Lip Teh

January 2006

Rhinophyma

·  Greek rhis, for nose, and phyma, meaning growth

·  Lay terms - rum blossom and whiskey nose

Epidemiology

·  Rosacea is slightly more common in women

·  phymatous rosacea more common in men (5:1 to 30:1) - ?due to androgens

o  5-alpha reductase activity is higher in acne-prone sebaceous units

·  Rhinophyma seen most in English/Irish, rare in blacks and asians

Pathogenesis

·  Virchow associated rhinophyma with acne rosacea in 1846

·  Rosacea

o  defined by persistent erythema of the central portion of the face lasting for at least 3 months.

o  Supporting criteria include flushing, papules, pustules, and telangiectasias on the convex surfaces.

o  Secondary characteristics are burning and stinging, edema, plaques, a dry appearance, ocular manifestations, and phymatous changes. These define the subtypes

Rosacea Subtypes / Rosacea Symptoms
Erythematotelangiectactic Rosacea / Facial Redness
Papulopustular Rosacea / Papules & Pustules
Phymatous Rosacea / Facial Skin Growth/Thickening
Ocular Rosacea / Eye Symptoms
Neuropathic Rosacea / Facial Burning/Stinging Sensations

·  Etiology

1.  multi-factorial mechanism where the basic defect is due to facial vascular hyper-responsiveness or dysfunction

2.  triggers may be external (sun, wind, hot environments, cold environments, vasodilator medications, caffeine) or internal (emotions, exercise)

3.  associations with Dermodex and H pylori unproven

·  4 stages of rosacea that culminate in rhinophyma (Rebora)

1.  Pre rosacea

o  Characterised by intermittent transient facial flushing caused by triggers

2.  Vascular rosacea

o  facial blood vessels tend to become even more reactive - dilating more easily and for longer periods than in pre-rosacea

o  increased vascularity causes skin thickening

3.  Inflammatory rosacea

o  characterized by erythematous papules and pustules of the forehead, glabella, malar region, nose, and chin.

o  Pustules can sometimes be seen in other areas, including the chest, back, and the scalp of balding men.

4.  Phymatous rosacea

o  nose is usually the only structure affected, but mentophyma, otophyma, and zygophyma have been describe

Freeman (PRS 1970)

Rhinophyma features

·  Defined as tuberous enlargement of the lower half of the nose.

·  Nasal skin is erythematous with telangiectasias, sometimes purple in color.

·  Pits, fissures, and scarring in severe cases

·  Inspissated sebum and bacteria result in chronically infected skin and, often, an unpleasant odor.

·  The nasal tip is preferentially enlarged. The nasal dorsum and side walls are involved, but to a lesser degree.

·  Aesthetic subunits of the nose are distorted, merged, and obliterated.

·  Secondary nasal airway obstruction from weight of the mass

·  Tumorous growths can develop in late, nodular forms of the disease, resulting in dramatic cosmetic deformity.

·  In the vast majority of cases, the bony and cartilaginous frameworks are unaffected.

Histological features

1.  Dermal and Sebaceous hyperplasia

2.  Acanthosis (thickening of stratum spinosum)

3.  Fibrosis

4.  Inflammation

Differential Diagnosis

  1. Skin cancer (15-30%)
  2. 3 to 10% incidence of occult basal cell carcinoma in patients with rhinophyma
  3. SCC, adenoid squamous cell carcinoma, sebaceous carcinoma and angiosarcoma reported.

Management

Non-surgical

·  Spontaneous regression of rhinophyma is rare.

·  Avoid triggers – alcohol, sun exposure

·  Topical and oral antibiotics (metronidazole, tetracycline, and retinoids(isotretinoin – Roaccutane) are the mainstay in the treatment of rosacea.

·  Medical treatment is usually only undertaken in conjunction with surgical resection as medications have not been conclusively shown to halt the progression from rosacea to rhinophyma or cause regression of existing rhinophyma.

·  Patients should stop isotretinoin 1 year before surgery based on evidence that it impairs reepitheliazation in patients undergoing chemical peels. 3-4 weeks for topical treatment.

Surgical

·  Dieffenbach excised rhinophymatous skin and closed the nose primarily in 1845.

·  Von Langenbeck (1851) performed full-thickness excision of nasal skin and allowed the surface to heal secondarily.

·  Stromeyer(1864) performed partial thickness excision of involved skin, allowing reepithelialization from retained sebaceous glands – which forms the basis of current treatments

·  Excision with local flap coverage was described by Grattan in 1920. Split-thickness skin grafts were preferred in the early 1900s, and full-thickness grafts were popularized in the 1940

·  Surgery consists of excision and resurfacing

·  Excision usually partial thickness but full thickness required for:

1.  deeply infiltrating rhinophyma

2.  rhinophyma with underlying cancer

3.  presence of excess scar tissue making partial thickness excision difficult

·  Excision options

o  Dermaplaning

§  tangential excision

§  10blade or Weck knife

§  Shaw knife (heated scalpel blade) gives more hemostasis

§  placement of the surgeon's finger in the nose during excision allows for tactile perception of the thickness of the remaining soft tissue while sculpting the tip and alae

o  Dermabrasion

§  Best used as an adjunct for feathering the edges.

o  Cryosurgery

o  Electrocautery – causes more scarring

o  Lasers(CO2, Erbium, Argon)– Har-El found no difference in operative time, pain, postoperative bleeding, overall complications, or subjectively graded aesthetic outcome but better intraoperative hemostasis with laser

o  Harmonic (ultrasonic) scalpel

·  Destructive excisional methods (laser, electrocautery) may cause difficulty in diagnosing malignancies

·  Resurfacing options

o  Healing by secondary intention – most cases

§  Dress with bacitracin ointment and Xeroform.

§  Re-epithelialization complete in 2 to 3 weeks.

o  Where full thickness excision undertaken

§  SSG

§  FTSG

§  Flaps – forehead flap

Complications

Bleeding

Skin necrosis

Scarring

Missed malignancy