I have a painful persistent scab inside my nostril; how should I manage it?

Management of Persistent Painful Nasal Scab

For a painful scab inside your nostril that won't heal, apply mupirocin 2% ointment to the affected area twice daily for 5-10 days if there are signs of active infection (purulent drainage, increasing pain, surrounding redness), combined with regular saline irrigation and nasal moisturization. 1

Determining If You Have Active Infection vs. Simple Trauma

Key distinction: Active infection presents with purulent (pus-like) drainage, crusting with yellow-green discharge, increasing pain, redness spreading beyond the scab, or warmth around the area. 1 Simple trauma or irritation shows only dry crusting without these inflammatory signs. 2

• If signs of infection are present: Staphylococcus aureus causes 70-81% of nasal vestibule infections, making antibiotic treatment necessary. 2, 1
• If no infection signs: The scab likely represents mechanical trauma, chronic irritation, or excessive dryness requiring only supportive care. 3

Treatment Algorithm

For Infected Scabs (purulent, painful, red)

• Apply mupirocin 2% ointment to both nostrils twice daily for 5-10 days as recommended by the Infectious Diseases Society of America. 1
• Add systemic antibiotics only if you develop fever, extensive surrounding cellulitis, or feel systemically unwell. 1
• The FDA notes mupirocin should be discontinued if severe itching or rash develops. 4

For Non-Infected Persistent Scabs (dry, painful, no pus)

• Use saline nasal spray or gel multiple times daily to maintain mucosal moisture and promote healing. 5, 3
• Apply petroleum-based nasal lubricant (not mupirocin) to the affected area 2-3 times daily. 5
• Perform gentle saline irrigations to remove crusting without traumatizing the area. 5

Common Underlying Causes to Address

Mechanical trauma is the leading cause of persistent nasal scabs, including: 2

• Nose picking (8.5% of cases) 2
• Excessive nose blowing (9.3% of cases) 2
• Nasal hair plucking (14.4% of cases) 2
• Nose piercing (3.4% of cases) 2

Stop these behaviors immediately to allow healing. 2

Atrophic rhinitis causes chronic nasal crusting with dryness and paradoxical sensation of congestion despite wide nasal cavities. 5 This requires continuous nasal hygiene with saline or sodium bicarbonate irrigations and periodic debridement if necessary. 5

Critical Warning Signs Requiring Urgent Medical Attention

Seek immediate care if you develop: 5

• Periorbital swelling or redness
• Vision changes or double vision
• Severe frontal headache
• Frontal swelling
• Fever with worsening symptoms
• Spreading facial cellulitis

These may indicate serious complications requiring emergency evaluation. 5

Important Caveats

Do not use mupirocin for simple nasal trauma without infection signs - this promotes antibiotic resistance without clinical benefit, as emphasized by the American College of Physicians. 3

Avoid prolonged mupirocin use beyond 10 days, as the FDA warns this can lead to overgrowth of resistant organisms including fungi. 4

Polyethylene glycol in mupirocin ointment can be absorbed through damaged skin and should be avoided if you have moderate to severe kidney disease. 4 A paraffin-based formulation exists for intranasal use if needed. 4

If the scab persists beyond 2-3 weeks despite appropriate treatment, see an ENT specialist to rule out underlying conditions such as chronic rhinosinusitis, granulomatous disease, or rarely, neoplasia. 5