Clinical Challenge: Progressive Enlargement of the Nose - MPR

Clinical Challenge: Progressive Enlargement of the Nose

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  • Rhinophyma_0413 Derm Dx

A 63-year-old man complains of years long progressive enlargement of his nose. He has tried topical metronidazole cream and oral doxycycline without improvement. He is very embarrassed by the condition.

Rhinophyma is caused by hypertrophy of the sebaceous glands of the nose. Rhinophyma is a consequence of rosacea - specifically, the phymatous variant of rosacea.  The term rosacea is often confusing to both clinicians and patients. Rosacea does not represent...

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Rhinophyma is caused by hypertrophy of the sebaceous glands of the nose. Rhinophyma is a consequence of rosacea – specifically, the phymatous variant of rosacea. 

The term rosacea is often confusing to both clinicians and patients. Rosacea does not represent a single disease entity, but rather represents a spectrum of signs and symptoms that affect the skin of the central face. Broadly, these signs and symptoms may include facial erythema, acneform inflammatory papules and pustules, frequent facial flushing, telangiectasias, ocular inflammation, and phymatous changes. 

Rosacea most commonly affects middle-aged women. The exception is phymatous rosacea, which is seen mostly in males.

There are four major subtypes of rosacea. Patients may present with only one subtype, or they may demonstrate signs and symptoms of multiple subtypes.

Papulopustular rosacea is characterized by small inflamed papules and pustules localized over the convexities of the central face. The lesions may be single or multiple, last for several weeks, and then fade into a blotchy erythema. Scarring is rare.

Erythematotelangiectatic rosacea is almost exclusively seen in patients with a fair skin tone. It is characterized by a tendency for facial flushing, generally on a background of erythema. Telangiectasias may be present. Patients with this subtype often complain of having very sensitive skin.

Ocular rosacea occurs most commonly in patients with the erythematotelangiectatic or papulopustular variants. The clinical signs and symptoms are varied. Patients often complain of ocular itching, dryness or crusting. They may develop styes and/or chalazions. On exam, they may have eyelash “dandruff,” eyelid scaling or conjunctival injection. Rarely they suffer from severe ocular disease such as keratitis or uveitis. 

Phymatous rosacea most commonly presents as rhinophyma. Patients with rhinophyma may suffer from other symptoms of rosacea or may present uniquely with the phymatous changes. Older Caucasian males are predominantly affected. The nose, especially the tip, becomes thickened with large and dilated pores. With time the tissue hypertrophies and may develop into frank nodules. Tissue hypertrophy may cause significant disfigurement and/or lead to blockage of the nasal passages.

Although the nose is by far the most common skin area affected, the chin, forehead, ears and eyelids may rarely develop phymatous changes.  

Diagnosis & Treatment

The diagnosis of rhinophyma is very straight forward with the appearance of thickened nasal skin with large pores on the nose of an older Caucasian male. The diagnosis may be confirmed with a biopsy, but this is rarely needed.

Treatment may include oral retinoids (i.e. isotretinoin), which shrink the sebaceous glands. However, this treatment is usually only affective in mild or early disease. 

Patients with severe disease, such as the patient featured in this case, require surgical management to resect or ablate the hypertrophied tissue. This can be accomplished by surgical excision, electrosurgery or ablative lasers to debulk and reshape the nose.

In our practice we use a combination of surgical debulking followed by laser surgery to refine the nasal contours. 

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.

References

  1. Bolognia J, Jorizzo JL, Rapini RP. “Chapter 37: Rosacea and Related Disorders.” Dermatology. St. Louis: Mosby/Elsevier, 2008.
  2. James WD, Berger TD, Elston DM et al. “Chapter 13: Acne.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.