Septal ulcers and perforations may result from nasal surgery; repeated trauma, such as chronic nose picking; cosmetic piercing; toxic exposures (eg, to acids, chromium, phosphorus, or copper vapor); chronic cocaine use; chronic nasal spray use (including corticosteroids and over-the-counter phenylephrine or oxymetazoline sprays); transnasal oxygen use; or diseases such as tuberculosis, syphilis, leprosy, systemic lupus erythematosus (SLE), and granulomatosis with polyangiitis (GPA, formerly known as Wegener granulomatosis).