Treatment of Nasal Septal Perforation from Scab Picking
Conservative management is the first-line treatment for nasal septal perforations caused by picking scabs, with nasal saline irrigation, topical corticosteroids, and nasal lubricants forming the cornerstone of therapy; surgical repair should be considered a last resort due to poor long-term success rates. 1
First-Line Conservative Management
Nasal saline irrigation is essential to remove crusts and maintain mucosal moisture, preventing the cycle of crusting and picking that perpetuates the perforation 1. This should be performed multiple times daily using isotonic saline solution.
Topical intranasal corticosteroid sprays or creams reduce inflammation and prevent further mucosal damage 1. These help decrease the inflammatory response that leads to crust formation.
Nasal lubricants are critical to prevent dryness and crusting that triggers picking behavior 1. Options include:
Regular debridement of crusts by a healthcare provider helps maintain nasal patency and comfort, reducing the urge to pick 1.
Antimicrobial Therapy
Long-term oral co-trimoxazole and topical anti-staphylococcal creams may be beneficial due to the potential role of Staphylococcus aureus in maintaining perforation 1. This addresses bacterial colonization that can perpetuate inflammation and crust formation.
Mechanical Options for Symptomatic Perforations
Septal buttons can be offered to patients with symptomatic perforations, though they may paradoxically increase crusting in some cases 1. These prosthetic devices physically close the perforation and can provide symptom relief without surgery.
When Surgery Might Be Considered
Surgical repair of septal perforation is unlikely to be successful in the long term and should be considered a last resort 1. The evidence shows:
- Success rates vary widely, with complete closure achieved in 63-81% of cases in surgical series 3, 4
- Endoscopic surgery has a very limited role and is associated with poor outcomes, increased scarring, and adhesions 1
- Anterior perforations are more symptomatic but potentially more accessible surgically 1
Surgery should only be attempted after:
- Extensive trial of conservative management has failed 1
- The patient has stopped all trauma to the nose (picking behavior must cease) 1
- Any underlying autoimmune conditions have been treated and controlled 1
- The disease has been quiescent for at least one year if cosmetic correction is desired 1
Critical Pitfalls to Avoid
Do not attempt surgical repair without adequate conservative management trial 1. Most perforations from picking will stabilize or improve with consistent conservative therapy.
Address the underlying picking behavior through behavioral modification or psychiatric consultation if needed. Continued trauma will cause any repair to fail.
Avoid excessive cautery during any nasal procedures, as this is a common iatrogenic cause of septal perforation 1. Bilateral cautery should be used selectively and cautiously to minimize perforation risk 2.
Do not overlook underlying causes such as autoimmune disease, vasculitis, or medication effects (particularly bevacizumab and other anti-angiogenic agents) that may lead to repair failure 1, 5.
Monitoring and Follow-up
Patients should be monitored for: