What is the recommended treatment for cellulitis (inflammation of the skin and subcutaneous tissues) on the tip of the nose?

Treatment of Cellulitis of the Tip of the Nose

For cellulitis of the nasal tip, initiate oral antibiotic therapy targeting streptococci with cephalexin 500 mg four times daily, dicloxacillin, penicillin, or amoxicillin for 5 days, and elevate the head of the bed to reduce edema. 1, 2, 3

Antibiotic Selection

First-Line Therapy

• Select an antibiotic active against streptococci, which are the most common causative organisms in typical non-purulent cellulitis. 1, 2, 3
• Recommended oral options include:
  • Cephalexin 500 mg four times daily 2, 3
  • Dicloxacillin 1, 3
  • Penicillin 1, 3
  • Amoxicillin 1, 3
  • Clindamycin (provides dual coverage for streptococci and MRSA if needed) 1, 3

MRSA Coverage - Usually NOT Needed

• MRSA is an unusual cause of typical cellulitis and routine coverage is unnecessary. 2, 3, 4
• Add MRSA coverage ONLY if specific risk factors are present: penetrating trauma to the nose, purulent drainage, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or systemic inflammatory response syndrome (SIRS). 1, 3
• If MRSA coverage is warranted, use clindamycin monotherapy or add trimethoprim-sulfamethoxazole to a beta-lactam. 3

Treatment Duration

• Treat for 5 days if clinical improvement occurs; extend only if the infection has not improved within this initial period. 1, 2, 3
• Traditional 7-14 day courses are no longer necessary for uncomplicated cases. 3

Adjunctive Measures

Elevation

• Elevate the head of the bed to promote gravity drainage of edema and inflammatory substances from the nasal tip. 1, 2, 3

Anti-Inflammatory Therapy

• Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in non-diabetic adult patients to reduce inflammation and hasten resolution. 2, 3
• NSAIDs may also accelerate resolution of inflammation, though evidence is limited. 5

Diagnostic Testing

• Blood cultures or tissue aspirates are NOT routinely recommended for typical cellulitis. 1, 2
• Consider cultures only if the patient has malignancy on chemotherapy, neutropenia, severe immunodeficiency, or systemic signs of infection. 1

When to Hospitalize

Most patients with nasal tip cellulitis can be managed as outpatients. 2 Hospitalize if:

• SIRS is present (fever, tachycardia, tachypnea, abnormal white blood cell count) 1, 2
• Altered mental status or hemodynamic instability 1, 2
• Concern for deeper infection or necrotizing fasciitis 1, 2
• Severe immunocompromise 1, 2
• Poor adherence to outpatient therapy 1

For hospitalized patients with severe infection, use vancomycin plus piperacillin-tazobactam or a carbapenem. 1, 3

Common Pitfalls to Avoid

• Do not automatically add MRSA coverage for typical non-purulent cellulitis without specific risk factors - this is the most common error in cellulitis management. 2, 3, 6
• Do not extend treatment beyond 5 days if clinical improvement has occurred - unnecessary prolonged courses increase antibiotic resistance and adverse effects. 2, 3
• Do not order routine cultures for uncomplicated cases - they rarely change management and are not cost-effective. 1, 2
• Ensure the diagnosis is truly cellulitis and not a mimic condition (herpes zoster, contact dermatitis, or other inflammatory conditions). 4

Addressing Predisposing Factors

• Identify and treat underlying conditions such as nasal vestibulitis, chronic rhinitis, or skin breakdown that may predispose to infection. 1, 7
• For recurrent episodes (3-4 per year), consider prophylactic antibiotics such as oral penicillin or erythromycin. 2