Rhinophyma: everything you need to know about this final stage of rosacea that disfigures the nose.

Rosacea is a fairly common chronic skin condition that primarily affects individuals. The symptoms can vary depending on the stage of the disease, ranging from simple redness and red spots to a thickening of the skin, including ocular irritations. Rosacea typically manifests on the central part of the face, particularly on the nose, cheeks, forehead, and chin. When rosacea reaches an advanced stage, the nose is affected and a condition known as rhinophyma appears. This rare form affects approximately 5% of patients with rosacea.

The term rhinophyma originates from the Greek "rhis", meaning nose, and "phyma", meaning growth. This condition is characterised by a slow and progressive hypertrophy of the sebaceous glands and connective tissue of the distal part of the nose. Other common skin signs include redness (erythema), dilation of blood vessels (telangiectasias), and an enlargement of the nose's pore diameter. Tumour-like nodules, with the risk of nasal obstruction and sleep apnea, may also appear.

Although rosacea predominantly affects women, rhinophyma generally manifests in men, particularly those aged between 45 and 60 years. This condition can lead to a significant social stigma, as individuals suffering from rhinophyma display a "drunkard's nose", even if they do not consume alcohol. This aesthetic issue, coupled with the risk of nasal obstruction, quickly makes it clear that this form of rosacea is particularly debilitating.

The mechanisms behind the progression from mild rosacea to rhinophyma are still poorly understood. It has been noted that Caucasian men are more affected than Asian and African populations, and that the pathology progresses more rapidly in the case of stress, elevated temperature, and consumption of spicy foods. These factors that exacerbate the condition are in fact the same as for less severe forms of rosacea, such as vascular rosacea.

A hormonal influence is also suspected, with some researchers considering that the 5-alpha reductase plays a role in the pathogenesis of hypertrophic rosacea, although there is no tangible evidence. This enzyme catalyses the transformation of testosterone into dihydroxytestosterone (DHT), a hormone notably involved in sebum production. If 5-alpha reductase is suspected, it's because its activity is more significant in men, who are more affected by rhinophyma.

Furthermore, a link has been established between the development of rhinophyma and the colonisation of the sebaceous glands by the parasites Demodex. Naturally present in the epidermis, these parasites play a seboregulatory role and secrete proteases, enzymes involved in protein degradation. However, these proteases also play a role in various inflammatory processes and are suspected to be involved in the formation of rhinophyma.

It is possible toeliminate rhinophyma. In the majority of cases, patients manage to achieve a satisfactory result. However, it is important to bear in mind that a recurrence is still possible. In the event of rhinophyma reappearing, a new treatment will need to be considered.

How to manage mild rhinophyma?

When rhinophyma is at an early stage, the topical application of creams or gels may be sufficient. These treatments are typically based on azelaic acid or ivermectin, which have anti-inflammatory properties, and metronidazole, an antiparasitic. They can also be combined with antibiotics to be taken orally such as doxycycline or tetracycline. These antibiotics help to inhibit the synthesis of proteins necessary for bacterial growth by the bacteria themselves.

Finally, in some cases, isotretinoin, a derivative of vitamin A, may be prescribed to reduce the activity of the sebaceous glands. Traditionally used in cases of persistent acne, isotretinoin can also prove useful when rhinophyma is still in an early stage.

How to treat severe rhinophyma?

When rhinophyma reaches an advanced stage, it becomes necessary to undergo surgery. Before making a decision and opting for a particular technique, it is recommended to seek advice from a dermatologist. They are indeed capable of assessing the condition of the rhinophyma and guiding their patient towards a surgery that best suits their needs.

• Surgical removal.

  Surgical ablation is a procedure involving the removal of excess tissue and skin on the nose using a scalpel or a surgical knife. It is often used in cases where rhinophyma is severe and there is a significant amount of hypertrophied tissue to remove. This operation carries a low risk of recurrence but may result in scarring and hypopigmentation.

• Dermabrasion.

  Dermabrasion is a technique that utilises a rotating device with abrasive burrs to remove the upper layer of the skin. This method is used to smooth the skin's surface and eliminate irregularities caused by rhinophyma. The risk of scarring is reduced compared to surgical removal.

• The laser.

  Various types of lasers can be used to treat rhinophyma, including the CO2 laser, the pulsed dye laser (PDL), and the potassium titanyl phosphate (KTP) laser. These lasers work by selectively removing hypertrophic tissues while minimising damage to surrounding tissues. This method can be used to reshape the nose and improve its appearance, by reducing dilated blood vessels and smoothing skin irregularities. The laser generally yields good results on rhinophyma with a low risk of scarring. However, there are instances where rhinophyma may reoccur after its removal.

• ADAMS W. P. & others. Rhinophyma: Review and Update. Plastic and Reconstructive Surgery (2002).

• GRANDE D. J. & others. Rhinophyma: A Review of Treatment. Dermatologic Surgery (2017).

• ALI F. & et al. Rosacea. British Journal of Hospital Medicine.(2021).