Rhinophyma that is severe enough to require surgery is rare. Knowing that it is rare should firstly put you as ease. This means that most like you will never require surgery.

Before you get too far along this route, and see too many grotesque pictures on the internet, can I suggest that you read – How to cure a red swollen nose. This article offers some good non-surgical options that you can consider along with your doctor.

Should you find yourself in the situation where you do require surgery, then suddenly how it works becomes much more interesting.

For sure this sort of surgery requires careful research into the methods available from your treating surgeon.

Going back in the archives we find this 2001 paper which was published in the respected journal Lasers in Surgery and Medicine. You can also find more recent papers featuring the combined erbium:yttrium-aluminium-garnet (YAG)/CO₂ laser – for eg. see the 2004 paper The Gold Standard for Decortication of Rhinophyma: Combined Erbium-YAG/CO2.

So here is the abstract for the 2001 paper;

Treatment of rhinophyma with Er:YAG laser, Lasers Surg Med. 2001;29(3):230-5. Orenstein A, Haik J, Tamir J, Winkler E, Frand J, Zilinsky I, Kaplan H.

Rhinophyma is a benign, disfiguring disorder of the nose which presents the end stage of acne rosacea, and can also occasionally result in nasal airway obstruction. We describe the first series of patients treated with Erbium laser.

Study design/Materials and Methods: Severe-to-moderate rhinophyma in six patients were treated at our institution between 1995 and 1996, using the Erbium:YAG (Erb:YAG) laser.

Results: All patients achieved marked cosmetic improvement, with no complications. Post-operative healing time was seven to fourteen days-signicantly shorter than similar other modalities.

Conclusions: The Erbium laser provides very accurate tissue ablation and allows the sculpturing of the hypertrophied areas, offering good cosmetic results, with a very short healing period as shown in our study

The laser was used in a 5mm beam diameter and a power of 1.2J, a pulse frequency of 10Hz, with up to 10 passes on the prominent lobules and 3 passes between the lobules.

The paper tells us that the post-operative redness subsided after 1 month and none of the patients required re-treatment in the following 2 years. Further “The surgical results were good to excellent. A good result was defined as an acceptable nasal contour with minimal scar formation and an excellent result was defined as normal nasal contour without clinical scarring. All patients were satisfied with their results. No post operative complications were encountered”. The patients ranged in age from 46 to 84, and their cosmetic results are listed as either good or excellent.

A gauze with diluted adrenaline was used to control bleeding, the paper also refers to the usage of a meshed Omniderm sheath. The Er:YAG offers minimal thermal damage to the neighbouring tissue.

The final conclusion of the paper was “the Er:YAG laser ideal for removal of superficial skin layers with maximum sparing of adjacent structures, short healing process and minimal and short-term redness.”

You may also like to read about a new surgical technique for rhinophyma using a microdebrider + floseal. For some more background reading see treating rhinophyma with accutane.

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The red swollen nose of rosacea is a much hated symptom. I know that this was the symptom that I despised most and indeed drove me 10 years ago to start to look for good information about how to treat rosacea. Incidentally, this drive lead to the creation of the internet based Rosacea Support Group in 1998.

I hated that I looked like I had adult acne and a constant sun-burned nose. Especially as I have somewhat fair skin, a red nose stood out a mile away.

There has been quite a lot of interest in a article I wrote titled “how to cure a red face (facial erythema or redness)“. That article gave some tips on how to deal with general facial redness. What about a red and swollen nose ? What can you do to treat a red rosacea nose ? Read on for some suggestions.

A rosacea nose has the extra complication that one might end up suffering from rhinophyma. Although rare, rhinophyma is also a much hated symptom of rosacea. While we don’t know for sure how any particular rosacea sufferer’s symptoms will progress, reducing your inflammation and flushing is a good start to winning the battle.

Here are my top tips for dealing with the red nose of rosacea.

Rosacea-LTD III

Rosacea-LTD was one of my first discoveries after starting to look for treatments on the internet in 1998. They consist of compressed disks of sulfur and various salts. You wet your face and glide them over the skin, leaving a thin film. For me these `disks’ did a great job of reducing the papules and pustules on my nose. I could feel them shrinking all those acne looking lumps and bumps. As much of my redness was associated with my papules and pustules, this treatment was a good step in the right direction. I continued to use rosacea-ltd for several years.

