Rhinophyma
What is Rhinophyma?
Rhinophyma is a condition that causes progressive enlargement and deformity of the nose. It is a disease of the skin and does not affect the bone or cartilage. Rhinophyma is a condition that is usually diagnosed and treated by dermatologists
however surgery to correct it is performed by dermatologic surgeons, ENT surgeons
and plastic surgeons.
It is primarily linked to rosacea and is often considered to be a form of advanced
rosacea. There is an element of controversy in this as some doctors believe that it is
a condition in its own right and not a subtype of rosacea. It is known that chronic
inflammation in the skin can also lead to a thickening of the facial skin and over
affected areas.
Therefore even though rhinophyma is often considered to be an advanced form of
rosacea, rosacea is not the exclusive cause of rhinophyma and there is still a lot of
research being undertaken into the exact causative factors and specific mechanisms
that lead to tissue overgrowth in rhinophyma.
Chronic inflammation of the skin in rosacea and other disorders that cause inflammation around the hair follicles and leads to an excessive growth and thickening of the sebaceous glands and connective tissue in the skin around the nose.
The overgrowth of sebaceous glands (sebaceous hypertrophy) and excessive formation of dermal connective tissue causes thickening and deformity of the skin of the nose. This deformity leads to the clinical picture seen in rhinophyma. Typically a bulbous thickening of the lower two thirds of the nose.
It is a condition more typically seen in males of lighter skin types. However all skin types are affected and both males and females can develop rhinophyma.
Rosacea prevalence in the UK is estimated at around 5% of the population.
https://cks.nice.org.uk/topics/rosacea/background-information/prevalence/
Rhinophyma tends to be more common in men even though rosacea is more common in women vs men. Not all rhinophyma is caused by underlying rosacea.
How does Rhinophyma affect patients?
Rhinophyma is a condition that causes enlargement and deformity of the nose. As such the main patient concern is a cosmetic concern. The nose becomes large and bulbous at the tip. In more advanced cases the nose may lose its shape completely and functional difficulty with breathing can occur with alar thickening and excessive tissue over the lower third. Patient suffering with rhinophyma have reduced confidence in their appearance and low self-esteem. It is not a condition that is treated by the NHS and as a result rhinophyma patients find it difficult to find specialists who can help them with correction of the deformity.
Although there is no known link with rhinophyma and alcohol consumption it is often perceived that patients who suffer with rhinophyma drink excessively. This is an incorrect association that adds additional trauma to rhinophyma patient psychology.
Surgery can be performed to correct the nasal shape and reduce rhinophyma. The preferred modality is ablative laser surgical correction. In this procedure CO2 laser is used to remove excessive thickened tissue from the nose and restore a more normal shape. Once surgery is performed oral isotretinoin is the mainstay treatment that must be administered to prevent recurrence. In fact if rhinophyma is identified early oral isotretinoin therapy can be commenced and the condition can be highly controlled and minimised enabling the patient to retain a more normal nose shape.
Diagnosis and treatment issues rhinophyma
Enlargement, thickening and deformity of the nose occurs slowly over time and is not easily noticed even by the patients that are mild to moderately affected by the condition. As the changes of can occur slowly over time many patients may not understand that these changes are due to rhinophyma and have difficulty understanding that their nose shape is changing progressively over time. Eventually when they do realise that something is not quite right, they often will feel that the first port of call is a plastic surgeon. To the patient this is logical as they believe that the solution to correcting nose shape will be in the form of a rhinoplasty with a plastic surgeon.
Often there is following the consultation as an experienced plastic surgeon will realise that the nose shape is not due to bone or cartilage structure but thickened skin. Once the issue of thickened skin has been identified the patient first has to understand that this is a rhinophyma issue. Given that in the UK rhinophyma treatment is not available on the NHS finding treatment is very difficult. There are a few private specialist centres in the UK that specialise in CO2 laser surgical correction of Rhinophyma.
Rhinophyma is an underdiagnosed condition. Due to a lack of understanding of rhinophyma and a low priority in its treatment it takes a skilled dermatologist to pick up and appropriately diagnose the condition. Many patients suffering with rhinophyma are picked up by plastic surgeons who cannot offer a rhinoplasty solution and then refer to the dermatologist. Unfortunately, once an appropriate referral is made due to a lack of training and equipment in the NHS there are few dermatologic surgeons who have the specialist laser surgical skills required to deal with surgical correction of the problem.
