A 75-year-old man presented with a 3-year history of an intermittent ulcer on his left ala. His medical history was significant for chronic obstructive pulmonary disease. He also had a complicated ophthalmic history, which included left-sided tic douloureux with intractable pain that had been treated by trigeminal ganglionectomy 12 years earlier. He subsequently developed a left-sided neurotrophic cornea and Bell palsy. He wears protective glasses to prevent corneal trauma.
An asymmetrical nose with left alar lobule atrophy (Figure 1 and Figure 2) was observed on physical examination of the patient’s skin. A small ulcer with crust was at the base of the alar rim. A Tzanck preparation and a 6-mm shave biopsy of the cutaneous edge and ulcer were performed (Figure 3).
Cvancara JL, Wentzell JM. Asymmetric Ala—Quiz Case. Arch Dermatol. 2005;141(7):897-902. doi:10.1001/archderm.141.7.897-g