Rhinophyma progress slowed with swift diagnosis, treatment

June 1, 2011

Rhinophyma, a progressive benign condition causing a large, swollen, bulbous nose, can be treated most effectively if identified early, according to Joseph Bikowski, M.D., director, Bikowski Skin Care Center, Sewickley, Pa. No one knows the cause of rhinophyma, which rarely occurs in women. The condition was once believed to be caused by excessive alcohol consumption, but that was unfounded.

Key Points

No one knows the cause of rhinophyma, which rarely occurs in women. The condition was once believed to be caused by excessive alcohol consumption, but that was unfounded.

Dr. Bikowski says rhinophyma is diagnosed on clinical examination. Early detection and intervention are key in treating the condition successfully.

"People often wear heavy eyeglass frames that have a constricting band and a nosepiece across the nasal bridge, and that stops blood and lymph from coming back up to the root of the nose, so the nose becomes red and swollen," Dr. Bikowski says. "You can diagnose this easily by removing the glasses and seeing the constricting band of normal skin proximal to the swollen red nose," he says. The treatment is to obtain a pair of glasses with individual silicone nose pieces.

Rhinophyma causes swelling of facial soft tissues, with redness, thickening of the skin and nodular growths, and produces a bulbous-shaped nose. Swelling results from a combination of fibrosis, sebaceous hyperplasia and lymphedema, Dr. Bikowski says.

Mistaken identity

Researchers commonly consider rhinophyma a type of rosacea, among the classifications of erythematotelangiectatic, papulopustular, ocular and phymatous rosacea. Dr. Bikowski says he disagrees with that designation.

"I think rhinophyma is probably not rosacea," he says.

Dr. Bikowski says he believes rhinophyma is not rosacea because he has never seen a woman with rhinophyma in his 33 years of practice and rosacea is more common in women. Furthermore, he says, the scarcity of rhinophyma cases in women has been reinforced in the literature and by his colleagues.

"I think it's a separate condition that's been confused with rosacea over the years," he says.

Effective treatments

"Usually, systemic antibiotics, which are used to treat papulopustular rosacea, are not effective in treating rhinophyma," he says.

He has found isotretinoin to be most effective in prevention of progression.

"Mid- to high-dose isotretinoin can certainly impede the progress, if not halt the development of severe rhinophyma once the condition starts," Dr. Bikowski says.

For patients with rhinophyma in conjunction with papulopustular rosacea, he also prescribes 40 mg per day of anti-inflammatory-dose doxycycline (Oracea, Galderma), which he says is probably most safe and effective. Alternatively, topical retinoids can be used.

"For example, topical tretinoin can be tried to see if that might be effective, but usually you have to go with systemic retinoids," he says.

Medications will not, however, eradicate the condition once it has progressed.

"There are no medicines that make it go away, so you're left with surgical intervention," Dr. Bikowski says.

Other options

A number of techniques may be used to contour the nose, such as a surgical blade, electrosurgery or numerous lasers or a combination of techniques.

"In the hands of an experienced cosmetic dermatologist, very good results can be accomplished," he says.

Surgery will not cure the condition, however.

"You can improve the appearance, but you won't get a perfect nose," he says. "You can debulk or decrease the size of the nose, but the overall texture may still not be very smooth."

Surgical interventions may not stop progression, so it is often necessary to combine a surgical intervention with a medication such as isotretinoin.

Fortunately, Dr. Bikowski says he usually sees only a few cases of fully developed rhinophyma per year. He sees five or six early cases each year and treats those patients with isotretinoin to prevent progression.

Given treatment limitations once rhinophyma has progressed and because of the psychological impact of this disfiguring condition, Dr. Bikowski emphasizes that it's important to diagnose cases early and intervene as quickly as possible to stop the progression.

"Once it does occur, it's necessary to make sure patients understand there are surgical procedures that can be beneficial," he says.

Disclosures: Dr. Bikowski is a consultant and speaker for Galderma.