What causes a burning sensation in the nose and how can it be treated?

Burning Sensation in Nose: Causes and Treatment

A burning sensation in the nose is most commonly caused by irritant exposure (chemical or environmental), and the primary treatment is immediate avoidance of the offending irritant, with intranasal corticosteroids as first-line pharmacotherapy if symptoms persist. 1

Primary Causes of Nasal Burning

Irritant-Induced Rhinitis

• Chemical irritants are the most common cause of acute nasal burning, including formaldehyde, tobacco smoke, perfumes, strong odors, cleaning agents, and industrial fumes 1
• Formaldehyde specifically causes stinging and burning of the nose, lacrimation, and decreased nasal mucus flow through direct irritant effects 1
• The burning sensation occurs because irritants cause reversible inflammatory reactions at the site of contact, with severity depending on the degree of irritation, duration of exposure, and individual sensitivity 1
• Occupational exposures should be suspected when symptoms worsen at work and improve away from the workplace, presenting acutely with nasal burning and hypersecretion of mucus 1

Reactive Upper Airways Dysfunction Syndrome (RUDS)

• High-level acute exposure to irritants can trigger chronic rhinitis with prominent nasal burning as the presenting symptom 1
• This condition requires recognition of the acute exposure event and temporal relationship to symptom onset 1

Other Causes to Consider

• Drug-induced rhinitis from ACE inhibitors, phosphodiesterase-5 inhibitors, alpha-receptor antagonists, or intranasal decongestant overuse (rhinitis medicamentosa) 1
• Allergic rhinitis typically presents with itching rather than burning, though irritant sensitivity is common in allergic patients 1
• Atrophic rhinitis can cause burning sensations but is associated with crusting and foul odor 1

Diagnostic Approach

Key History Elements

• Temporal relationship to specific exposures (workplace chemicals, cleaning products, perfumes, tobacco smoke) 1
• Improvement when away from the suspected irritant environment 1
• Medication history, particularly ACE inhibitors, nasal decongestants, or cocaine use 1
• Occupational exposures requiring industrial hygienist evaluation if work-related 1

Physical Examination Findings

• Nasal mucosa may show nonspecific inflammatory changes or watery rhinorrhea during active symptoms 1
• Absence of pale, edematous mucosa and allergic signs (nasal crease, dark circles) helps distinguish from allergic rhinitis 1

Testing Considerations

• Allergy testing is negative in irritant-induced rhinitis, which helps differentiate from allergic causes 1
• Nasal cytology may show inflammatory cells without eosinophilia 1
• Environmental assessment may be needed to identify specific irritants in buildings or workplaces 1

Treatment Algorithm

First-Line: Avoidance

• Immediate removal from the irritant exposure is the most effective intervention and should be the first step 1
• For occupational exposures, modify the workplace, use filtering masks, or remove the patient from adverse exposure 1
• Ensure good ventilation in indoor environments to prevent accumulation of volatile irritants 1
• Avoid passive tobacco smoke exposure completely 1

Second-Line: Pharmacotherapy

For persistent symptoms after irritant avoidance:

• Intranasal corticosteroids are first-line pharmacotherapy, providing superior relief for nasal inflammation and congestion 2
• Daily use of intranasal corticosteroids is recommended for chronic occupational rhinitis when complete avoidance is not possible 1

Additional options if intranasal corticosteroids are insufficient:

• Intranasal antihistamines (azelastine) may provide additional benefit, particularly if there is a mixed allergic/irritant component 2
• Intranasal anticholinergics (ipratropium bromide) are effective specifically for rhinorrhea but do not address burning or other symptoms 2
• Combination of intranasal corticosteroid plus ipratropium is more effective than either alone for rhinorrhea 2

What NOT to use:

• Oral antihistamines are ineffective for nonallergic irritant-induced rhinitis and should not be prescribed 2
• Avoid prolonged intranasal decongestants (>3-5 days) as they cause rhinitis medicamentosa with rebound congestion 2
• First-generation antihistamines should be avoided due to sedation and performance impairment 1, 2

Third-Line: Adjunctive Measures

• Nasal saline irrigation can help clear irritants and provide symptomatic relief 2
• Address any coexisting rhinitis medicamentosa by discontinuing topical decongestants 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for irritant-induced nasal burning, as this is not an infectious process 3
• Do not rely on antihistamines alone for nonallergic irritant rhinitis, as they are ineffective for this condition 2
• Do not overlook occupational causes by failing to ask about workplace exposures and temporal patterns 1
• Do not continue intranasal decongestants beyond 3-5 days, as this creates a cycle of rebound congestion requiring specialist intervention 2
• Do not miss drug-induced causes by failing to review all medications, particularly ACE inhibitors and nasal decongestants 1

When to Refer to Specialist

• Symptoms not responding to avoidance measures and intranasal corticosteroids after 4-6 weeks 2
• Suspected occupational rhinitis requiring workplace modification or disability evaluation 1
• Development of complications such as nasal polyps or chronic rhinosinusitis 2
• Need for systemic corticosteroids, which should prompt specialist referral 2