What is the diagnosis and treatment for a patient with a weeping, easily irritated patch of skin on the nose, potentially with a history of skin cancer or high risk of skin cancer?

Weeping, Irritated Patch on Nose: Diagnosis and Management

This presentation requires urgent evaluation to exclude skin cancer, particularly basal cell carcinoma or squamous cell carcinoma, which commonly present on the nose with persistent weeping, crusting, or non-healing characteristics. 1, 2

Immediate Diagnostic Considerations

High-Priority Differential: Malignancy

• Any persistent, weeping, or non-healing lesion on the nose warrants biopsy or urgent dermatology referral to exclude invasive squamous cell carcinoma (SCC) or basal cell carcinoma (BCC), especially if the lesion is bleeding, painful, or has palpable substance when held between fingers. 1
• Use the 2-week-wait urgent cancer pathway for suspected skin cancer when lesions demonstrate bleeding, pain, or thickness. 1
• Actinic keratosis (AK) can present with weeping when inflamed or traumatized, but persistent weeping suggests possible progression to SCC or superimposed infection. 1

Secondary Considerations: Inflammatory Dermatoses

• Facial eczema can present with weeping patches when acutely inflamed or secondarily infected, typically accompanied by pruritus as the hallmark symptom. 3
• Assess for pruritus severity, personal or family history of atopy (asthma, hay fever, childhood eczema), and aggravating factors like irritant exposures. 4, 3
• Secondary bacterial infection (impetiginization) presents with crusting, weeping, or honey-colored exudate and requires prompt antibiotic treatment. 4, 3

Critical Red Flag: Eczema Herpeticum

• If multiple uniform "punched-out" erosions or vesiculopustular eruptions are present, this is a medical emergency requiring immediate systemic acyclovir for suspected eczema herpeticum. 4, 3

Diagnostic Workup

Essential History Elements

• Duration of lesion and any changes in size, color, or symptoms. 1, 2
• History of sun exposure, previous skin cancers, or actinic keratoses. 1
• Pruritus presence and severity (suggests eczematous process if prominent). 4, 3
• Personal or family history of atopic disease. 4, 3
• Occupational or environmental irritant exposures. 4
• Previous treatments attempted and response. 3

Physical Examination Priorities

• Document whether the lesion is bleeding, painful, or has palpable thickness (suggests malignancy). 1
• Assess for signs of infection: crusting, weeping, pustules, or honey-colored exudate. 4, 3
• Look for uniform punched-out erosions (eczema herpeticum emergency). 4, 3
• Examine surrounding skin for additional actinic damage, eczematous changes, or other suspicious lesions. 1

Diagnostic Testing

• Skin biopsy is mandatory if malignancy cannot be excluded clinically, particularly for non-healing, bleeding, painful, or thickened lesions. 1, 2
• Bacterial swab if infection suspected (failure to respond to initial treatment or obvious signs of infection). 3
• Viral culture if herpes simplex suspected based on grouped vesicles or punched-out erosions. 3

Management Algorithm

If Malignancy Suspected (Non-healing, Bleeding, Painful, or Thick)

1. Refer urgently via 2-week-wait pathway for biopsy or excision. 1
2. Do not delay referral to attempt empiric treatment. 1

If Inflammatory Dermatosis Suspected (Pruritic, Eczematous Features)

For Uncomplicated Facial Eczema:

• Apply low to moderate potency topical corticosteroids (e.g., hydrocortisone 1% or desonide 0.05%) twice daily to the affected area. 3
• Never use very potent corticosteroids on the face except under dermatologist supervision for maximum 2 weeks due to high risk of atrophy and telangiectasia. 3
• Prescribe liberal emollient use at least twice daily, most effectively after bathing to trap moisture. 3
• Use soap-free cleansers and avoid alcohol-containing products. 3

If Secondary Bacterial Infection Present (Crusting, Weeping, Honey-Colored Exudate):

• Treat with oral flucloxacillin (or appropriate anti-staphylococcal antibiotic). 3
• Continue topical corticosteroids during antibiotic treatment. 3
• Obtain bacterial swab if not responding to initial treatment. 3

If Eczema Herpeticum Suspected:

• Immediate oral or IV acyclovir - this is a medical emergency. 3
• Send viral culture for confirmation. 3

If Actinic Keratosis Suspected (Sun-Damaged Skin, Rough Texture)

• Lesions with persistent weeping require biopsy to exclude SCC before treating as simple AK. 1
• Once malignancy excluded, treatment options include cryotherapy, topical field therapy, or photodynamic therapy depending on extent. 1

Common Pitfalls to Avoid

• Do not assume a weeping facial lesion is "just eczema" without thoroughly excluding malignancy, especially in sun-exposed areas like the nose in patients with risk factors. 1, 2
• Do not use very potent corticosteroids on the face - this causes irreversible atrophy and telangiectasia. 3
• Do not miss eczema herpeticum - look for uniform punched-out erosions that distinguish it from bacterial infection. 4, 3
• Do not delay biopsy for persistent non-healing lesions - early detection of skin cancer is critical for favorable outcomes. 2
• Steroid phobia leads to undertreatment; educate patients on appropriate corticosteroid use and safety. 3

When to Refer

Urgent dermatology referral (2-week-wait) if:

• Lesion is bleeding, painful, or has palpable thickness. 1
• Non-healing despite appropriate treatment. 1
• Clinical suspicion of malignancy. 1

Routine dermatology referral if:

• Failure to respond to moderate potency topical corticosteroids after 4 weeks. 3
• Diagnostic uncertainty. 3
• Suspected eczema herpeticum. 3