What is rhinophyma

Rhinophyma is a progressive skin condition affecting the nose in which the skin is thickened and the sebaceous (oil) glands are enlarged. The skin appears skin colored or red and often has prominent blood vessels, which may be thin and red (telangiectasia) or larger and purplish in hue (venulectasia). The affected skin may be bulbous, pitted due to prominent pores (which may ooze sebum or contain a scaly plug), and scarred.

Typically, rhinophyma affects the tip of the nose, although the sides and skin on the top of the nose can also be involved. Rhinophyma can be cosmetically unsightly as skin thickening may result in irregular nodular growth and deformity of the nose.

Rhinophyma predominantly affects male patients. The male-to-female ratio in patients with rhinophyma ranges from 5:1 to 30:1. This is possibly due to androgens (male hormones) ¹.

Rhinophyma is a type of rosacea, a rash that can affect the cheeks, forehead and nose. While rosacea is more common in patients with fair skin and blue eyes, the cause is largely unknown, although chronic vasodilatation (perhaps due to a primary error in vascular control) appears to be a factor. Other forms of rosacea may or may not be present ². If rosacea progresses, the nose becomes redder, swollen at the end and gains a bumpy surface which changes in its shape. This swelling is because there is formation of scar-like tissue and the sebaceous glands (which produce oil on the skin) get bigger. Much more rarely, swelling can arise on other parts of their face such as the ears and chin. Rhinophyma usually only develops in rosacea which has been active and untreated for many years. However, although rosacea affects women more than men, rhinophyma mainly affects fair-skinned men aged 50 to 70 years.

Rhinophyma occurs in a subgroup of rosacea known as phymatous rosacea. Phymatous rosacea can also affect the following sites:

• Chin (gnathophyma)
• Ears (otophyma)
• Eyelids (blepharophyma)
• Forehead (metophyma).

Occasionally, rhinophyma is preceded by acne.

Treatment of established rhinophyma can be very challenging and can include a combination of different treatment options. Oral treatments do not usually work very well in established rhinophyma, and surgery is often necessary. The aims of surgical treatments are to remove the excess tissue and restore the natural shape of the nose as much as possible by shaving off the extra layers of skin. It takes about a week to heal from the surgery and about 6 weeks after the procedures, the skin will look smoother.

Depending on the severity and extent of the rhinophyma a doctor may offer some of the following treatments:

1. Non-surgical

• Oral isotretinoin, a retinoid (see relevant leaflet) commonly used for the treatment of acne, may be effective by reducing redness and the growth of the sebaceous glands.

2. Surgical

• Carbon dioxide (CO2) laser, is the preferred and most common method of treating thickened skin. It shaves down the bumps induced by thickening skin. This procedure causes the least amount of bleeding, however, by using the traditional fully ablative CO2 laser, there is risk of pigmentary changes and scarring ³.
• Scalpel or razor blade excision –this involves using either a scalpel or razor blade in a controlled manner to help remove the excess tissue.
• Dermabrasion, this technique involvesusing a wire brush or a burr (a wheel with rough edges) which rotates rapidly and removes the upper layers of the skin. It causes bleeding and there is a risk of cutting too deep, which can cause scarring and permanent color changes to the skin.
• Electrosurgery and Electrocautery,this procedure uses devices that deliver high frequency electrical currents that heat up and help remove excess tissue. It may cause bleeding.

The surgical treatments can be performed either by dermatologists, plastic surgeons or ear nose and throat surgeons. There are advantages and disadvantages with all of the above treatments which your specialist will discuss with you. Sometimes more than one attempt or a combination of different treatments is required to obtain a good outcome. Surgical treatments for rhinophyma are not routinely commissioned. Please check with your doctor if funding may be available locally and if not how to apply in exceptional circumstances.

It is important to note that these treatments do not cure rhinophyma; they aim to remove overgrowth of excess tissue and reshape the nose. Recurrence of the problem can occur which may then require further treatments.

Is rhinophyma linked to alcohol?

No. It is important to recognize that rhinophyma is not linked to alcohol intake, though in the mind of the general public, it has been blamed as a cause ³.

Is rhinophyma hereditary?

There is no clear genetic link.

Can rhinophyma be cured?

Although there is no cure for rhinophyma, treatments can be effective in improving the appearance and prevent deterioration.

What does rhinophyma look like?

Rhinophyma is a disorder of the nose which alters it’s shape. The nasal skin slowly thickens and develops nodules (lumps), eventually causing a larger, bulbous, misshapen looking nose. The oil glands are enlarged and the pores are more prominent.

The majority of people with rhinophyma also have inflammatory rosacea, with acne-like lumps and bumps and sometimes pustules affecting the central face. The nose and surrounding skin are frequently red with an increased numbers of blood vessels.

Figure 1. Rhinophyma nose

Figure 2. Rhinophyma nose

Rhinophyma severity classification

Rhinophyma, along with other forms of phymatous rosacea, is graded on a clinical scale of severity from 1 to 3 ².

