Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Rhinophyma Rhinophyma is a descriptive term derived from the Greek "rhis" meaning nose and "phyma" meaning growth. It was probably known to Greek and Arabian physicians as early as 2000 B.C. but this cannot be confirmed. In those early days there were several tuberous conditions of the nose such as tuberculosis, syphilis, and leprosy which were likely confused with rhinophyma. The medical literature is silent for centuries, but the condition is well- documented in art and literature. Rhinophyma is a disease that typically afflicts white males between 40 and 60 years of age, although there have been a few patients who developed it in their 20s. It is far more common in men than women, with the ration of 12:1 generally reported. This is very interesting when you consider that the disease is the end-stage of acne rosacea, which is three times more common in females. It is seen more commonly in persons of English or Irish descent and only very rarely in blacks (only a handful of cases have ever been recorded). There does not seem to be any strong hereditary links in rhinophyma although one study by Freeman el al in 1970 reported that 12 of 55 patients had parents or grandparents with similar nasal disfigurements. The only clearly associated entity and precursor of rhinophyma was first recognized by Virchow in 1846, and that is rosacea progressing to acne rosacea. It begins as an accentuation of the normal flush reaction in adolescence and young adulthood and can involve the nose, central forehead, malar areas, and chin. With time, the vessels of the nose become progressively dilated and the skin thickens and may become involved with cysts and pustules, and the skin can be quite oily. The nose thickens at the tip and sebaceous glands hypertrophy. As the deformity worsens, pits, nodules, fissures, lobulations, and pedunculation contort the nose into grotesque cosmetic problems. There is no uniformity in the end stage or final appearance. Progression of disease in the chin has been termed "mentophyma," and involvement of the pinna can lead to "otophyma," but these areas are much less frequently involved than the nose. Histopathologically there is hyperplasia and hypertrophy of the sebaceous glands, and the ducts become elongated, dilated, and plugged. There is irregular fibrous tissue proliferation and varying degrees of inflammation with inflammatory cell infiltrate and bacteria seen. Foreign body reactions can be seen, and the Demodex folliculorum mite regularly takes up residence in the pilosebaceous units of these noses. Many have reported the presence of occult basal cell carcinomas in removed rhinophymatous tissues in the range of 3% to 10% of cases, and Graham and McGavran (1964) have demonstrated that basal cell carcinomas occur in direct proportion to the concentration of sebaceous glands in sun-exposed skin. Squamous cell carcinomas and other tumors have also been seen in an association that can only be considered incidental. Acne rosacea may respond to local medical or dermatologic treatment and prevent progression to rhinophyma. Medical treatment classically has been limited to the avoidance of stimulation factors, appropriate cleanliness, and treatment of secondary infection and inflammation with antibiotics and steroids. There have been many studies of treatment with vitamins, hormones, fibrinolysis, steroids, ice slush, liquid oxygen, liquid nitrogen, silver nitrate, caustics, mercury vapor, ultraviolet wave, and others; but none have been found to be particularly effective. Treatment with X-ray and radium seemed promising in the 1920s when it was shown to reduce sebaceous activity in acneiform conditions. Unfortunately, it took nearly 20 years to determine that it lead to a greater incidence of skin cancer and thyroid tumors. More ancient remedies involving herbs, spices, potions, and rituals were ineffective, but at least they did less harm. Modern topical therapy includes cleansing the skin with detergents that have defatting effects, avoiding creams or ointments. Anti-inflammatory and anti-bacterial medications in a non-irritating base or benzoyl peroxide (3-5%) are often helpful. Topical corticosteroids have no place in the treatment of rosacea. It is true that they can be effective over a short period, but the disease recurs after it is discontinued and long term use can lead to steroid-damaged skin. Weak concentrations of sulphur (2%) or icthyol (2%) may be helpful in some cases. Modern systemic therapy includes oral antibiotics such as Flagyl (250 mg/day x 10 days) for acute exacerbations. Long term use is contraindicated because of risk of polyneuropathies and possible carcinogenic effects. Tetracycline (250 mg QID or 500 mg BID) can be used in more long-term management but is often less effective. Isotretinoin (13-cis-retinoic acid "Acutane") in doses of 0.2-1.0 mg/kg for 10 to 16 weeks has been shown to provide up to a 90% reduction in the volume of sebaceous glands. It remains to be seen whether this agent will be able to alter the natural history of the disease process. Once the violaceous, hypertrophic, bulbous stage of the disease becomes manifest, only surgical manipulation can reverse the deformity. Regression with or without medical therapy simple does not occur. Full thickness excision followed by application of split thickness skin grafts seems like an appropriate procedure which should provide satisfactory results, but, in fact, there are certain disadvantages. The first is that the junction of the normal perinasal skin with the skin graft is always obvious. Color match is a problem as well, as the graft is usually hypopigmented in relation to the rest of the face, especially when taken from the abdomen or the thigh. A full thickness graft provides better texture, and color match may be better as well, especially if obtained from other "blush" areas such as behind the ear, the low neck, and the upper chest. Grafts provide rapid coverage but if there are residual dermal appendages left under the graft, recurrent cyst and sinus tract formation can be a problem. Most authors recommend partial thickness excision as the treatment of choice, and this has been termed "decortication." The