Rhinophyma
Etai Funk, M.D.
February 26, 2004

Rhinophyma was first recognized in ancient Greece and Arabia.  In 1629, Daniel Sennert, pictured here, performed the first known rhinophyma surgery.  In 1845, rhinophyma was coined by von Hebra.  He derived this word from the Greek word “rhis” meaning nose and “phyma” meaning growth.  In 1846, Virchow associated rhinophyma with acne rosacea.  In 1864, Stromeyer was the first to leave the sebaceous gland fundi intact.  In 1920, Groton describes full-thickness skin graft coverage.  Later full-thickness skin grafts were used, and the most common method today is decortication with re-epithelialization. 

There is a male-to-female ratio reported of about 5:1 to 30:1 by Wiemer and Elliott.  Usually it occurs in the fifth to seventh decade of life in white males, predominantly in people of English and Irish descent.  It is fairly rare in African-Americans and Asians and, in fact, our visiting professor from Korea, was observing at the VA during our case; and he informed us that he had never seen a case of rhinophyma.  This painting by Domenico Ghirlandaio in the late 15th century entitled “An Old Man and his Grandson” hangs in the Louvre with an early depiction of rhinophyma.  Familial components and hereditary aspects have not been well studied and are unclear.  Odou and Odou in 1961 in the American Journal of Surgery published an article describing the many synonyms of rhinophyma.  This was descriptive for its inaccurate association with alcohol and similarity to animal snouts and vegetables.

I want to talk a little bit about the etiology of rhinophyma because there is a lot of speculation, controversy, and folklore concerning it. Virchow was the first to demonstrate the histologic similarity between acne rosacea and rhinophyma.  It is the only confirmed etiology for rhinophyma or predecessor for rhinophyma.  The prevalence of acne rosacea is about 0.5% to 10%.  It is usually seen in the glabellar, malar region, nose, and chin.  Paradoxically, women are more affected with acne rosacea than men, as opposed to rhinophyma where men are more affected than women.  This is thought to be likely due to the fact that woman receive treatment for their acne rosacea early in the course of the disease compared to men, therefore preventing the onset of rhinophyma.  It also is the reasoning behind the theory that androgens may contribute to rhinophyma.  Rebora described four stages of acne rosacea: the pre-rosacea stage where you see frequent facial flushing; the vascular rosacea stage where you see thickened skin, telangiectasias, and erythema; the inflammatory stage where you seen erythematous papules and pustules; and the fourth stage, which he described as rhinophyma.  There are not many controlled or randomized studies investigating the etiology of rhinophyma.  However, if we accept that it is the final stage of acne rosacea, then we can study the etiological findings of acne rosacea and apply them to rhinophyma.  However, the exact etiology to acne rosacea is also unclear and unknown.  Rembrandt was another famous figure, depicted here in a self portrait, who also had acne rosacea.

Demodex folliculorum is another questionable etiology of rhinophyma, which was first demonstrated to be associated with rosacea by Ayres and Anderson in 1932.  This saprophytic parasite is found in high concentration within the sebaceous glands of rosacea biopsies, and it may cause parafollicular inflammation and a granulomatous reaction.  It originally was described as found in only 19% of rosacea biopsies by Marks, therefore discrediting the mite as an etiologic factor.  A different biopsy technique used by Forton looked at Demodex density and  demonstrated that 80% of all rosacea biopsies had Demodex.  According to Forton, it is difficult to establish the pathogenicity due to the ubiquity of the mite in normal skin. However, Sibenge reported only a 1% incidence of this mite in normal skin.  Forton also looked at the skin surface biopsies of controlled subjects versus rosacea patients and found a statistically significant larger density of Demodex mites in the stage III rosacea, or the inflammatory stage, with pustules and papules.  This would be compatible with a theory that early vascular changes in stage I and stage II may predispose to increased dermal invasion of the mites.  However, in his study Forton had three rhinophyma patients that did not have increased density of mites despite being considered as stage IV disease.  Sibenge sums it up well stating that whether the mite has a part in initiating rosacea and rhinophyma or simply finds the lesions a convenient home is uncertain; however, it can stimulate an inflammatory reaction that results in connective tissue damage and telangiectasias. 