Disclaimer: rosacea-ltd is a site sponsor of rosacea-support.org

Oral Antibiotics

If the nasal swelling is associated with the papules and pustules normally seen in rosacea, then systemic antibiotics along with topical metrogel or finacea may also be of benefit. Once the papules and pustules are under control, the associated swelling may be reduced enough to see an overall benefit in appearance. One of the newer antibiotics on the market is a low dose form of doxycycline called Oracea, which may be useful in helping to maintain a long term benefit from antibiotic usage.

Accutane

Accutane or roaccutane has been used for many years to treat cystic acne. There is a good body of evidence to say that you can successfully treat rosacea with accutane. Additionally there are some published papers that deal specifically with treating rhinophyma with accutane.

Isotretinoin has also been demonstrated to decrease nasal volume in rhinophyma. The most significant regression has been noted in younger patients with less advanced disease.

…

Isotretinoin has also been demonstrated to decrease nasal volume in rhinophyma. The most significant regression has been noted in younger patients with less advanced disease.

Biopsy specimens from phymatous skin prior to isotretinoin therapy showed numerous large sebaceous glands. During isotretinoin therapy, the glands diminished in size and number. Other studies have confirmed the usefulness of isotretinoin for phymatous change.

[See treating rhinophyma with accutane]

Accutane is not a drug to be taken lightly. If you would like to try this as an option, the above references might help you find a doctor that can support you using this as a treatment option. You may also want to discuss the option of low-dose accutane with your doctor.

Covering Up

As you start to reduce the inflammation, you will probably also benefit from covering over some of the redness. Some options include the easily available Clinique Redness Solutions, or Eucerin Redness Relief which may be able to offer some relief from the redness. Additionally the green tinted version of the Tone Perfecting Cream may cover some redness.

Perhaps you can find some foundation or tinted moisturizer that you can also include in your daily regime. It might not be easily obtainable worldwide, but The Cancer Council in Australia has a range of tinted moisturiser SPF 25 that looks interesting. Don’t discount a liquid foundation as a possibility, even if you are a guy.

IPL and Lasers

We now know that IPL is excellent for treating a red face and broken blood vessels. Will any of the benefits of IPL also help a red swollen nose ? In general IPL and pulsed dye lasers are useful in reducing the redness flushing, burning,  itching, dryness and swelling of rosacea.

The AAD suggests that for thickening of the skin on the nose and cheeks as seen in rhinophyma, the CO2 laser and erbium:YAG laser can be used.

Surgical Options

When the growth of the nose tissue becomes impossible to manage with topicals or isotretinion, surgical intervention can be an option. Surgery can naturally have its own risks. With the removal of extra tissue also comes the risk of scarring.

CO2 Laser

A 2004  paper; The Gold Standard for Decortication of Rhinophyma: Combined Erbium-YAG/CO2 Laser, details how the authors suggest that the combined YAG/CO2 laser is superior to other lasers, scalpel, radiotherapy and skin grafts in dealing with rhinophyma.

Also some related comments from the AAD page Is laser treatment right for your rosacea? ;

Some patients with longstanding rosacea develop thickening skin on the nose and cheeks, which is called rhinophyma. The CO₂ laser and erbium:YAG laser can be used to remove this thickening skin and improve the contour of the nose. Other surgical procedures used to treat this condition include dermabrasion and excision with a scalpel. Treatment options may be combined to obtain best results.

Dermatologists recommend early treatment of rhinophyma to help prevent the condition from progressing and becoming more difficult to treat. In the advanced stages, rhinophyma can cause difficulty breathing through the nose. It also is possible for the nostrils to collapse.

Other Surgical Methods

A 2003 paper; New surgical adjuncts in the treatment of rhinophyma: the microdebrider and FloSeal details a novel technique using a standard microdebrider followed by a haemostatic sealant to eliminate bleeding.

Now Over to You

What have you found to be useful in your battles with a red nose ? Please help your fellow rosacea sufferers by leaving a comment below.

