Sebaceous Hyperplasia
What is Sebaceous Hyperplasia?
Sebaceous hyperplasia is a benign skin condition that result in small flesh-coloured bumps with a yellowish hue developing on the face and body. As men and women grow older these lumps tend to accumulate and give the skin a grainy, bumpy and rough texture. This is known as senile sebaceous hyperplasia.
Low level sebaceous hyperplasia is normal as we age. It is responsible for pore like texture on the skin. The pores or orange-peel texture that women and men often complain about as they age become more prominent on the nose and cheeks. This is a low-grade form of sebaceous hyperplasia that naturally occurs with time. Essentially the oilier your skin the more prone to low grade sebaceous hyperplasia formation and the formation of prominent pore texture on the nose and central face you will be. In this sense it is not a disease as such. Sebaceous hyperplasia are effectively benign, enlarged and over-active sebaceous glands in individuals who have a genetic predisposition to oily skin. Everybody is essentially on a spectrum of dry to oily skin. This is why when choosing a moisturiser, the sales assistant will ask if you skin type is dry, oily or combination skin.
There are also some rare medical genetic and drug induced conditions that may result in multiple sebaceous hyperplasia bumps developing on the skin surface such as:
Muir-Torre syndrome
Presenile Diffuse Familial Sebaceous Hyperplasia (PDFSH)
Eruptive Sebaceous Hyperplasia that can develop as a consequence of drugs such as cyclosporin or immunosuppressive therapy medication
The hyperlinks will take you to the relevant medical literature if you would like to understand more about rare causes of sebaceous hyperplasia.
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.
Treatment of Sebaceous Hyperplasia
From a medical perspective as the condition is benign and to a certain extent normal as we age dermatologists will usually not be too concerned about actively treating sebaceous hyperplasia. It is regarded as a cosmetic issue rather than a medical condition. However, that being the case the cosmetic issue is one that is not appreciated by individuals that suffer with it. These bumps will affect the central face and as a result will consequently cause concern and loss of confidence in the people that have multiple and prominent sebaceous hyperplasia.
Treatment of Sebaceous Hyperplasia
https://www.ncbi.nlm.nih.gov/books/NBK562148/
These bumps are not dangerous but when they develop on the face, they are a significant cosmetic nuisance. In general, when these oil glands enlarge and form bumps, they are not easy to get rid of. In fact, given that sebaceous hyperplasia is an enlargement of a sebaceous gland around a central hair follicle the resulting lump looks as though if squeezed it may pop. However, this is not the case, and it is impossible let alone not advisable to pop or drain these lesions. Attempting to do so may result in irreversible scarring and injury to the skin.
Self-treatment is most definitely not an option. Topical creams such as retinoids and niacinamide only confer a very mild improvement but as all dermatologists are aware there is no effective topical (cream) therapy for sebaceous hyperplasia.
In the UK the NHS will not treat Sebaceous Hyperplasia.
Dermatologists will often help individuals that suffer with sebaceous hyperplasia privately. These individuals are seen privately from a cosmetic perspective and dermatologists will often treat these lesions in a destructive manner. Multiple different dermatologist-applied destructive techniques are used for sebaceous hyperplasia. However, when it comes to destroying lesions that have already formed these destructive treatments will usually leave a small scar or indentation in the skin that can be noticeable. The residual scar or mark is usually flatter and smaller than the original sebaceous hyperplasia lesion which is the reason that the following treatments are regarded as acceptable destructive methods for sebaceous hyperplasia that are a cosmetic nuisance:
Electrocautery
Cryotherapy
Laser ablation or coagulation
Chemical cautery
When sebaceous hyperplasia becomes more severe and lesions are multiple in nature, the condition becomes more of an issue patient self-confidence and mental health can be affected. Destructive treatments are not really an option here as multiple scars can be result from destructive therapy for numerous lesions. Moreover, if the underlying condition of sebaceous hyperplasia is left untreated then new lesions will always form leading to a continual requirement for destructive therapy in the long-term which will invariably lead to more scar formation.
Antiandrogen medications such as spironolactone can be used to help improve the condition in women (these medications can only be used in women) however they only have a mild effect.
The most effective way of prevention and control of sebaceous hyperplasia is low lose long-term oral isotretinoin therapy. This is universally recognised amongst dermatologists and its success in treatment of sebaceous hyperplasia is well documented. It is often regarded as a treatment of last resort as this is a benign condition and taking an oral medication such as isotretinoin with potential side effects is seen as an unnecessary. In short, the condition of sebaceous hyperplasia is benign and does not warrant dermatologist supervised oral isotretinoin therapy. It is also something that will be needed in a very low dose but for a long period. Sometimes in cases that are more severe it is better to manage sebaceous hyperplasia completely and prevent recurrence with lifelong low dose therapy.
