A destructive nasal lesion | The BMJ

A man in his 50s was referred to the dermatology clinic from the plastic surgery clinic with a two year history of a right sided nasal lesion. The lesion started as a papule that enlarged slowly and appeared to be locally erosive. Topical mupirocin 2% was prescribed but there was no resolution. A biopsy was performed which showed no active inflammation, granuloma, dysplasia, or malignancy. He continued to attend follow up outpatient appointments with plastic surgery, however, no definitive diagnosis was reached. No further investigations or treatments were started because the lesion’s appearance seemed stable. However, two years from the original onset, similar lesions developed around the nasal tip and superior columella, extending into the left soft triangle and a second opinion was sought from dermatologists. A second biopsy was performed which produced the same result as the first. Further history revealed use of injected drugs and sex with men. The patient did not report any systemic symptoms such as visual or neurological disturbance and reported no history of genital ulcers or rash.

Clinical examination revealed a gummatous lesion involving the skin and underlying cartilage of both nostrils and the nasal septum, with resulting structural collapse and loss of definition at the superior aspect of the nostrils and columella, which extended posteriorly to the level of the middle turbinate. The base of the lesion was copper red with a punched out appearance and scalloped borders (fig 1). Binocular diplopia on left gaze and reduced …