• Grade 1: Prominent follicular openings with no skin thickening
• Grade 2: Prominent follicular openings with mild skin thickening
• Grade 3: Prominent follicular openings, skin thickening and overactive sebaceous glands and nodular nasal contour

What causes rhinophyma

The cause of rhinophyma is not fully understood. Rhinophyma is believed to be multifactorial in origin with a principal cause of unregulated superficial vasodilation ⁴. The extravasation leads to chronic edema of the dermal interstitium with a sequela of local inflammation, fibrosis, and dermal and sebaceous gland hyperplasia ³. Over time, this leads to the characteristic bright red to purplish telangiectasias and irregular, lobulated thickening of the skin of the nose.

Theories include:

• Enlarged blood vessels may predispose to skin thickening ².
• Vascular instability may lead to leakage of fluid into the tissues. This subsequently triggers inflammation and scarring ¹.

Rhinophyma can occur as a more severe stage of rosacea. However, some people have rhinophyma without having rosacea. Although commonly believed to be due to alcohol, there is no link between rhinophyma and excessive alcohol drinking ³.

Rhinophyma complications

Basal cell carcinoma is a common form of skin cancer that has been reported to arise in rhinophyma. However, rhinophyma is not considered a precursor for malignancy ².

Rhinophyma diagnosis

There are no special investigations for rhinophyma. The diagnosis of rhinophyma is usually made from the appearance of the skin on the nose and the previous history of rosacea. If the diagnosis is unclear, a dermatologist may take a small skin biopsy under local anaestheticfor examination under the microscope.

Rhinophyma treatment

Management of rhinophyma is twofold: firstly, management of the underlying rosacea and secondly, treatment directed towards the thickened nasal skin.

Non-surgical management

Treatment of rosacea may inhibit the progression of rhinophyma but this has not been conclusively confirmed ¹.

• Topical metronidazole
• Topical azelaic acid
• Topical retinoids
• Oral tetracycline antibiotics

The most effective medical treatment appears to be systemic isotretinoin, which can reduce the bulk of rhinophyma ⁵.

Typically, people with rosacea and rhinophyma will require oral medication to reduce the inflammation. The most commonly used medications are tetracycline antibiotics (doxycycline, minocycline). A low dosage of isotretinoin can also be effective in shrinking enlarged oil glands.

Rhinophyma surgery

The mainstay of treatment however is some type of surgical removal of the thickened and redundant skin. Multiple treatment modalities exist for rhinophyma depending on the size of the lesion and experience of the surgeon. Ablative laser such as carbon dioxide and erbium lasers are commonly used. Other devices include the use of electrical currents (diathermy) to remove tissue. Such treatment creates a raw wound which will heal over 2 to 3 weeks to leave an improved appearance. Treatment of the blood vessels can be targeted by laser and light systems.

Techniques used to improve the cosmetic appearance of rhinophyma include:

• Dermaplaning (excision of thickened skin by shaving off the surface)
• Dermabrasion (scraping the surface skin)
• Cryotherapy (freezing)
• Laser resurfacing (CO2 , Argon, Nd:YAG, Er:YAG)
• Electrosurgery

With regard to recurrence rates after surgical treatment of rhinophyma, only scarce data from long-term follow-up studies exist ⁶. Some case series of patients who were treated with carbon dioxide lasers had a follow-up of up to 10 years ⁷.

Rhinophyma self care

• Protect your skin from the sun by using a sun block (with a sun protection factor of at least 30) on your face every day.
• Use a soap substitute to cleanse your face such as a gentle moisturizer.
• Use a non-perfumed moisturizer on a regular basis if your skin is dry or sensitive.
• Camouflage products can often cover up redness effectively, and some patients may benefit from the use of skin camouflage to cover redness. A health care professional will be able to help you find a local service if necessary. Camouflage can be very effective in altering the skin colour, but they cannot alter the shape or texture of the skin.

Rhinophyma prognosis

Rhinophyma will progress without adequate treatment. A combination of both medical and surgical management provides excellent results.

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2. Chapter 7: Rosacea and Related Disorders. Bologna Dermatology 3rd Edition.[↩][↩][↩][↩]
3. Rhinophyma: diagnosis and treatment options for a disfiguring tumor of the nose. Sadick H, Goepel B, Bersch C, Goessler U, Hoermann K, Riedel F. Ann Plast Surg. 2008 Jul; 61(1):114-20.[↩][↩][↩][↩]
4. The treatment of giant rhinophyma – Case Report. Popa D, Osman G, Parvanescu H, Ciurea R, Ciurea M. Curr Health Sci J. 2012 Jan; 38(1):41-4.[↩]
5. Chapter 43.9: Rhinophyma and other phymas. Rook’s Dermatology 8th Edition.[↩]
6. Powell F.C. Clinical practice. Rosacea. New England Journal of Medicine. 2005;352:793–803.[↩]
7. Karim Ali M., Streitmann M.J. Excision of rhinophyma with the carbon dioxide laser: a ten-year experience. Annals of Otology, Rhinology and Laryngology. 1997;106:952–955.[↩]