Sebaceous Hyperplasia is naturally lower in the order of priority for medical dermatology if in the order at all!
Oral isotretinoin therapy also forms a relatively controversial issue depending on the view taken on drug management of a benign cosmetic condition. Many dermatologists will feel like the condition does not merit treatment at all due to its benign nature. Many patients would also wish to avoid taking long-term drug therapy if possible.
Dermacne is not here to make the decision for you. Dermacne is here to present the factual information regarding oral isotretinoin therapy and as a patient you can decide whether it is appropriate for you.
Oral Isotretinoin therapy in
Sebaceous Hyperplasia
All dermatologists worldwide are aware that oral isotretinoin is the most effective treatment for sebaceous hyperplasia reduction and long-term prevention. Whether or not it will be prescribed by dermatologists is not a question of efficacy.
Factors that will affect dermatologist led prescribing of oral isotretinoin in sebaceous hyperplasia:
Male patient vs female patient.
Prescribing low dose oral isotretinoin therapy for sebaceous hyperplasia in a female patient will be seen as a greater risk due to the fact that a female of childbearing age will wish to become pregnant or may accidentally become pregnant during therapy with oral isotretinoin. Given that the treatment of sebaceous hyperplasia with oral isotretinoin is long-term and sometimes lifelong the risk obviously is greater for this purpose. Men obviously do not have pregnancy risk, so it is easier to prescribe long-term for a male patient suffering from sebaceous hyperplasia. If dermatologists are considering prescription of a long-term or indefinite low dose oral isotretinoin course for women, they will only usually do so if the following conditions are met:
The woman has no childbearing potential IE medically confirmed as sterile or has undergone surgical sterilisation via hysterectomy / ovarian removal / ligation or removal of fallopian tubes. Confirmation of menopause is
The woman is on long-term effective contraception such as and IUD (coil) or implant. Oral Contraceptive Pill is acceptable but is a higher risk as one must remember to take it whereas and IUD or implant contraceptive method is safer as it is permanently in place.
Oral Isotretinoin therapy will be discontinued when pregnancy is planned. It will be discontinued 2 months prior to attempting conception and only restarted after childbirth and breastfeeding are completed.
It is unlikely that in the case of sebaceous hyperplasia a female patient refusing
Severity of the sebaceous hyperplasia
If lesions are multiple and extensive or there is an underlying medical or genetic condition that has triggered your sebaceous hyperplasia a dermatologist is more likely to prescribe oral isotretinoin. Obviously the greater the severity and lesion count the more likely the patient is likely to have their mental health affected and for this reason the prescription threshold for oral isotretinoin for the treating dermatologist will be lower.
Prescribing dermatologist personal Ethical consideration
Depending on the personal views and beliefs of the dermatologist they may encourage or discourage treatment. The efficacy of oral isotretinoin is not in question.
However, the condition of sebaceous hyperplasia is benign and regarded largely as cosmetic. Some dermatologists will take a standpoint that the problem of sebaceous hyperplasia does not merit treatment with oral isotretinoin.
Other dermatologists may regard the severity of the sebaceous hyperplasia and the degree to which it causes physical and psychological distress to the patient when considering oral isotretinoin therapy.
How do Sebaceous Hyperplasia lesions form within the skin?
Sebaceous hyperplasia is a condition in which the oil gland that is associated with the hair follicle becomes enlarged. It is a benign tumour of the hair follicle. In sebaceous hyperplasia the structure of the actual oil glands are normal but the numbers of the glandular structures associated with the hair follicle increase. These excessive glands locate themselves more superficially within the skin and as a result from a bump like swelling around the hair follicle. This often gives them the appearance of a yellowish or flesh coloured donut shaped lesion with a central dimple which is the opening of the hair follicle with which the glands are associated. This fleshy donut is typically around 2-4mm in size and often small visible blood vessels can be seen on the surface of the bump. The diagnosis of sebaceous hyperplasia is a clinical one and easily made due to the very typical physical appearance of sebaceous hyperplasia lesions. However, where there is uncertainty diagnosis can be confirmed with biopsy. Often sebaceous hyperplasia is diagnosed by inexperienced clinicians as papular acne scars. These lesions are not scars and if there is uncertainty biopsy can be performed for diagnostic certainty.
