Treating Rhinophyma

By Dr Daron Seukeran / 05 Oct 2018

Dr Daron Seukeran discusses this rare skin condition and describes his treatment approach using CO2 laser.

The name rhinophyma comes from rhino (nose) and phyma (growth). It is a disfiguring, rare disease that is characterised by a progressive hypertrophy of the soft tissues of the nose that displays with increased volume, mainly in the lower half.The diagnosis of rhinophyma is easy to ascertain based on the clinical features of the disease. In advanced cases, medical management is believed to be inferior to the results seen with surgical treatment.1

Rhinophyma is often associated with the end stage in the development of rosacea, accompanied by hypertrophy of the sebaceous glands, which causes an enlargement of the nose. However, its exact cause is unknown.

Rhinophyma is an uncommon condition that often results in both functional and cosmetic impairment. A study from Estonia stated that the 1% of all patients with rosacea may get a rhinophyma,2 while other studies have suggested that around 10-15% of the population present with rosacea.3,4

Interestingly, rhinophyma is more commonly found in men than women, but unfortunately we don’t know the reasoning behind this. A large variety of surgical and non-surgical treatments have been published in the literature to treat it.5

Although rhinophyma is not a common dermatological concern that patients will present with in an aesthetic clinic, it is important for aesthetic practitioners, who are assessing patients’ skin regularly, to understand the disease and know how to identify it in order to recommend or to refer for treatment. It is also important to know that patients may present with accompanying rosacea, where there is redness and flushing of the face.

Aetiology

As mentioned, the exact cause of rhinophyma is unknown; it is believed to be multifactorial in origin with a principal aetiology of unregulated superficial vasodilation. The extravasation leads to chronic oedema of the dermal interstitium with a sequela of local inflammation, fibrosis, and dermal and sebaceous gland hyperplasia.6 Over time, this leads to the characteristic bright red to purplish telangiectasias and irregular, lobulated thickening of the skin of the nose.6

Psychological impact

Historically, rhinophyma was mistakenly considered to be linked with alcohol consumption. This is because substances such as alcohol and caffeine can cause local vasodilation.6 This alleged association with alcohol has caused much social stigma and loss of self-esteem in patients suffering from the disease. There are several nicknames for the condition, with the most common being ‘whiskey nose’ and ‘rum nose’.5

Dermatology conditions like this can also have a psychological impact on other people’s perceptions of an individual. It is interesting to note that according to a 2017 study by Croley et al., which looked at the dermatologic features of classic movie villains, six (60%) of the all-time top 10 American film villains have dermatologic findings. These include cosmetically significant alopecia (30%), periorbital hyperpigmentation (30%), deep rhytides on the face (20%), multiple facial scars (20%), verruca vulgaris on the face (20%), and rhinophyma (10%). The authors also found that the top 10 villains have a higher incidence of significant dermatologic findings than the top 10 heroes (60% vs 0%; P = .03).7

Diagnosis

The diagnosis of rhinophyma is usually clinical and is identified by an increasing bulbous deformity of the nose. The surface of the nose can be pitted and often has telangiectasias. The thicker and more sebaceous nasal tip and alae are preferentially enlarged in most patients, but involvement can spread to the thinner nasal dorsum and sidewalls to a lesser degree. As the nose enlarges, the aesthetic subunits of the nose merge and become less defined. While the underlying frameworks of the skin are usually unaffected, it is possible for patients to also suffer from secondary nasal airway obstruction at the external nasal valves.2 Rhinophyma can occasionally be complicated by unnoticed cutaneous malignancies such as basal cell carcinomas, squamous cell carcinomas, or lymphomas, so a practitioner should be aware of this before considering treatment.2

Treatment

There are multiple treatment modalities available to practitioners in the treatment of rhinophyma. However, there are no randomised, prospective, control studies for any treatment, which makes it difficult to recommend a single treatment over another.

Nonetheless, practitioners should recognise that there is an increased risk of scarring and hypopigmentation which can occur on or near the nasal ala. As well as this, a patient’s risks may increase if their tissue destruction extends to the papillary dermis or if their pilosebaceous units are ablated.8

The initial consultation should include counselling about the treatment, ensuring that the patient has realistic outcome expectations and is aware of potential complications.I recommend that the patient is given an adequate opportunity to seek information and ask questions, and this can be reinforced with written information. Detailed consent forms need to be completed by the patient and they should include information on the technique used, possible post-operative course expected and post-operative complications. Pre-operative photography should be carried out in all cases.9

Treatment of rhinophyma must have a surgical approach. These are divided into:

  1. Full-thickness excision followed by split-thickness skin graft (includes the epidermis and part of the dermis).
  2. Full-thickness excision followed by full-thickness skin graft (includes the epidermis and the entire thickness of the dermis).
  3. Decortication or partial excision. Decortication techniques include dermaplaning, dermabrasion, cryosurgery, electrosurgery, laser surgery and sharp blade excision.1

