Rhinophyma Management
Surgery is the gold standard treatment for advanced rhinophyma, with surgical decortication using electrosurgical instruments (monopolar loop and ball electrodes) or CO2 laser ablation providing the best combination of tissue removal, hemostasis, and cosmetic outcomes. 1, 2
Early-Stage Medical Management
For early, mild rhinophyma before significant tissue hypertrophy develops:
- Oral isotretinoin can be used in early stages to slow progression, though it will not reverse established hypertrophic changes 3, 4, 5
- Isotretinoin is indicated for severe recalcitrant nodular acne and may prevent progression when rhinophyma is minimal 3
- Oral antibiotics (metronidazole) may be attempted in early stages but are generally ineffective once significant tissue hypertrophy has occurred 5
- Medical management alone is insufficient once moderate to severe rhinophyma develops - these cases require surgical intervention 1, 5, 2
Surgical Treatment: The Definitive Approach
Surgery should be performed by an experienced rhinosurgeon due to risk of complications and potential injury to deeper nasal structures 1
Optimal Surgical Technique
- Electrosurgical decortication using monopolar loop and ball electrodes provides simultaneous tissue removal, excellent hemostasis, and precise nasal contour refinement 2
- This technique is simple, safe, efficient, and cost-effective using instruments readily available in every operating room 5
- CO2 laser (fractional or fully ablative) is highly effective with excellent hemostasis, minimal morbidity, and good cosmetic outcomes 1, 4, 6
- Fractional CO2 laser may be preferred over fully ablative in some patients to reduce scarring risk, particularly in younger patients 4
Surgical Principles
- Preserve follicular epidermal islets from deeper skin layers - these serve as departure points for re-epithelialization of the wound surface 1
- Avoid excessively deep decortication to prevent injury to perichondrium or nasal cartilage, which leads to cosmetically unattractive scar formation 1
- Complete healing typically takes 3-4 weeks regardless of technique used 6
Alternative Surgical Methods
- Dermal shaving, dermal abrasion, or abrasive cylinders/burrs can be combined with decortication techniques 1
- Excision with primary suture or free grafts is less commonly used 1
- Preoperative injection into nasal tumor masses followed by fibrin glue wound coverage can optimize outcomes 1
Post-Surgical Management
- Long-term low-dose oral isotretinoin following laser treatment prevents relapse in patients at risk for recurrence 4
- This is particularly important in younger patients who developed rhinophyma before age 30 4
Critical Pathology Consideration
- All surgically removed tissue must undergo histopathological examination to rule out coincident basal cell carcinoma or squamous cell carcinoma, which can occur with rhinophyma 2
Common Pitfalls to Avoid
- Never attempt medical management alone for moderate to severe rhinophyma - it will not resolve spontaneously and requires surgical removal 1, 5
- Avoid fully ablative CO2 laser in patients at higher risk for scarring - fractional CO2 may be safer 4
- Do not perform surgery without adequate rhinosurgical experience due to risk of complications and poor cosmetic outcomes 1
- Never assume the absence of skin cancer - always send tissue for histopathology 2