Normal individuals both male and female will tend to develop sebaceous hyperplasia as they grow older. This is due to a genetic predisposition as well as a natural change in circulating hormones that affect sebaceous glands and cause them to multiply as we age. Sebaceous hyperplasia forms in females and males but a little more so in males. Lesions become more numerous in women typically peri-menopausal Ly and males tend to develop lesions more lesions in middle age to old age.
Excessive sebaceous hyperplasia development or early extensive sebaceous hyperplasia development maybe linked to genetic conditions such as PDFSH or Muir-Torre. Some babies are born with prominent sebaceous glands due to exposure to excessive levels of certain hormones during pregnancy.
Genetic syndromes aside, most cases of sebaceous hyperplasia are found in normal healthy males and females and present as a slowly forming normality. The downside of these lesions is the compromise to physical facial appearance and is principally cosmetic in nature,
Why is oral isotretinoin treatment so effective in the treatment and prevention of sebaceous hyperplasia?
How is Oral Isotretinoin Taken in the treatment of Rosacea
https://doi.org/10.1590/abd1806-4841.20153192
Oral isotretinoin is the most effective treatment for sebaceous hyperplasia. This is because the drug acts directly to shrink sebaceous glands.
Oral isotretinoin is highly effective in sebaceous hyperplasia, and this is due to its efficacy in reducing the size of the sebaceous gland. Essentially it acts to diminishing the proliferation of basal sebocytes and suppress the production of sebum. It also inhibits the cell differentiation and maturation of sebocytes.
This mechanism essentially amounts to a physical shrinkage of sebaceous glandular tissue surrounding the hair follicle. In essence the sebaceous hyperplasia lesions will shrink in size in response to taking isotretinoin orally. Lesion counts and numbers decrease once the drug is started, and the bumps will flatten and disappear. This effect on oil glands is one of the features of oral isotretinoin that makes it so effective in tackling acne also.
The difference in acne is that a sufficient course of oral isotretinoin will lead to complete remission of acne in around 50% of cases. With sebaceous hyperplasia it is more likely that discontinuing oral isotretinoin will result in recurrence of lesions further down the line albeit at a reduced speed and severity. It is therefore recommended that if sebaceous hyperplasia is to be treated with oral isotretinoin it is done so with an initial period of daily dose therapy and then some form of ongoing permanent or long-term maintenance therapy will be required to keep sebaceous hyperplasia from recurring and keep the patient free of lesions in the long-term.
Dosing of oral isotretinoin in sebaceous hyperplasia treatment
https://doi.org/10.1016/j.abd.2020.09.001
https://doi.org/10.1590/abd1806-4841.20153192
The are no strict guidelines for dosing regimens for oral isotretinoin for the treatment of sebaceous hyperplasia.
Studies that have been performed illustrating its use in successful cases recommend various dosing regimens.
In general, it should be understood that the patient aiming to treat their sebaceous hyperplasia problem through use of oral isotretinoin therapy will typically commence treatment on a higher initial isotretinoin dose for a period of up to 6 months. This will adequately reduce lesion count and lesion size. Once this higher initial dose phase is complete maintenance therapy will be useful in the long-term to reduce the recurrence of sebaceous hyperplasia.
Typical Dosing regimen recommended by Dermacne in Sebaceous hyperplasia
Initial dose therapy:
0.3-0.5mg/kg depending on side effect tolerance for up to 6 months
Ongoing maintenance of oral isotretinoin 5-10mg daily or a minimum for prevention of recurrence.
For a 70kg male this would mean an initial 6-month period of between 20-40mg daily for 6 months followed by a maintenance regimen of 5-10mg daily or 20mg twice weekly for life.
The same regimen will apply to a 70kg female however dermacne protocol will insist that for women of childbearing potential oral isotretinoin can only be prescribed if on a suitable contraceptive method such as the IUD, Implant or combined oral contraceptive pill. These suitable methods should also be used in conjunction with additional barrier methods such as condoms to further reduce risk of pregnancy. Due to the long-term nature of oral isotretinoin therapy in sebaceous hyperplasia management it is generally recommended that women of childbearing use an IUD or implant to minimise pregnancy risk whilst on isotretinoin. Additional barrier contraception should also be used to further reduce pregnancy risk.
Given the teratogenicity (risk of physical and developmental deformity of the foetus during pregnancy) of oral isotretinoin it is the protocol of dermacne to require contraception to be in place prior to prescription of oral isotretinoin in women with child- bearing potential.