Alcohol and rhinophyma have an invalid yet persistent association.  Relief from this stigma is frequently the patient’s primary goal in seeking correction of the nasal deformity.  Dr. Wiemer states that the accentuated flush from vasoactive substances, such as alcohol, to the already dilated vasculature of rhinophyma has led to the false belief that this is an etiologic agent rather than merely stimuli for the disease, while Rebora states that the flushing is simply more pronounced and longer lasting in patients with rosacea.  I think this theory involving alcohol came from a Freeman study in 1970 where he stated that 18 of his 55 patients had a significant alcohol history.  However, no other epidemiologic studies were found and the basis for this etiology is unfounded.  W.C. Fields only propagated the association as he famously suffered from rhinophyma and was known to be quite fond of imbibing. 

Many patients with acne rosacea also complain of gastrointestinal symptoms.  Many of the medications used in rosacea overlap with the H. pylori meds.  In Dr. Sharma’s study, 35% to 67% of acne rosacea patients had gastrointestinal symptoms compared to 25 to 32% of controls.  However, in uncontrolled studies by Rebora and Powell, you can see there is a high zero prevalence and positive histology for H. pylori in rosacea patients.  However, in controlled studies you can see that the zero prevalence in rosacea patients versus controls was equal to or even less with H. pylori.  In another study by Bamford, he showed that the treatment and cure of H. pylori does not clear rosacea and demonstrates no difference from the placebo. Other things that may exacerbate rhinophyma or be associated with rhinophyma include stress, androgenic hormones, caffeine, vitamin deficiencies, and psychogenic factors. 

Marks described the histopathology beginning with vascular instability leading to a loss of fluid into the dermal interstitium, which causes inflammation and fibrosis.  The skin will become thickened, sebaceous gland hyperplasia may be seen, mites may actually even be seen in your histologic section, and you will see basal cell proliferation and acanthosis.  The sebaceous gland ducts will become cystic and plugged with sebum.  Acker statistically demonstrated that basal cell carcinoma can be expected to occur on the nose in a significantly greater proportion of patients who have rhinophyma compared to those who do not have the disease. 

Some clinical features of rhinophyma you may start to see are erythema and telangiectasias which will later lead to thickened skin, pits, fissures, scarring, tuberous nodules and lobules, inspissated sebum, and an unpleasant odor.  The disease is preferential to the nasal tip, and it can extend to the ala and lead to external nasal valve collapse.  There have been three severity grading scales in rhinophyma.  Freeman described the first one, which was based on the extent of the disease.  El-Azhary proposed one on a more descriptive analysis with telangiectasias in the minor, early lobules in the moderate, and prominent lobules in the major.  Clark based his on how extensive it was across the regions of the nose.  You can see this is a progression: the early vascular leading to telangiectasias, lobules on the tip, and then lobules extending to the ala and up onto the dorsum. 

The treatment for rhinophyma is predominantly surgical.  The nonsurgical treatment is mainly for rosacea.  There is the prevention aspect, such as avoidance of sun exposure.  Topical treatment includes metronidazole gel and Retin-A; however, Retin-A may exacerbate the erythema.  Oral treatments include tetracycline, metronidazole, and Accutane.  Radiation and chemical scarification are no longer accepted methods.

This was an algorithm proposed by Redett in 2001.  You can see the three stages of rosacea in the fourth stage rhinophyma.  For the first stage of the pre-rosacea, he mainly stresses prevention.  The second stage, some topical and oral treatments, and the same for the third stage.  In rhinophyma he mainly talks about surgical treatments.

