Nose and Paranasal Area



Nose and Paranasal Area





OVERVIEW

The nose has two outstanding features—its prominence and its abundance of sebaceous glands—both of which make it, and its surrounding area, a site prone to develop the most common inflammatory conditions: acne vulgaris, rosacea, seborrheic dermatitis, periorificial dermatitis, as well as sun-related dermatoses. Also, the central location of the nose makes it a cosmetic feature of prime importance.

Many benign neoplasms occur on the nose. They can be easily recognized, particularly in younger patients. Melanocytic nevi, or moles, are extremely common benign facial papules that appear in childhood. Fibrous papules of the nose, also benign, are acquired lesions that first appear in adulthood.

The prominence of the nose also presents it as a prime target for photosensitive disorders (e.g., systemic lupus erythematosus) and the development of ultraviolet-induced premalignant and malignant neoplasms such as actinic keratoses, squamous cell carcinomas, and basal cell carcinomas. Pigmentary lesions such as solar lentigines, and much less commonly, in situ melanoma known as lentigo maligna, may be seen on the nose in the elderly.








ADULTS


Nasal Bridge and Ala Nasi


Rosacea



Rosacea is frequently mistaken for acne. When acne-like lesions appear on the nose, it is sometimes difficult to distinguish between the two conditions; however, if there is evidence of acne or rosacea elsewhere on the face, it can be of diagnostic significance.


Distinguishing Features



  • Appears later in life than acne (30 to 50 years of age)


  • Persistent acne-like erythematous papules, pustules, and telangiectasias against a background of erythema (Fig. 6-1)


  • Evidence of rosacea may be seen on the cheeks, eyelids, or sclera (ocular rosacea) (see Eyelids and Periorbital Area and Cheeks)


  • Rosacea lacks the comedones (“blackheads” or “whiteheads”) that are seen in acne



Diagnosis



  • Clinical


  • Rarely, a biopsy may be necessary in atypical cases



Management



Rhinophyma



Rhinophyma is an unsightly manifestation of rosacea. This condition usually occurs in men over 40. It is quite uncommon and is rarely seen in women. There is no evidence that alcohol ingestion causes or exacerbates it.







Distinguishing Features



  • Men over 40


  • Consists of knobby nasal papules that tend to become larger and swollen over time (Fig. 6-2)



Management



  • The usual treatments that are described to treat rosacea are not effective for rhinophyma


  • Recontouring procedures with a scalpel or a carbon dioxide laser have been used to remove the excess nose tissue of rhinophyma by “sculpting” it down to a more normal shape and appearance. This may also be accomplished by electrocautery and dermabrasion


Cutaneous Sarcoidosis



Cutaneous sarcoidosis is an example of a systemic disease in which granulomatous infiltrates produce dermal skin lesions. It is a chronic, multisystem disease of unknown origin. Most often, sarcoidosis presents with bilateral hilar adenopathy, pulmonary infiltration, eye lesions, and arthralgias (see Cutaneous Manifestations of Systemic Disease). Sarcoidosis is seen most commonly in young adults, particularly in blacks in the United States and South Africa.

Of patients with sarcoidosis, 20% to 35% have cutaneous lesions, which usually accompany systemic symptoms; however, the skin may be the only site of involvement. Lesions are generally asymptomatic but are often of great cosmetic concern because they occur commonly on the face.


Distinguishing Features



  • Dermal papules, nodules, or plaques that are brown or violaceous in color








  • Often involves the nasal rim (Fig. 6-3) and periorbital areas (see Fig. 4-14)


  • So-called “apple jelly” nodules are seen upon blanching lesions with a glass slide (diascopy). Such nodules represent the gross appearance of granulomas


Clinical Variant

Lupus pernio, a distinct variant, consists of reddish-purple indurated plaques and nodules around and on the nose. It occurs with a higher frequency in female African Americans and Puerto Ricans and it can be quite disfiguring (Fig. 6-4). It also has a high association in particular with lung involvement by sarcoid.



Diagnosis



  • Skin biopsy demonstrates noncaseating sarcoidal granulomas



Management



  • Potent topical steroids applied under occlusion, if necessary


  • Intralesional steroid injections can help flatten lesions


  • Oral minocycline may help to arrest lesion progression


  • Oral antimalarial agents such as hydroxychloroquine (Plaquenil) and chloroquine (Aralen) may be prescribed for therapeutically unresponsive or widespread disease







Fibrous Papule



Fibrous papule (angiofibroma) is an acquired benign lesion that arises in late adolescence or early adult life. They are very common and are found on, or sometimes near, the nose as solitary or multiple lesions. Most often the diagnostic differential is between a melanocytic nevus and a basal cell carcinoma (BCC).


Distinguishing Features



  • Firm, dome-shaped, flesh-colored, or slightly pink, shiny, smooth papule 2 to 4 mm in size (Fig. 6-5)


  • Hairless


  • Most often occur on the nose; less commonly, elsewhere on the face


  • Similar in appearance to a skin-colored dermal nevus


  • Harmless, but persists unchanged lifelong



Diagnosis



  • Clinical


  • Shave biopsy if diagnosis is in doubt









Management



  • No treatment is required


Basal Cell Carcinoma



Basal cell carcinoma (BCC), the most common malignancy of the skin, is commonly seen on the nose. BCC is locally invasive and slow-growing and very rarely metastasizes. It has many of the same risk factors that predispose to actinic keratoses and squamous cell carcinomas (see also Forehead and Temples, Eyelids and Periorbital Area and Ears).


Distinguishing Features



  • Nodular BCC is the most common type


  • Pearly papule or nodule with rolled raised border and telangiectasias (Fig. 6-6)


  • Erosion or ulceration (rodent ulcer)


  • BCCs frequently appear on the ala nasi, nasal creases, nasal tip, and bridge of the nose


Clinical Variant

Pigmented BCC contains melanin; brownish to blue-black coloration that often is seen in more darkly pigmented persons (Fig. 6-7)



Diagnosis



  • Shave biopsy; excisional biopsy is rarely necessary



Management



  • Treatment options depend on histologic subtype and specific location on the nose


  • Mohs micrographic surgery is the optimal treatment of choice for large or recurrent lesions, especially those that arise on the nasal alae or tip of the nose (see Appendix: Diagnostic and Therapeutic Techniques)



Differential Diagnosis



  • Actinic keratosis


  • Squamous cell carcinoma


  • Keratoacanthoma


  • Fibrous papule of the nose


  • Melanocytic nevus