensive laboratory evaluation 8
• Unilateral redness, epistaxis, severe headache, or anosmia suggest alternative serious diagnoses requiring immediate investigation 4
• Multiple biopsies should be obtained if ulcers involve different sites with varying characteristics 8

Key Historical Elements

• Medication history (antihypertensives, topical decongestants, cocaine use) is essential 4
• Occupational exposures to chemicals, fumes, or irritants must be identified 4, 7
• Pattern of symptoms (seasonal vs. perennial, exposure-related) helps differentiate allergic from other causes 4, 6
• Duration of symptoms distinguishes acute viral infections (days) from chronic conditions (weeks to months) 4, 5

Common Pitfalls to Avoid

• Never assume a persistently red nose is benign without biopsy, as malignancy and serious systemic diseases present similarly 8, 2
• Do not overlook systemic causes—persistent nasal erythema may be the first manifestation of granulomatous disease 8
• Inadequate or superficial biopsies may miss critical diagnostic features in infiltrative processes 8
• Color of nasal discharge alone does not differentiate bacterial from viral infection 5