idea is that the rhinophymatous tissue is shaved off in layers with care taken not to injure the underlying cartilage. The operator may place fingers in the nostrils or use magnification in order to halt removal of tissue once a thickness of 2 mm to 3 mm above the upper and lower lateral cartilages and nasal bones is estimated to remain. At this point the remaining fundi of the hypertrophic sebaceous glands should be sufficient to totally re-epithelialize the nose. If one stops resecting above this plane, the nose will remain bulbous, and to go below it will leave raw, granulating, non-epithelializing areas. Areas that are difficult to mold and refine with the scalpel can be dermabraded to achieve a better result. Decortication retains the overall architecture of the nose and reformation of sebaceous gland pores contributes to a more normal surface texture. Additionally, the color match of the re-epithelialized nose is closer to normal than any of the skin grafting techniques. Decortication has been performed using cryosurgical techniques, chemical peels, dermabrasion, the cold scalpel, the Shaw knife (a thermally heated scalpel), the Bovie, hot wire loops, and the Argon and CO2 lasers. The scalpel and dermabrader often lead to significant bleeding that can compromise accuracy. Electrosurgical techniques are better, but most authors now recommend use of the CO2 laser which can allow operation in a near bloodless field. Our method uses the hand-held attachment for the CO2 laser set in a continuous mode at 12 watts of power. The depth of excision is determined by visualization of the nasal contour and by the distinct crackling sound and odor emitted by sebaceous glands as they are vaporized. Contracture of remaining dermis and sebaceous elements exudes ribbons of sebaceous material so that if you don't see sebum or hear crackling, you are probably too deep. Particular care is taken around the nasal alae. Wound care consists of covering with an antibiotic-impregnated or other nonadherent gauze (e.g. Xeroform). Bacitracin ointment is applied to the gauze three times daily. The gauze is removed between the third and fifth postoperative day and bacitracin ointment application is continued until re-epithelialization occurs, which may take up to three or four weeks. Early complications include hemorrhage and wound infection. Exposure of cartilage can lead to chronic infection and chondronecrosis with resultant deformity so that if the cartilage is exposed, it should be covered by grafting. This is particularly true along the nasal alae where injury can lead to notching that may be particularly difficult to correct. Late complications include delayed healing which may lead to eschar formation and cicatrix. Most commonly, this occurs after decortication at a level just below the sebaceous elements. If the wound has failed to heal by three to four weeks postop, split thickness skin grafting should be carried out. Excessive scarring is best avoided by adhering to the above principles, paying attention to the depth of excision, and avoiding exposure of cartilage. Irregular or prominent scars may sometimes be improved by dermabrasion. Color mismatch from grafting may improve gradually, but is best avoided by careful preoperative planning. Case Presentation A 68-year-old white male with mild hypertension presented to the Otorhinolaryngology Service complaining of progressive deformity of his nose over a 10 year period. He noted that changes in his skin began at age 24. He has been followed by Dermatology for many years, where he has received intermittent 1% hydrocortisone cream treatment and various antibiotics, most commonly tetracycline 250 mg orally on twice daily schedules. Despite the use of multiple sunscreens, he has had numerous actinic keratoses treated with liquid nitrogen but has never developed a malignant lesion. Over recent months he has noted nasal obstruction secondary to the deforming weight of his nasal tip. Pre- and postoperative photographs will be shown with a discussion of surgical management using the carbon dioxide laser. Bibliography Ali MK, Callari RH, Mobley DL. Resection of rhinophyma with CO2 laser. Laryngoscope 1989;99:453-455. Amedee RG, Routman MH. Methods and complications of rhinophyma excision. Laryngoscope 1987;97:1316-1318. Clark DP, Hanke CW. Electrosurgical treatment of rhinophyma. J Am Acad Dermatol 1990;22:831-83 Dotz W, Berliner N. Rhinophyma: a master's depiction, a patron's affliction. Am J Dermatopathol 1984;6:231-23 Eisen RF, Katz AE, Bohigian RK, Grande DJ. Surgical treatment of rhinophyma with the Shaw scalpel. Arch Dermatol 1986;122:307-30 el-Azhary RA, Roenigk RK, Wang TD. Spectrum of results after treatment of rhinophyma with the carbon dioxide laser. Mayo Clin Proc 1991;66:899-905. Elliott RA Jr, Ruf LE, Hoehn JG. Rhinophyma and its treatment. Clin Plast Surg 1980;7:277-20. Farrior RT. Dermabrasion in facial surgery. Laryngoscope 1985;95:534-55. Graham PG, McGavran MH. Basal-cell carcinomas and sebaceous glands. Cancer 1964;17:803. Gursel B, Yalciner G. Rhinophyma: treatment by excision and silver impregnated amniotic membrane. Rhinology 1988;26:63-6. Haas A, Wheeland RG. Treatment of massive rhinophyma with the carbon dioxide laser. J Dermatol Surg Oncol 1990;16:645-64 Hassard AD. Carbon dioxide laser treatment of acne rosacea and rhinophyma: how I do it. J Otolaryngol 1988;17:336-33 Lloyd KM. Surgical correction of rhinophyma. Arch Dermatol 1990;126:721-72 Odou BL, Odou ER. Rhinophyma. Am J Surg 1961;102:3. Pastorek NJ. The management of rhinophyma. Otolaryngol Clin N Am 1972;5:639-66. Reese BR. External rhinoplasty approach to unusual rhinologic procedures. Ear Nose Throat J 1991;70:431-43 Riefkohl R, Georgiade GS, Barwick WJ, Georgiade NG. Rhinophyma: a thirty-five year experience. Aesthetic Plast Surg 1983;7:131-13 Roenigk RK. CO2 laser vaporization for treatment of rhinophyma. Mayo Clin Proc 1987;62:676-60. Sibenge S, Gawkrodger DJ. Rosacea: a study of clinical patterns, blood flow, and the role of Demodex folliculorum. J Am Acad Dermatol 1992;26:590-59 Wiemer DR. Rhinophyma. Clin Plast 1987;14:357-365. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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