Life & Times Rhinophyma: when Red Nose Day is no laughing matter

Rhinophyma is commonly linked to chronic ACE inhibitors, and simvastatins have been CO2 laser shaving; cryosurgery; harmonic alcohol use, colloquially being misnamed reported as aggravating factors of rosacea,4 scalpel; and YAG laser. ‘whisky nose’ or ‘rum blossom’. However, the and studies have found possible associations true reason for this disfiguring condition has between rosacea and the face miteDemodex CONCLUSIONS no clear causative trigger. folliculorum 5 and H. pylori.6 Some studies have linked rhinophyma The prognosis of rhinophyma is variable, with sudden emotional responses that MANAGEMENT and patients should be aware of the trigger flushing.1 Rhinophyma is a benign Patients are often referred to ENT surgeons pathophysiology of the condition and its link dermatological condition of the nose, derived due to the emotional upset caused by the to the underlying rosacea. Although this is a from the Greek word ‘rhis’ for nose and disfigurement. They often have feelings of dramatic and distressing variant of rosacea, ‘phyma’ for growth. It is the end-stage low self-esteem, embarrassment, or anxiety the condition is treatable, and with supportive presentation of phymatous rosacea, and about their facial disfigurement and flushing. management of patients’ emotional and may occur in patients with few or no other The resulting nasal hypertrophy may even be clinical needs every day need not be Red features of rosacea. severe enough to cause visual impairment, Nose Day. Although recognised by Greek and Arabian nasal obstruction, or sleep apnoea.7 physicians as early as 2000 bce,2 it may have The diagnosis of rhinophyma is generally Alison Liu, easily been confused with tuberous conditions made on a clinical basis; however, a Doctor, ENT Department, Surrey & Sussex of the nose such as leprosy, syphilis, and biopsy may be necessary to exclude other Hospitals NHS Trust, Surrey. tuberculosis. First accurately described by conditions such as: lupus pernio (sarcoidosis Email: [email protected] Virchow in 1846, it can result in significant of the nose); basal cell carcinoma; squamous facial disfigurement, emotional suffering, cell carcinoma; angiosarcoma; and nasal Ali Al-Lami, and even serious ocular complications. lymphoma. ENT ST8 Doctor, Surrey & Sussex Hospitals NHS Trust, Surrey. PATHOPHYSIOLOGY TREATMENT Rhinophyma, also termed ‘end-stage It is essential to fully understand the patient’s Karan Kapoor, rosacea’, is the most frequent phymatous concerns and consider the emotional impact ENT Consultant, Surrey & Sussex Hospitals NHS manifestation of the disease. It starts of the condition on the patient. Attention Trust, Surrey. as an accentuation of the normal tissue must be given towards systemic treatment DOI: https://doi.org/10.3399/bjgp19X701585 over the nose in adolescence and young of rosacea and avoiding trigger factors to adulthood. This is followed by progressive achieve symptoms control. dilation of the nasal vessels, involvement of REFERENCES cysts and pustules resulting in oily skin, and MEDICAL OPTIONS 1. Millikan L. Recognizing rosacea. Postgrad significant hypertrophy and hyperplasia of The early stages of rhinophyma may respond Med 1999; 105(2): 149–150, 153–158. the sebaceous glands and connective tissue to topical treatments such as metronidazole, 2. Verna G, Raso F, Fava L, et al. Rhinophyma’s of the nasal tip. azelaic acid, and topical retinoids, and oral fibrous variant: an immunohistochemical As the condition progresses pits, nodules, antibiotics such as tetracycline, doxycycline, study with mib-1 antibody. Eur J Plast Surg 2001; 24(3): 114–117. lobulations, fissures, and pedunculations and metronidazole can also be used. conceal the normal contour of the nose 3. Sadick H, Goepel B, Bersch C, et al. More severe cases should be referred to Rhinophyma: diagnosis and treatment leading to the unpleasant disfigurement. a specialist, who may consider using options for a disfiguring tumour of the nose. Nasal involvement can be localised or topical ivermectin and brimonidine, or oral Ann Plast Surg 2008; 61(1): 114–120. generalised, but most commonly affects the isotretinoin. 4. Litt JZ, Pawlak WA Jr. Drug eruption lower two-thirds and the nasal tip. There is Topical steroids should be avoided as they reference manual. New York: Parthenon, no uniformity within the final appearance of can exacerbate symptoms.8 However, once 1997. the nose and the condition can spread to the the disease progresses to its hypertrophic 5. Roihu T, Kariniemi AL. Demodex mites in acne rosacea. J Cutan Pathol 1998; 25(10): 550–552. chin (omentophyma) or the ear (otophyma).3 and bulbous stage only surgical intervention 6. Bamford JT, Tilden RL, Blankush JL, can reverse the deformity. Gangeness DE. Effect of treatment of AETIOLOGY Helicobacter pylori infection on rosacea. Arch Although rosacea is commoner in females, SURGICAL OPTIONS Dermatol 1999; 135(6): 659–663. the incidence of rhinophyma is higher in Several surgical techniques have been 7. Lomeo PE, McDonald JE, Finneman J. males. Rhinophyma typically afflicts white described in the management of rhinophyma. Obstructing rhinophyma: a case report. males between the age of 40 and 60years, The main principle is shaving the redundant Otolaryngol Head Neck Surg 2005; 133(5): 799–800. and is more common in men with English or tissue while avoiding damage to the 8. Tanghetti E, Del Rosso JQ, Thiboutot D, et Irish descent. underlying cartilage. The depth of shaving al. Consensus recommendations from the Numerous exacerbating factors have should leave enough skin adnexal structures American Acne & Rosacea Society on the been reported to trigger rosacea such as at the wound surface to allow proper healing management of rosacea, part 4: a status extreme emotional states, sun exposure, and by secondary intention. report on physical modalities and devices. Cutis 2014; 93(2): 71–76. cold weather. Drugs such as vasodilators, Surgical techniques include: dermabrasion;

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