What are the treatment options for a patient with frequent nose sores, possibly related to underlying conditions such as allergies or asthma?

Treatment of Frequent Nose Sores

For frequent nose sores, the primary treatment is continuous nasal saline irrigation as the mainstay of therapy, with topical mupirocin ointment applied three times daily if bacterial infection is suspected, and intranasal corticosteroids if underlying allergic rhinitis is contributing to mucosal inflammation and crusting. 1, 2

Initial Assessment and Underlying Causes

Frequent nose sores typically manifest as nasal crusting, dryness, and mucosal breakdown. The most common underlying conditions include:

• Atrophic rhinitis (primary or secondary): characterized by progressive nasal mucosal atrophy, crusting, dryness, and abnormally wide nasal cavities on examination 3, 1
• Rhinitis medicamentosa: caused by prolonged use (>3-5 days) of topical decongestants like oxymetazoline or phenylephrine, resulting in reduced mucociliary clearance and loss of ciliated epithelial cells 3, 1
• Allergic rhinitis: can contribute to nasal mucosal inflammation and secondary crusting, particularly in perennial allergic rhinitis 3
• Chronic rhinosinusitis: may lead to secondary atrophic changes with persistent crusting 3, 1

Primary Treatment Approach

First-Line Therapy: Nasal Saline Irrigation

Continuous nasal hygiene with intranasal irrigations is the cornerstone of treatment for nasal crusting and sores. 1

• Use buffered hypertonic saline (3%-5%) irrigation, which has superior anti-inflammatory effects and better ability to thin mucus compared to isotonic saline 1
• Perform irrigations 2-3 times daily consistently
• Periodic debridement of crusts may be necessary if saline irrigation alone is insufficient 1

Topical Antibiotic Therapy

If purulent secretions or signs of bacterial infection are present, apply mupirocin ointment to affected areas three times daily. 1, 2

• Mupirocin ointment demonstrated 71% clinical efficacy versus 35% for placebo in treating bacterial skin infections 2
• Apply a small amount to the affected nasal area three times daily 2
• The treated area may be covered with gauze if desired 2
• Re-evaluate patients not showing clinical response within 3-5 days 2
• Systemic antibiotics are indicated when purulent nasal secretions appear, suggesting secondary bacterial infection 3, 1

Intranasal Corticosteroids for Underlying Allergic Rhinitis

If allergic rhinitis is contributing to nasal inflammation and crusting, intranasal corticosteroids (fluticasone, mometasone, or budesonide) should be prescribed as first-line therapy for moderate to severe symptoms. 3, 1

• Intranasal corticosteroids are strongly recommended for patients with allergic rhinitis whose symptoms affect quality of life 3
• These medications reduce mucosal inflammation and swelling that can predispose to crusting 1
• Continue twice daily dosing for maintenance therapy 3

Critical Management Pitfalls to Avoid

Never Use Prolonged Topical Decongestants

Topical decongestants (oxymetazoline, phenylephrine) must never be used beyond 3-5 consecutive days, as they cause rhinitis medicamentosa with rebound congestion and worsening nasal crusting. 3, 1

• Prolonged use (30 days or more) causes reduced mucociliary clearance due to loss of ciliated epithelial cells 3
• Benzalkonium chloride in vasoconstrictor sprays augments local pathologic effects 3
• Rare cases can progress to nasal septal perforation 3

If rhinitis medicamentosa is present:

• Immediately discontinue topical decongestants 3
• Administer intranasal corticosteroids to control symptoms while rebound effects resolve 3
• Consider a short course of oral corticosteroids if symptoms are severe during the withdrawal period 3
• Evaluate for underlying allergic rhinitis once rhinitis medicamentosa is treated 3

Avoid Antihistamines in Nonatopic Patients

Antihistamines have no role in symptomatic relief for nonatopic patients with nasal crusting and may worsen congestion by drying the nasal mucosa, potentially exacerbating crusting. 1

Avoid Excessive Surgical Intervention

Excessive nasal debridement or turbinate surgery can lead to secondary atrophic rhinitis with persistent nasal dryness and worsening crusting. 1

Addressing Underlying Allergic Rhinitis or Asthma

If allergic rhinitis or asthma is suspected as a contributing factor:

• Perform specific IgE testing (skin or blood) for patients who do not respond to empiric treatment or when the diagnosis is uncertain 3
• Assess for associated conditions including asthma, atopic dermatitis, sleep-disordered breathing, rhinosinusitis, and otitis media 3
• Consider allergy testing in patients with recurrent rhinosinusitis or chronic rhinosinusitis, as up to 60% have substantial allergic sensitivities 3
• Second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) may be offered for sneezing and itching if allergic rhinitis is confirmed 3, 4

When to Refer to a Specialist

Referral to an allergist/immunologist or otolaryngologist is appropriate when:

• Symptoms persist despite adequate medical management 3
• There are complications such as nasal polyps, chronic sinusitis, or asthma 3
• Rhinitis medicamentosa has been diagnosed 3
• Multiple costly medications are required over a prolonged period 3
• Anatomic defects obstruct sinus outflow and contribute to recurrent infections 3
• Consideration for immunotherapy or surgical intervention is needed 3