Printed on: September 24th, 2026

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Epistaxis: acute and recurrent

Recurrent epistaxis is a common problem seen in primary care. Anything can walk through the door, from the ‘still bleeding, hang on, do I need to resuscitate you?’ older person on warfarin, to the 5-year-old you suspect is picking their nose and causing regular small anterior bleeds.

Considering how common it is, there have been surprisingly few guidelines to support our management in primary care. In this article, we look at a useful BMJ 10-Minute Consultation summary (BMJ 2012;344:e1097), but also draw on a NEJM review (NEJM 2021;384:944) and an older Cochrane review (Cochrane 2012:9:CD004461).

This article was updated in May 2026.

This section is taken from BMJ 2012;344:e1097.

Usual first aid measures apply should a patient arrive with an ongoing nosebleed:

• Airway.
• Breathing.
• Circulation – assessing haemodynamic status with HR, BP and capillary refill time.

Advise the patient to sit leaning forwards so that any bleeding runs forward out of the nose or mouth.

• Apply pressure to the soft cartilaginous part of the nose for 10 minutes.
• If bleeding does not stop, consider next steps: vasoconstrictors or cautery (IF these are available and in your skillset), and consider whether transfer to the emergency department is now necessary.

Topical vasoconstriction agents (oxymetazoline, phenylephrine, epinephrine or lidocaine with epinephrine) can be considered if you can see a clear bleeding point and you work in a setting where these are available. However, there have been reports of acute coronary syndrome after use of nasal oxymetazoline so caution should be used in those with hypertension or coronary artery disease (NEJM 2021;384:944).

Nasal cautery can be used if the bleeding point can be seen and the procedure can be tolerated (again, if and only IF you have the skills and equipment required!). 

Nasal packing can be attempted in primary care IF the above measures have failed and IF clinicians have the skills and equipment required (and, at Red Whale, we want to add: are you sure that the patient has no facial or nasal fractures?). If nasal packing is required, secondary care review is advised (ENT UK - global guideline on nosebleeds). 

More commonly, the presentation of epistaxis in primary care will be of recurrent minor bleeding.

There are two important questions to answer:

• Are any red flags present (see below)?
• Is the bleeding anterior (blood running from the nose, usually unilateral) or posterior (blood running from the mouth or both nostrils)? Bleeding which is posterior is likely to need endoscopic assessment to identify and treat bleeding points (BMJ 2012;344:e1097).

History 

(BMJ 2012;344:e1097)

• Triggers.
• Frequency.
• Duration: for heavy or prolonged bleeds, consider checking a FBC.
• How does the patient control the bleeding?
• Is the bleed anterior or posterior?
• Any red flags, as above?
• Any history of trauma (ask children "Which finger do you use to pick your nose?" to get a spontaneous honest response!)?
• Any other unexplained bleeding or bruising?
• Past medical history:
  • Hypertension.
  • Previous nasal surgery.
  • Medication: anticoagulant or antiplatelet agents, herbal and over-the-counter treatments.
  • Clotting disorders or family history of clotting disorders.

Management

If the history suggests recurrent anterior epistaxis without serious underlying cause, even if a bleeding point is not seen (BMJ 2012;344:e1097), management options include:

• Antiseptic treatment: offer a 2-week course of topical neomycin 0.5% and chlorhexidine 0.1% (Naseptin) to reduce crusting and vestibulitis.
  • The BMJ article suggests petroleum jelly as an alternative if Naseptin is not tolerated.
• Nasal cautery: has been shown to be as effective as topical antiseptic treatments, but may be more uncomfortable (Cochrane 2012:9:CD004461).

Evidence for using topical treatments

At a time when we are trying to reduce antimicrobial prescribing, what is the evidence for this treatment?

Not a great deal.

• A Cochrane review in 2012 found a small, low-quality RCT showing that topical Naseptin may have been more effective than no treatment at achieving complete resolution of bleeding at 8 weeks in children, and an RCT which showed that topical antiseptics were as effective as cautery at preventing recurrent bleeds in children (Cochrane 2012:9:CD004461).
• A single small RCT in adults compared topical Naseptin with cautery, and found them equally effective at preventing recurrent bleeds (J Clin Otolaryngol Allied Sci 1999;24:228).

Self-care advice

As well as first aid advice, patients should be given advice to help prevent recurrence of bleeding. A useful patient information leaflet can be found in the useful resources box below.

nhs.uk advises the following in the first 24 hours after a nosebleed:

• No alcohol or hot drinks.
• No blowing or picking the nose.
• No lifting or strenuous exercise.
• Do not lie flat.

Epistaxis Management can be divided into acute ‘first aid’ and prevention of recurrence. Identifying whether the bleed is anterior or posterior is key to deciding your treatment options. Anterior bleeds can be managed in primary care with nasal cautery (if skills and equipment allow) or topical antiseptics. Posterior bleeds, or any associated red flags for serious underlying causes, should be referred to ENT.

Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) ENT UK – nosebleeds (epistaxis) (patient information leaflet)