The role of oral isotretinoin in the management of Rhinophyma
The following links will take you to authoritative information on the role of oral isotretinoin in the management of rhinophyma. There is a significant evidence base for its utilisation and its role in rhinophyma management is recognised universally by dermatologists.
Oral Isotretinoin is an essential tool in the treatment of early stage rhinophyma and also essential in prevention of recurrence of rhinophyma following laser surgical corrective procedures.
If type 2 rosacea is detected early or rhinophyma is detected early oral isotretinoin can be administered in order to bring both conditions under control. When it comes to Rhinophyma and rosacea treatment with oral isotretinoin patients guidelines advocate the use of a lower dose extended course of oral isotretinoin. Following completion of this course 65% of patients will have prevented recurrence of the problem. In around 35% of patients the problem of rosacea or rhinophyma may recur. In these cases a prolonged repeat course followed by a lifelong maintenance dose will keep both conditions controlled in the the longterm and prevent recurrence.
In summary oral isotretinoin therapy is the most powerful medication in the management of rhinophyma and rosacea therapy. Its role is summarised below:
Oral Isotretinoin is known by dermatologists to be a powerful tool in the treatment of moderate to severe rosacea.
Oral Isotretinoin is essential and can halt progression of rhinophyma if diagnosed early.
Following any corrective CO2 laser surgical procedure for rhinophyma oral isotretinoin should be commenced at 3 months post-surgery in order to prevent recurrence of the condition.
In cases where there is relapse a repeat course followed by low dose maintenance therapy may be required.
Dermacne for Rhinophyma and Rosacea
Even though oral isotretinoin is a mainstay treatment for rhinophyma and rosacea it is difficult to access via the NHS as this is an off-label indication. Rhinophyma is viewed as a cosmetic condition and rosacea is of relatively low priority and is mainly managed in the GP setting with limited options. Oral isotretinoin is available only as an option via referral to NHS dermatology but this can take many months and will only be made for severe cases.
Who can have Dermacne?
- If you are visiting dermacne as a rosacea or rhinophyma patient you are probably doing so as you have come to the end of treatment options via the NHS. Oral isotretinoin may not have been suggested. Primarily because you will not have been referred to NHS dermatology unless you are suffering with severe rhinophyma or rosacea.
- If you suffer with rosacea the likelihood is that you are considering oral isotretinoin privately in order to prevent your rosacea from worsening and potentially triggering rhinophyma formation.
- If you suffer with early stage rhinophyma and you have been diagnosed appropriately your clinician has informed you on the efficacy of oral isotretinoin therapy in halting the progression of rhinophyma and even reducing the existing thickening if it is mild.
- If you suffer with moderate to severe rhinophyma the chances are that you may be visiting Dermacne after a surgical procedure has already been performed or is planned to be performed. Your surgeon has prepared you and instructed you that a course of oral isotretinoin is essential for the prevention of recurrence of the rhinophyma and should be initiated 3 months after surgery.
Oral isotretinoin will also improve textural issues with the nose skin that are encountered after surgery. Bumps and rough texture of the surgically corrected nose is common. This will be significantly improved with a course of oral isotretinoin.
Which type of patient are you? Next steps
1. Rhinophyma patient who has undergone surgery for correction of nasal shape. (CO2 laser surgery/ electrocautery / dermabrasion)
Your surgeon will most likely have made an instruction to commence oral isotretinoin usually 3 months after surgery. Sometimes the surgeon will be specific about the dosing and the regimen. If this is the case we will follow the oral isotretinoin protocol that has been instructed by your surgeon.
2. Patient with early diagnosis of Rhinophyma or patient suspecting rhinophyma.
If you are a patient who has been diagnosed with early stage rhinophyma. In this case you will already have been informed by your dermatologist, surgeon or doctor about oral isotretinoin therapy. NHS treatment is likely to be not an option. At Dermacne we are here to assist in the early management of rhinophyma where easy access to oral isotretinoin therapy the NHS is not an option. Please book for consultation with our dermatologists and they will be happy to help.
3. Patient with rosacea and symptoms that are worsening or poorly controlled.
As rosacea progresses treatment with oral tetracyclines, topical metronidazole gel, topical azelaic acid and topical soolantra become less effective in controlling symptoms adequately. In these circumstances oral isotretinoin can be an extremely effective treatment option for long term reduction of the condition. Please take a look at the section of the dermacne website (link below) that will inform you about oral isotretinoin therapy in the management of rosacea. Please book a consultation with our dermatologist to get started with oral isotretinoin therapy for your rosacea.