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Otophyma: A Case Report and Review of the Literature of Lymphedema (Elephantiasis) of the Ear., Am J Dermatopathol. 2008 Feb;30(1):67-72, Carlson JA, Mazza J, Kircher K, Tran TA

Phymas (swellings, masses, or bulbs) are considered the end-stage of rosacea and mostly affect the nose (rhinophyma), and rarely involve the chin (gnatophyma), the cheek (metophyma), eyelids (blepharophyma), or ears (otophyma).

Herein, we report the case of a 57-year-old man who developed unilateral enlargement of his left ear over 2 years. Biopsy revealed changes of rosaceous lymphedema associated with Demodex infestation. Corticosteroid and minocycline therapies resulted in partial reduction of the ear enlargement. Literature review examining for cases of lymphedema (elephantiasis) of the ear revealed that chronic inflammatory disorders (rosacea (most frequent), psoriasis, eczema), bacterial cellulitis (erysipelas), pediculosis, trauma, and primary (congenital) lymphedema can all lead to localized, lymphedematous enlargement of the ear. Depending on the severity, medical treatment directed at the inflammatory condition for mild, diffuse enlargement to surgical debulking for extensive diffuse enlargement or tumor formation can improve the signs and symptoms of otophyma.

Decreased immune surveillance secondary to rosaceous lymphedema may explain why Demodex infestation is common in rosacea and support the suspicion that phymatous skin is predisposed to skin cancer development.

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Unfortunately doctors are finding it harder and harder to prescribe accutane. The wikipedia page on iPledge  (the mandatory distribution program in the United States for isotretinoin) has the following quote on how hard it is becoming to get accutane.

In the RxDerm dermatology user group, a physician said, “It will be easier to get a firearm, an abortion or Thalidomide, than to obtain this safe and important medication.”

See Also:  Dermatologists Frustrated With Problematic iPledge Program, AAD 64th Annual Meeting, Focus session, March 6, 2006

Hopefully good, peer-reviewed medical data may help you explore accutane as a rhinophyma treatment option.

CONTINUING MEDICAL EDUCATION: Rosacea: II. Therapy (Full Article PDF) J Am Acad Dermatol 2004;51:499-512, Michelle T. Pelle, MD, Glen H. Crawford, MD, and William D. James, MD, Boston, Massachusetts, and Philadelphia, Pennsylvania

Page 7:

Isotretinoin has also been demonstrated to decrease nasal volume in rhinophyma [70][75]. The most significant regression has been noted in younger patients with less advanced disease [75].

Biopsy specimens from phymatous skin prior to isotretinoin therapy showed numerous large sebaceous glands. During isotretinoin therapy, the glands diminished in size and number. Other studies have confirmed the usefulness of isotretinoin for phymatous change [76][77].

Page 11:

Phymatous subtype

Isotretinoin monotherapy is beneficial for early to moderate phymatous rosacea. Advanced phyma should be treated with surgical therapy or the combination of surgery followed by isotretinoin therapy. Surgical approaches to the reshaping of rhinophyma have included the use of a heated scalpel, electrocautery, dermabrasion, laserablation, tangential excision combined with scissor sculpturing, and radio frequency electrosurgery. Often a combination of these approaches is used to obtain the best aesthetic result [76][117][118].

These 2 short extracts refer to the following papers:

• [70] Schmidt JB, Gebhart W, Raff M, Spona J. 13-cis-Retinoic acid in rosacea. Clinical and laboratory findings. Acta Derm
  Venereol 1984;64:15-21.
• [75] Irvine C, Kumar P, Marks R. Isotretinoin in the treatment of
  rosacea and rhinophyma. In: Marks R, Plewig G, editors. Acne
  and related disorders: proceedings of an international sym-
  posium. London: Martin Dunitz; 1988. p. 301-5.
• [76] Lloyd KM. Surgical correction of rhinophyma. Arch Dermatol
  1990;126:721-3.
• [77] Jansen T, Plewig G. Clinical and histological variants of rhinophyma, including nonsurgical treatment modalities.
  Facial Plast Surg 1998;14:241-53.
• [117] Kotrajaras R, Kligman AM. The effect of topical tretinoin on photodamaged facial skin: the Thai experience. Br J Dermatol
  1993;129:302-9.
• [118] Kligman AM, Leyden JJ. Treatment of photoaged skin with topical tretinoin. Skin Pharmacol 1993;6:78-82.

