What are the treatment options for rhinophyma, a subtype of rosacea?

Treatment Options for Rhinophyma

Surgical intervention is the definitive treatment of choice for rhinophyma, as medical therapies alone are insufficient for this advanced form of rosacea. 1

Understanding Rhinophyma

Rhinophyma is characterized by:

• Hyperplasia of sebaceous glands and adjacent tissue
• Irregular thickening of nasal skin
• Nodular deformation of the nose
• Primarily affects Caucasian men in their fifth decade of life
• Considered the end stage of rosacea 2

Treatment Algorithm

First-Line Treatment: Surgical Approaches

1. Decortication (Preferred Surgical Method)

   • Involves removal of hyperplastic nasal tissue down to basal parts of sebaceous glands
   • Allows spontaneous re-epithelialization without scarring
   • Superior cosmetic outcomes compared to deeper excision methods 1

2. Other Surgical Options

   • Surgical excision with electrocautery
   • Healing by secondary intention and reepithelialization (typically complete within 2 weeks) 3

3. Important Surgical Consideration

   • Histopathological examination of excised tissue is mandatory to exclude malignancies (basal cell or squamous cell carcinomas) which are frequently associated with rhinophyma 1

Adjunctive Medical Management

While surgery is the mainstay treatment for established rhinophyma, the underlying rosacea should be managed according to a phenotype-based approach 4:

1. General Measures

   • Trigger avoidance
   • Gentle skincare
   • Sun protection 4

2. For Inflammatory Components

   • Topical options: azelaic acid, metronidazole, ivermectin, or encapsulated benzoyl peroxide 5% (E-BPO 5%) 4
   • Oral options: doxycycline (anti-inflammatory dose) for more severe cases 4

3. For Erythema Components

   • Topical α-adrenergics (brimonidine)
   • Oral beta blockers may be considered 4

Special Considerations

• Patient Selection: Surgical intervention is appropriate for patients with cosmetic concerns or functional impairments (nasal airway obstruction, difficulty eating) 2

• Limitations of Medical Therapy: Isotretinoin, while effective for severe nodular acne, is not specifically indicated for rhinophyma in FDA labeling 5

• Combination Approach: For patients with multiple rosacea features, combination therapy targeting each specific feature is recommended 4

• Maintenance Therapy: The approach to maintenance depends on treatment modality and patient preference, using minimum treatment necessary to maintain control 4

Treatment Outcomes

• Successful surgical treatment can provide excellent cosmetic outcomes with relatively short recovery time 3
• A single surgical procedure is often sufficient, though the underlying rosacea requires ongoing management to prevent recurrence 6

Pitfalls to Avoid

• Delaying surgical intervention for established rhinophyma (medical therapy alone is insufficient)
• Failing to obtain histopathological examination of excised tissue
• Neglecting to treat the underlying rosacea after surgical correction
• Using deeper excision with skin grafting or flaps when decortication would provide superior cosmetic results 1