What is the treatment for nasal vestibulitis?

Treatment of Nasal Vestibulitis

Topical mupirocin ointment applied three times daily to the affected area is the mainstay of treatment for nasal vestibulitis, with or without oral antistaphylococcal antibiotics depending on severity. 1, 2, 3

First-Line Treatment

• Apply mupirocin 2% ointment to the affected nasal vestibule three times daily for 7-10 days. 1, 2, 3
• The treated area may be covered with gauze dressing if desired, though this is optional. 1
• Patients should be re-evaluated if no clinical response is observed within 3-5 days of initiating treatment. 1

When to Add Oral Antibiotics

• Add oral antistaphylococcal antibiotics (such as sodium fusidate, cephalexin, or dicloxacillin) when mid-facial cellulitis is present, which occurs in approximately 79% of cases requiring medical attention. 4, 5
• Consider oral antibiotics when nasal vestibular abscess is present (occurs in approximately 48% of cases) or when topical therapy alone fails after 3-5 days. 4, 2
• Oral antibiotics are particularly important in diabetic patients (who represent approximately 10% of cases) or immunosuppressed individuals. 4

Microbiology and Antibiotic Selection

• Methicillin-sensitive Staphylococcus aureus (MSSA) is the causative organism in approximately 81% of cultured cases. 4
• Culture is not routinely necessary for uncomplicated cases, but should be obtained if the patient fails initial therapy or has risk factors for methicillin-resistant Staphylococcus aureus (MRSA). 4, 2
• If MRSA is suspected or confirmed, switch to appropriate coverage such as trimethoprim-sulfamethoxazole or doxycycline. 2

Adjunctive Measures

• Counsel patients to avoid precipitating factors including nose picking (8.5% of cases), nasal hair plucking (14% of cases), aggressive nose blowing (9% of cases), and nose piercing (3% of cases). 4
• Gentle nasal hygiene with saline may help prevent recurrence, though specific evidence for this in nasal vestibulitis is limited. 2

Expected Treatment Duration and Outcomes

• Most cases resolve within 7 days with appropriate topical antibiotic therapy. 3
• In one study using topical basic fibroblast growth factor as adjunctive therapy, mucosal healing time averaged 18 days versus 36 days with conventional treatment alone, though this is not standard therapy. 6
• The total effective rate with topical mupirocin approaches 90-98%. 6

Complications and When to Escalate Care

• Despite nasal vestibulitis appearing as a localized infection, the risk of serious complications (cavernous sinus thrombosis, ophthalmic vein thrombosis) is extremely low, even in hospitalized cases. 4, 2, 5
• However, early recognition and treatment remain essential because the nasal vestibule drains via the angular and ophthalmic veins to the cavernous sinus, creating a theoretical risk of intracranial spread. 2, 5
• Refer immediately or hospitalize if signs of orbital involvement (periorbital edema, vision changes, ophthalmoplegia) or systemic toxicity (high fever, altered mental status) develop. 2, 5

Common Pitfalls to Avoid

• Do not confuse nasal vestibulitis with viral rhinitis or rhinosinusitis—nasal vestibulitis presents with localized erythema, tenderness, and swelling at the nasal vestibule/nasal tip (the "Rudolph sign"), not with rhinorrhea or sinus symptoms. 4, 5
• Do not use topical decongestants or intranasal corticosteroids, as these are ineffective for bacterial infection of the nasal vestibule. 2
• Avoid prescribing oral antibiotics alone without topical mupirocin, as topical therapy directly targets the site of infection. 2, 3