The full article: Rosacea: II. Therapy is available via a PDF download.

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New surgical adjuncts in the treatment of rhinophyma: the microdebrider and FloSeal. Short Communication. The Journal of Laryngology & Otology. 2003 Jul;117(7):551-2. Kaushik V, Tahery J, Malik TH, Jones PH. Department of Otolaryngology – Head and Neck Surgery, South Manchester University Hospitals NHS Trust, Manchester, UK

The paper’s author was kind enough to supply a copy of the paper. Email me if you’d like to read it.

Abstract: Rhinophyma is considered to be the final stage of rosacea and has an unknown aetiology. We present two new surgical adjuncts for the treatment of this condition. The microdebrider is easy to use and allows precise contouring of the nose. It shares the same underlying principle as free-hand scalpel shaving but outperforms this method in key areas. We also describe a novel use for FloSeal® , a gelatin-thrombin co-mixture, utilizing its haemostatic properties to address bleeding from the re-shaped denuded nose.Our experience with the surgical treatment of rhinophyma is based mainly on the use of free-hand scalpel shaving. Drawbacks of this method include its limited abilty to perform predictable debridement and precise contouring. In contract microdebriders have proved successful in sinonasal surgery by virtue of the fact that they enable precise control of the amount and location of tissue that needs to be removed. This led us to believe that the microdebrider could play a useful role in surgery for rhinophyma.

Most surgical modalities used to treat rhinophyma are associated with significant surface bleeding. We attempted to combat this by using a haemostatic agent called FloSeal.

Surgical Technique: The procedure was conducted under a general anasthetic. A standard microdebrider was used. The shaving end of the instrument was stabilized by resting the distal shaft on the free index finger, thus enabling precise sculpting to take place.
…
Once a satisfactory shape to the nose had been achieved, FloSeal matric haemostatic sealant was applied. This was covered in a wet swab and light pressue applied for two minutes to prevent the substance being washed away by the bleeding surface. At the end of the procedure excess FlowSeal sealant was removed with normal saline irrigation. This achieved complete haemostasis. No dressins were required. At six week followup the result was good. This is the second occasion we have successfully used FloSeal for haemostatis in rhinophyma.

Discussion: Rhinophyma is characterized by a slow progressive over growth of the soft tissue of the nose. It can be very disfiguring and cause considerable psychosocial disability. Severe cosmetic deformity or nasal obstruction are indications for surgical treatment.

The microdebrider is a powered rotary shaving device. It has been applied usccessfully to various aspects of sinonasal surgery such as nasal polypectomy, functional endoscopic sinus surgery, turbinate reduction surgery, and septal surgery. However there appears to be only one report in the literature describing the application of this device to the nasal dorsum. Krouse successfully used a microdebrider to sculpt the bony nasal dorsum under endoscopic guidance.

In the case described, the microdebrider was easy to use and overcame some of the difficulties that can be encountered during free-hand shaving.
…
Floseal (Fusion Medical Technologies Inc, Mountan View, CA) is a gelatin-thrombin co-mixture and has been using in a variety of clinical settings, notably cardiac curgery where it has been demonstrated to be superior in its efficacy to that of gelfoam-thromin when used as a topical haemostatic agent. Following application to a bleeding area, blood perfuses therough the aggregate of thrombin coated gelatin granules, which expand to form a mechanical haemostatic plug. Where there is no contact with blood, coagulation does not occur. This excess rinses free with irrigation, leaving a coating of `sealant’ over the wound. Haemostasis was achieved immediately following the application of FloSeal in our cases.
…
To our knowledge this is the first reported use of a microdebrider and FloSeal as adjuncts in the surgical treatment of rhinophyma. The microdebrider appeared to provide satisfactory results, and overcame some of the disadvantages associated with free-hand scalpel shaving. We advocate FloSeal because of its significant haemostatic properties and ease of use. Further studies, including long-term follow-up, are required in order to ensure the safety and applicability of these techniques.

