RHINOPHYMA: ROSACEA'S ATTACK ON THE NOSE
From Washington University Physicians, posted February 1, 2012, written by Mary Jo Blackwood, RN, MPH
Rosacea, or adult acne, is a chronic condition usually characterized by red skin across the cheeks, nose, and forehead, more prominent fine blood vessels, and sometimes pimples.
It is a largely benign condition primarily affecting Caucasians, three times more women than men, and usually after age 30. Rosacea cannot be cured but is managed by treating infections with topical or oral antibiotics, and managing redness with skin treatments or intense pulsed light (IPL) therapy.
Although men develop rosacea less often, because of their thicker skin and greater concentration of oil glands on the end of the nose, over a period of time, those glands can become chronically blocked from normal secretion of oils and sweat.
This puts the patient’s skin at risk for frequent infections, causing the skin and glands on the end of the nose to grow out of control, sometimes doubling in size.
Dr. Mark Checcone of the Washington University Facial Plastic Surgery Center says treating the rosacea at an early stage is the best prevention for the resulting deformity called rhinophyma (see photo below).
While it may appear to be a tumor since the tip of the nose seems to enlarge uncontrollably, rhinophyma is benign condition. It presents as a pink, lobulated mass over the nose with superficial vascular dilation; it mostly affects men past middle age.
Classic examples of rhinophyma include W.C. Fields, Karl Malden and Bill Clinton. W.C. Fields was considered to be an alcoholic because of the characters he played, so this type of nose became associated with alcoholism.
In truth, says Dr. Checcone, there are two different conditions. Alcoholics can develop red vascular webs on their faces because of venous congestion secondary to liver disease.
But in patients with rosacea, the problem lies directly in the skin (although alcohol consumption, along with spicy foods and other dietary triggers can make rhinophyma worse).
The two conditions can appear similarly in early stages—a reddened, swollen nose—but the treatments are different to address the underlying problem. A doctor can make the differential diagnosis of rhinophyma.
The best way to prevent rhinophyma is by treating the early rosacea and the infections that cause the skin proliferation. “Sometimes, despite treatment, the disease progresses. When the nose becomes large, bumpy and disfiguring, there are surgical remedies.” Checcone says the two main treatments used by him and his colleague Dr. Gregory Branham are:
This technique uses a power instrument with a diamond cutting tip to shave down the thickness of the skin. Performed in the office under local anesthesia, it results in a raw wound that requires daily care for at least a week while the outer skin surface heals.
Dermabrasion can be helpful for both early and late stages of rhinophyma because the amount of skin removed can be controlled by the practitioner.
This approach is usually reserved for more severe cases of cystic rhinophyma
and has extremely hypertophied skin. Debulking can be performed in the office or in the operating room under local or monitored anesthesia.
The excess deep tissue is surgically removed with a scalpel,
leaving good skin at the margins that can be pulled over as flaps to cover the
debulked areas. Depending on the extent of disease, skin grafting may also be used
in to reestablish a smoother curved nasal tip more normal in size. The photos below demonstrate surgical debulking and skin grafts performed by Dr. Gregory Branham.
If left untreated too long, rhinophyma becomes aesthetically distressing and can sometimes even interfere with breathing by blocking normal airflow through the nostrils, or close vision, if the tip of the nose becomes too large to accommodate glasses or interferes with the patient’s line of sight for reading.
According to Dr Checcone, early treatment is the best approach for preserving normal external nasal contours.