Originally all surgeries were skin grafted, as it was feared that the rhinophymatous tissue would recur.  Fisher, in 1970, demonstrated that this was untrue with long-term followup of his patients in 1970 after decortication.  Now, however, surgical decortication with preservation of the sebaceous glands fundi is the preferred method of excision.  Preservation of the glands will allow spontaneous re-epithelialization, which was first described by Stromeyer in 1864 and confirmed by Odou and Odou in 1961.  These are the frequently used devices that we may see in rhinophymatous surgery. 

We will talk about the first and oldest method of excision, which is the cold technique.  The risk of scarring and hypopigmentation are the least with cold seal according to Redett.  Linehan, however, demonstrated faster re-epithelialization compared to electrosurgery but otherwise similar aesthetic results.  The main disadvantage to using the cold technique is establishing hemostasis, which can be time consuming and lead to problems with judging the depth of the disease.  However, it can be achieved using injection and adrenaline-soaked gauze.  FloSeal has been reported, as well as Alginate dressings.  Har-El showed that patients complained of more pain with dressing changes after a cold conventional surgery compared to laser surgery.  Here are pictures of the patient three months postop after cold excision, and this is a Guillain dermatome. which has also been used. 

Electrosurgery for rhinophyma was first reported in 1950 by Rosenberg.  Its main advantage is hemostasis.  Cautery is available in almost all hospitals, even on an outpatient basis, and is inexpensive.  There is greater heat dispersion compared to CO2  laser and Cold Knife, which can lead to scarring and hypopigmentation.  One can use a wire loop or a hockey stick attachment.  Greenbaum, in an interesting study, took three patients and treated one-half of the nose with CO2  laser and then treated the other half of the nose with electrosurgery and concluded that both gave equivalent cosmetic results with equal time to re-epithelialization.  However, he stated that the laser technique took him twice as long compared to the electrosurgery technique and he also reported that CO2 laser is 15 to 20 times more costly than the electrosurgery.  Stucker states that you should reserve this technique only for diseases on the nasal tip.  You can see why, since sometimes you may get some alar notching here. 

In conclusion, the use of electrosurgery in experienced hands and being extremely vigilant of the depth of tissue destruction, can be very useful, cost effective, and convenient in the treatment of rhinophyma. 

The CO2 laser was first reported in 1980 by Shapshay.  It was originally used as a microscope with a laser attachment, as seen here.  Now there is a handheld attachment that we use.  Har-El found no significant difference in tissue preservation, pain, and scarring between cold and laser techniques in 23 patients.  The author did find the laser to be more time consuming but was more hemostatic, with easier postoperative care.  Excision of the bulk of rhinophyma is used with the CO2 laser, and vaporization is used for the rest with the depth of 0.1mm.  Thirty patients were reviewed by el-Azhary using the CO2 laser and vaporization was only required in the minor and moderate cases, whereas in the major cases debulking was used.  This is a picture of a patient immediately postop right here, and you can see the dramatic change in his nasal airway, and at six weeks postoperatively you can see a little bit of scarring here.

The YAG laser was first reported used in rhinophyma by Wenig in 1993.  He advocates the use of this technique, and he used it in six patients and found equally cosmetic results with shorter healing time compared to the CO2  laser.  This is thought to be due to the smaller thermal damage zone compared to the CO2. 

In 1983, Wenig was the first to use the Argon laser for rhinophyma and advocated its use for hemostasis and on telangiectasias but states that it is a poor instrument for debulking.  It affects the tissue to a depth of only 0.5 mm.  Stucker uses the TWA technique, tumescent anesthesia, wet blade pictured here, and the Argon beam coagulator.  He used it on 51 patients and reported good to excellent results in all but two patients in which resection was carried too deep leading to scarring.  He also stated that this is a cost effective technique that did not take more than ten minutes of operating time in all 51 of his cases. 

Dufresne recently used a harmonic scalpel for resection and found it to provide excellent hemostasis, improved tactile control with minimal tissue damage, and the samples of skin he took afterwards were comparable to that of skin excised with a scalpel; however, it is expensive and is not readily available.  Eisen, in 1986, is the only reported author to use the Shaw knife for rhinophyma.  This scalpel heats from 110 to 270 degrees.  It provides a narrower zone of tissue destruction than electrocautery.  However, the cord has been reported to be quite cumbersome.  

