Nose: Applied Aspects in Dermatology.

Nose is the most prominent part of the mid-face and has important physiological, aesthetic and psychological functions. Skin diseases on the nose are commonly seen by dermatologists, otorhinolaryngologists, and plastic surgeons. Because of its exposed, highly visible localization, lesions on the skin of the nose are often noticed by patients themselves, typically very early in the course of the disease. Similarly, the dermatological lexicon is well known with descriptive terminologies, synonyms, acronyms, eponyms, toponyms, misnomers. We have tried to compile the anatomical applications of nose in cosmetology and dermatosurgery subspecialities with nasal eponyms and signs encountered in clinical dermatology that would be helpful for residents.

What was known?

Facial dermatoses are a common dermatological complaint with several conditions under its umbrella. The clinical characteristics guide in their evaluation and diagnostic judgment. Nose forms an integral anatomical structure that helps to distinguish these conditions in many scenarios.

Introduction

Nasal topography and its external subunits have a unique significance in understanding the dermatoses involving the face and also are of utmost importance in cosmetic/dermatosurgical procedures for planning reconstruction surgeries. This article comprises anatomical applications of nose, nasal eponyms, and signs encountered in dermatology that are important in the daily practice of a dermatologist.

Nose has the most subdivisions on the face, the horizontal root, which borders the glabella on the forehead, is positioned superiorly. The midnose contains the dorsum medially flanked by the two lateral sidewalls. The dorsum is inferiorly bordered by the tip, which ends in the columella that separates the nostrils on the underside of the nose. The tip is bordered by the ala nasi, or alae, on both sides, and the columella is flanked by the soft triangles, which also border the tip and the alae.

Clinical Applications of Nasal Anatomy

The skin in the areas of the dorsum, columella, and sidewalls is thin, loose, compliant, and relatively less sebaceous, while the skin in the areas of the nasal tip and alae is thicker, more sebaceous, more adherent, and less flexible. The nose with its rich pilosebaceous skin at the nasal tip and alae can frequently exhibit comedones, sebaceous hyperplasia, rosacea, trichoepithelioma, trichostasis spinulosa, and trichofolliculoma [Figure 1].

Figure 1

(a) Sebaceous hyperplasia (b) trichoepithelioma

The anatomical characteristics and clinical significance are shown in Table 1.

Table 1

The anatomical characteristics of nose and their clinical significance

Nose Eponyms

Table 2 shows the nasal eponyms.

Table 2

Nasal eponyms

(a) Nasolabial sparing in systemic lupus erythematosus (b) pinched nose in systemic sclerosis

Nose Signs

The nose related signs are tabulated in Table 3.

Table 3

Characteristic signs related to nose

Mutilating Rhinopathies

The common dermatological causes of mutilating rhinopathies include Lepromatous leprosy, Leishmaniasis, Lupus vulgaris, Lues maligna (syphilis), Lupus pernio, and Lethal midline granuloma (6 Ls) [Figure 4].

Figure 4

(a) Mutilating rhinopathy due to discoid lupus erythematosus (b) saddle nose deformity

The nasal bone destruction and saddle nose deformity in the late stages of yaws constitutes gangosa, while goundou refers to hyper osteitis of the nasal process of the maxillae which gives rise to swellings on both sides of the bridge of the nose.

Acute rhino-orbital-cerebral zygomycosis caused by Mucor, Rhizopus, Rhizomucor, and Absidia is characterized by the progressive infection of upper turbinates or paranasal sinuses that leads to necrosis, mutilation of nose, ophthalmoplegia, and orbital cellulitis.

Rhinoentomophthoromycosis (subcutaneous zygomycosis) caused by conidiobolus and basidiobolus of class zygomycetes is characterized by painless, nonulcerating nasal swellings in inferior turbinates that extends to subcutis causing woody induration, obliteration of nasal cavity, mucosal thickening, and is disfiguring.

In congenital erythropoietic porphyria, scarring when deep may involve cartilage, ligaments, and bone with severe mutilation of fingertips, ears, and nose with hypertrichosis of face termed as wolf appearance.[34]

Cutaneous carcinomas such as basal cell carcinomas and squamous cell carcinomas can also cause disfigurement of nose.

Miscellaneous

Developmental midline anomalies of nose

Congenital nasal masses include dermoid cyst, dermal sinuses, cephaloceles, and heterotopic brain tissue (nasal gliomas) resulting from the faulty embryologic development of the frontobasal skull and/or adjacent ectodermal/neuroectodermal tissues.[35] It is important to recognize these as they can have intracranial communication.

Benign neoplasms in infancy that occur on the nose are infantile hemangioma [Figure 3], hemangiopericytoma, neurofibroma, melanotic neuroectodermal tumor of infancy, hamartomas (chondromesenchymal, chondroid, lipomatous, and angiomatous). Malignant neoplasms include rhabdomyosarcoma, fibrosarcoma, osteosarcoma, and neuroblastoma.[35]

Figure 3

(a) Infantile hemangioma involving glabella and (b) nasal tip

Congenital absence and duplication anomalies of nose

Arrhinia

Congenital absence of nose, nasal bones, cribriform plate, nasal septum, paranasal sinuses, and olfactory bulbs are associated with hypertelorism and high arched palate.

Polyrhinia

Existence of two external noses due to the development of two nasal placodes, which then undergo normal development and is associated with choanal atresia.

Supernumerary Nostrils

It is an extra opening, lateral, medial, or superior to the normal nostril, which may or may not communicate with nasal cavity. It may be unilateral or bilateral resulting from the localized abnormality of the lateral nasal process in which a fissure appears accidentally during mesenchymal proliferation.

Bifid nose

It is a rare congenital deformity due to failure of the paired nasal processes to fuse to a single midline organ during early gestation.

Midface hypoplasia

It is seen in craniofacial syndromes such as Aperts syndrome, Achondroplasia, Crouzon syndrome, Carpenters syndrome, Saethre-Chotzen syndrome, Marshall Stickler syndrome, Pfeiffer syndrome, Zellweger syndrome, Mucopolysaccharidosis[5] (coarse facies with midfacial hypoplasia).

Prenatal exposure to drugs such as phenytoin (short nose and anteverted nostrils), warfarin (nasal hypoplasia), isotretinoin, and alcohol also cause midfacial hypoplasia.[36373839]

Centrofacial melanosis

Centrofacial melasma is the most common facial melanosis, this variant occurs in 63% of melasma patients compared to maxillary and mandibular types.[40] [Figure 6b]. Pigmentation involves cheeks, nose, forehead, and chin. Post chikungunya pigmentation (chik sign) and Type I and Type III nevus of OTA involve the nose. In Type IB, mild zygomatic type nevus involves infrapalpebral fold, nasolabial fold, and zygomatic region and in Type ID, only ala nasi is involved. In Type III severe form, nevus involves scalp, forehead, eyebrow, and nose.[40]

Figure 6

(a) Cobb sign (b) centrofacial melasma

Chick sign in chikungunya

(a) Headlight sign in atopic dermatitis (b) Pavithran's nose sign on erythroderma

Conclusion

Nose constitutes the central anatomical structure of face with esthetic importance and its impact on the individual psyche has enhanced the significance of nose. We must be familiar with the special morphology and characteristics of skin diseases of the nose that gives clinical clues in understanding and identifying the conditions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

What is new?

This article is a compendium of regional dermatosis of the nose that specially highlights eponyms and signs.