• PubMed Abstract

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Basal cell carcinoma lurking within gross rhinophyma, Dennis John Mckenna, MBChB, Kevin Mckenna, MD, MBChB, Belfast City Hospital, Belfast, United Kingdom

A 77-year-old man with long-standing gross rhinophyma developed a 6- by 8-mm ulcerated nodular lesion on the right side of his nose. Such a lesion would normally have been clinically obvious when occurring on normal skin. However, given the soft tissue hypertrophy and general nodularity of the nose due to rhinophyma, it had not been initially apparent. He had been attending the dermatology clinic for treatment of his acne rosacea. He had also recently been assessed in plastic surgery for shave removal of the larger protuberant parts of the rhinophyma in an effort to improve the appearance of his nose. There was a history of severe ischemic heart disease. Surgery had therefore been cancelled because of concerns about unduly high anesthetic and surgical risks for this cosmetic procedure. The ulcerated nodule was only considered subsequently on close inspection as suspicious of being neoplastic. Diagnostic punch biopsy confirmed the presence of a nodular microcystic basal cell carcinoma. Despite development of quite a large basal cell carcinoma in a prominent location, the gross appearance of the nose had caused it to be initially overlooked.

Conclusion: The clinical photographs in this poster demonstrate the difficulty in diagnosing carcinoma in patients with gross rhinophyma. The distortion and soft tissue hypertrophy of gross rhinophyma make carcinomatous lesions more difficult to recognize clinically and early lesions may go unnoticed. We review the literature and show that opinion has been divided as to whether there is a causal association between rhinophyma and carcinoma. In theory a causal association might be explained by the chronic inflammation, hypertrophy, hyperplasia, and scarring which occurs in rhinophyma. There does not appear, however, to be definite proof that the two conditions do not occur together by chance.We are reminded that dual pathology can occur, and the importance of careful examination of the skin in rhinophyma for coincidental carcinoma and diagnostic biopsy of suspicious areas are emphasized by our case. We also discuss the best treatment options. Mohs micrographic surgery has been used in cases such as this when the surgical margins are difficult to define clinically. Alternatively, radiotherapy is an accepted treatment option for rhinophyma and for basal cell carcinoma and has successfully been used to treat both conditions when they occur together.

Author disclosure: Nothing disclosed at press time. Commercial support: None.

Poster Discussion Session P27, American Academy of Dermatology, 64th Annual Meeting, March 3-7 2006, San Francisco.

Supplement to Journal of The American Academy of Dermatology, March 2006, Volume 54, Number 3.

• JAAD Poster Abstracts Online

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Rhinophyma treated with kilovoltage photons, Australasian Journal of Dermatology, Volume 46 Page 88 – May 2005, CASE REPORT, Marketa Skala, Geoffrey Delaney, Vincent Towell and Nevin Vladica

A 72-year-old retired truck driver presented with a 10-year history of rhinophyma and was successfully treated with 90-kV photons to a total dose of 40 Gy in 20 daily fractions. A brief discussion of radiotherapy in the treatment of rhinophyma follows.

Some extracts from the paper ; 

The patient understood that radiotherapy had no routine role in the treatment of rhinophyma, and that ther was only one recent journal article supporting its use. The small risk of late effects, including radiation-induced malignancy, was discussed and written informed consent was obtained.

Treatment was in the supine position, with the nose protruding through a 5.1 x 5.5 cm lead shield cut-out. A 900kV, 28.1mA X-ray beam of 3 mm aluminium half-value layer was used at a focus-to-source distance of 30cm. An incident dose of 40Gy was delivered in 20 treatments over 32 days to the outlined area.
…
Two weeks after the completion of radiotherapy the skin of the nose was mildly erythematous, and appeared smoother, with a reduction in the number of pits and issures.
…
At 6 months there was no erythema, and no signs of suppuration. Eighteen months after radiation therapy the patient enjoys a significant improvement in the appearance of the nose and has not required any further treatment.

Discussion

The use of radiotherapy in the treatment of skin malignancies is well documented. The incidence of coexisting skin cancers in rhinophyma has been estimated to be as high as 10% for BCC. Squamous cell carcinoma, angiosacrcoma and sebaceous carcinoma have also been reported.