Dermabrasion is another technique used in rhinophyma; however, it is usually used as an adjuvant to other methods.  It is excellent for refining the shape and re-contouring the nose.  You may experience some bleeding.  Linehan used strips of coarse grade emery cuff on a gauze roll and sterilized these to make an effective hand dermabrader.  He also used Schneiderman dermabraders.  This was reported in 1970. 

This is a Bovie scratchpad that we used in our surgery.  Sebaceous glands are readily destroyed by low temperature, forming the theoretic basis for cryosurgery.  This minimizes bleeding and pain.  Cartilage is more resistant than skin to freezing injury; however, cryosurgery is not precise.  It lacks contouring effect and there is no control of depth of injury.  In addition, you may experience some hypopigmentation with it. 

Aesthetic outcomes have been reported and are somewhat difficult to grade in rhinophyma surgery.  There have been three scales reported.  Clark used one based mainly on scarring and contouring, Redett used one based on patient satisfaction and on scarring, and Har-El used one based on the complications and whether or not the patient had evidence that there was surgery.  The complications included infection, alar rim retraction, depression at the margins, dilated pores, scarring, leukoderma, recurrence, and hypopigmentation.  Many of these studies were scored by the principal investigator and surgeon; therefore, potential bias was present.  The problem here is one we run into often in facial plastic surgery, which is that it is difficult to grade aesthetic outcomes.  Therefore, it is difficult to assess which technique gives the best results. 

In summary, rhinophyma is a disfiguring soft tissue hypertrophy of the nose predominantly seen in older white men.  It is characterized by telangiectasias, erythema, thickened skin, tuberous nodules, and lobules.  Histologically there is sebaceous gland hyperplasia, fibrosis, and hypervascularity.  It is closely related and believed to be the final stage of acne rosacea.  It is thought to be due to numerous other factors including alcohol, Demodex folliculorum, and H. pylori. However, a direct causal link has not been proven.  Treatment is mainly surgical with many modalities providing similar cosmetic results.  The choice of surgical methods should be based on extent of disease, expense, availability, operating time, and user experience.  Once a universal classification scale has been developed based on aesthetic outcomes, patients can be evaluated without bias, and evidence-based results may be obtained on the best treatment.

Case Presentation

RD is a 63-year-old white male who was referred from the Dermatology clinic for management of his external nasal deformity.  He stated that over the last 5 years his nose has increased in size, nodularity, color, and skin thickness.  He denied any nasal obstruction.  He had been using the tetracycline and metronidazole gel recently prescribed by the Dermatology department.   The patient desired surgical management of his external nasal deformity.

On exam the patient’s facial skin was erythematous with telangiectasias and small pustules involving the glabellar, malar, and nasal areas.  His nasal skin was thickened, sebaceous, and telangiectatic with a lobulated/nodular tip and ala.  There was no evidence of external nasal valve collapse. 

The diagnosis of rhinophyma with acne rosacea was clinically confirmed.  The patient agreed to proceed with surgical management of his deformity. 

The patient was taken to the operating room and using electrocautery with a wire loop, the deformity was reshaped to a normal nasal contour.  Expression of sebum was periodically performed to ensure that resection was not extended below the level of the sebaceous glands.  The Bovie scratch pad was used as a dermabrader to refine and smooth any further deformity. Bacitracin ointment was applied and Adaptec non-adherent dressing was placed.  Post operatively, the patient performed dressing changes with Bacitracin and Adaptec for 4 days and then applied a mixture of Aquaphor and 0.25% acetic acid to the site. 

On his 6 week follow up clinic visit, the patient demonstrated no recurrence of his rhinophyma and had fully re-epithelialized his nose.  There were no complications and he was satisfied with his surgical outcome. 

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