Keratoacanthoma (KA), a typically less aggressive squamous cell carcinoma (SCC) subtype, is characterized by rapid growth with potential spontaneous resolution. Rarely, KA exhibits aggressive features including perineural invasion and vascular involvement. The authors report a 56-year-old female with a 2.5 cm papule on her right nasal supratip at initial presentation. Pathology revealed a well-differentiated squamous cell carcinoma, keratoacanthoma type. A gene expression profile test revealed a class 1 result. The papule grew rapidly into a 5 x 3.5 cm tumor by the time of Mohs surgery 4 weeks later. During Mohs, extensive perineural invasion was discovered. While peripheral margins were cleared, deep margin clearance proved impossible due to the inability to obtain adequate local anesthesia at the nasal bone. The patient was subsequently referred to an academic head/neck cancer clinic for further management. This case demonstrates that KAs can exhibit aggressive behavior, particularly in head/neck locations.