Laser surgery

Although there are several options available for treatment, my preferred option is the carbon dioxide (CO2) laser. This is because it has a low risk of complications and I have found that it has higher patient satisfaction compared to other approaches.5,10

The CO2 laser has become the common laser of choice in the treatment of rhinophyma because sharp margins and good haemostasis can be achieved with improved wound healing, compared with scalpel excision.5

In 2016, 24 rhinophyma patients were treated with a 10,600 nm CO2 pulsed laser. They had a six-month, post-treatment follow-up. In the follow-up, researchers identified that CO2 laser warrants a careful nasal surface ablation, allowing the remodelling of the hypertrophic areas, with an excellent cosmetic result, a very short healing time, and virtually no side effects.11

Positive results were also described by Corrandino et al. in 2013. They used a CO2 laser in 14 elderly male patients, using a personal approach, known as the ‘downward steps’ technique. With this technique, the authors removed the pathological hypertrophic tissue using a progressive reduction of the laser power during the treatment. In a single laser session, patients showed good results from both a morphological and aesthetic point of view, according to authors.12

In other research, Madan et al. reported on 124 cases between 1996-2008 where exuberant sebaceous tissue was ablated using the Sharplan 40C CO2 laser under local anaesthesia. They used varied techniques according to the severity of rhinophyma; the laser was used in a continuous mode to debulk the larger rhinophymas, and in a resurfacing mode or continuous mode to reshape the nasal contours. After three months, results were classified as good to excellent in 118 patients and poor in six patients.13

In my clinical experience, I have found that a single treatment with a CO2 laser is usually enough to produce the desired result, but occasionally with large rhinophymas a subsequent treatment may be required.

The impact is quite significant due to immediate reduction in the bulbous deformity, and there is marked improvement in the psychological distress caused by this condition.

Laser complications

The key complications of CO2 laser surgery are that there is a risk of both hypertrophic and atrophic scarring. Post-operative infection is also a risk, and there are concerns about post-inflammatory hypopigmentation. However, ensuring one stays within the appropriate limits of ablating, there is a low risk of these complications.13

Conclusion

Rhinophyma is an uncommon condition without any known causes. Treatment using CO2 laser combines the advantages of haemostasis and the gradual precise reduction of the nasal tissues layer by layer. It produces excellent results with a low risk of complications when used appropriately. Patients should be properly consulted and informed that the procedure is cost-intensive and time-consuming.

References

  1. Hakima EM, Zahra MF. Rhinophyma. Pan Afr Med J. 2017 Mar 3;26:122.
  2. Christopher Griffiths, et al., Rook’s Textbook of Dermatology, 4 Volume Set, 9th Edition, 2016. P.11,91
  3. McAleer MA, Fitzpatrick P, Powell FC. The prevalence and pathogenesis of rosacea. Poster presentation, British Association of Dermatologists annual meeting, Liverpool, July 1-4, 2008.
  4. Berg M, Liden S. An epidemiological study of rosacea. Acta Dermato-Venereologica. 1989;69:419-423.
  5. Wolter, Scholz T, Liebau J. Giant Rhinophyma: A Rare Case of Total Nasal Obstruction and Restitutio Ad Integrum. Aesthetic Plast Surg. 2017 Aug;41(4):905-909. Epub 2017 Mar 24.
  6. Laun J, Gopman J, Elston JB, Harrington MA. Rhinophyma. Eplasty. 2015 May 1;15
  7. Croley JA, Reese V, Wagner RF Jr. Dermatologic Features of Classic Movie Villains: The Face of Evil.JAMA Dermatol. 2017 Jun 1;153(6):559-564.
  8. Fink C, Lackey J, Grande DJ. Rhinophyma: A Treatment Review. Dermatol Surg. 2018 Feb;44(2):275-282.
  9. Krupashankar DS1; IADVL Dermatosurgery Task Force. Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing.Indian J Dermatol Venereol Leprol. 2008 Jan;74 Suppl:S61-7.
  10. Rapid treatment of rhinophyma with powered microdebrider. Case Rep Otolaryngol. 2013;2013:621639. doi: Faris C, Manjaly JG, Ismail-Koch H, Caldera S. 10.1155/2013/621639. Epub 2013 Feb 21.
  11. Bassi A, Campolmi P, Dindelli M, Bruscino N, Conti R, Cannarozzo G, Pimpinelli N. Laser surgery in rhinophyma. G Ital Dermatol Venereol. 2016 Feb;151(1):9-16. Epub 2014 Sep 18.
  12. Corradino B, Di Lorenzo S, Moschella F. ‘Downward steps technique’ with CO2 ultrapulsed laser for the treatment of rhinophyma: our protocol. Acta Chir Plast. 2013;55(1):16-8.
  13. Madan V1, Ferguson JE, August PJ. Carbon dioxide lasers treatment of rhinophyma: a review of 124 patients.

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