The beneficial effects of radiotherapy in rhinophyma are probably due to a reduction in the sizee and number of the sebaceous glads. Skin bipoies following a course of ionizing radiation show widespread atrophy of the pilosebaceous units.
…
Routine use of radiation in the treatment of hinophyma is to be discouraged. However, as our case report illustrates, it might be an option for patients who refuse or are unsuitable for surgery, and are unable or unwilling to ramain on long-term antibiotic therapy.

• Abstract Online (full copy available from author).
• PubMed Extract

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This study has a comforting conclusion, there is no proof that alcohol consumption leads to a rosacea nose (rhinophyma). This is a popular myth – that the famous red nose of WC Fields was due to drinking. It would be great to be able to dispell this myth once and for all. A secondary conclusion is also comforting, there is no proof of increased incidence of cancer found on patients affected by rhinophyma.

New: see also a recent article I wrote titled How to cure a red swollen nose

Rhinophyma: dispelling the myths, Plastic Reconstructive Surgery. 2004 Aug;114(2):351-4., Curnier A, Choudhary S., Canniesburn Plastic Surgery Unit, Glasgow, Scotland, United Kingdom.

Rhinophyma is a relatively common condition in the west of Scotland. The Canniesburn Plastic Surgery Unit receives 12 to 13 new patients per year for surgical treatment. The reported incidence of simultaneous carcinoma in the setting of rhinophyma is on the order of 15 to 30 percent. There are conflicting reports about the association between alcohol and rhinophyma in the literature, and these are supported with little or no statistical evidence. Retrospective epidemiologic data on 45 cases of rhinophyma are presented. An audit of case notes was performed to examine histology and also alcohol consumption in these cases. The authors found no coincidental malignancies at the time of surgery, which is contrary to many previous publications. The alcohol consumption of the rhinophyma cases was compared with that of a control group that consisted of 48 men presenting for blepharoplasty. The series did not demonstrate a positive association between alcohol and rhinophyma when compared with a similar cohort of patients presenting for blepharoplasty surgery (p > 0.20) or with statistics available from the Scottish Health Survey.

• Abstract Online
• PubMed Abstract

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Archives of Facial Plast Surg. Vol. 6 No. 4, Jul-Aug 2004. Edgar F. Fincher, MD, PhD; Hayes B. Gladstone, MD

Rhinophyma is a cosmetically deforming disorder characterized by nodular hypertrophy of the nasal soft tissue. Treatment of rhinophyma usually consists of laser ablation or surgical excision for correction of the associated tissue deformity. We describe 6 patients with mild to severe rhinophyma who were treated with a dual-mode erbium:YAG (Er:YAG) laser, which provides the advantages of controlled ablative energy for tissue reduction and excellent intraoperative hemostasis. Outcome measures included patient satisfaction, clinician observer ratings, and an assessment of complications, including scarring, pigment abnormalities, and postoperative bleeding. All patients were satisfied with their outcomes, and no complications were detected during follow-up. All treatment outcomes were rated as very good to excellent at a 3-month follow-up visit. The flexibility of the dual-mode Er:YAG laser provides both controlled ablation and hemostasis, making it an ideal laser for the surgical treatment of rhinophyma.

• PubMed Abstract
• Full Article Online for $12

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Pubmed lists this paper, but it requires a bit more digging to find any more information.

Photodynamic therapy for rhinophyma, J Dermatol. 2004 Sep;31(9):771-2.

It turns out that this paper is a Letter to the Editor, so is unlikely to be as promising as hoped. `J Dermatol’ is The Journal of Dermatology from the Japanese Dermatological Association. The journal lists

key words: topical application; Aminolevulinic Acid, ALA; edema reduction, Photosensitizing Agents, rhinophyma

http://www.dermatol.or.jp/Journal/JD/2004/031090771.html

Reprint requests to:
Noriko Amari, M.D.,
Department of Dermatology,
Teikyo University Mizonokuchi Hospital,
3-8-3 Mizonokuchi, Takatsu,
Kawasaki 213-8507,
Japan.

See also from 2002. Photodynamic Therapy for the Dermatologist

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