At the Tip of the Nose

A 57-year-old woman with no known immunocompromising condition presents with a 15-day history of progressive pruritus, burning, and paresthesia around the right eye and forehead. She initially used artificial tears after a first evaluation for presumed nonspecific ocular irritation, but symptoms persisted.

Three days later, she developed erythema and swelling involving the right upper eyelid and nasal tip, along with nasal congestion. She was diagnosed with blepharitis and started on topical tobramycin. Within 24 hours, the erythema progressed across the right forehead and periorbital region, and the diagnosis was revised to periorbital cellulitis. Oral clindamycin was started, but the lesions continued to evolve.

At follow-up one week later, examination showed grouped crusted and necrotic lesions involving the right frontal scalp/forehead and a prominent necrotic-crusted lesion on the nasal tip with surrounding erythematous halo.

Vital signs are stable, and she is afebrile. There is right periorbital erythema and edema without proptosis. Extraocular movements are intact without pain, and visual acuity is preserved on bedside assessment. Ophthalmology evaluation is requested to assess for corneal or intraocular involvement.