Key Insights Into Rhinophyma in Rosacea

With rosacea as its precursor, rhinophyma is the proliferation of sebaceous glands and underlying connective tissue that disfigures and deforms the nose.² Patients with rhinophyma can experience psychological distress, and their quality of life may be severely impacted.

In this exclusive interview with The Dermatologist, Michael Gold, MD, FAAD, discusses the characteristics, impact, and treatment of rhinophyma. Dr Gold is the founder of Gold Skin Care Center, Advanced Aesthetics Medical Spa, The Laser & Rejuvenation Center, and Tennessee Clinical Research Center in Nashville, TN. He is also a clinical assistant professor at Vanderbilt University School of Nursing and an adjunct assistant professor at Meharry Medical College School of Medicine, with expertise in medical and surgical dermatology; cosmetic dermatology; and aesthetics, including lasers and energy-based devices.

The Dermatologist: What are the characteristics of rhinophyma in patients with rosacea?

Dr Gold: Most of the time, it is a lot of sebaceous glands, and the nose increases in size, sometimes into a grotesque look. There are different classifications of rosacea, and this is the end of the food chain when it is as bad as it can get. You can put all the creams and lotions you want on it, and nothing is going to touch it.

When it comes to the characteristics of rhinophyma, one example that comes to mind is the actor W.C. Fields. He was the epitome of what rhinophyma looks like. Whenever anybody would give a lecture on rhinophyma, especially in the surgical dermatology world, his picture always ended up on the screen because of his bulbous nose.

The Dermatologist: How does rhinophyma impact patients with rosacea?

Dr Gold: Typically, there is a delay between when patients start to see rhinophyma and when they come to see us. This usually means it is pretty bad by the time they come in. Often, before we get into treatment, we will say, “Bring us a picture of yourself when you were younger, so we can actually get a sense of what your nose looks like.”

This is where it impacts the patient’s entire quality of life because by this point most people are embarrassed. They are withdrawn. They do not want to go out in public because they are tired of answering questions about their nose. If you look at the Dermatology Quality of Life Index, or DLQI, people with rosacea are generally “down,” but those with rosacea and rhinophyma are really down. It is a potentially life-altering skin problem that can cause patients to be isolated, withdrawn, depressed, and so on.

The Dermatologist: What are the current treatment options for rhinophyma?

Dr Gold: It depends on the specialty but for a plastic surgeon, surgery has always been an option. Cold steel, reshaping the nose, and so forth, dermatologic surgeons can still do that, but most of us would use dermabrasion with either a wire brush or diamond grazers to sand away the nose until we get it to the shape of the picture that the patient brings in.

However, when lasers came along, many of us started to use them, specifically the carbon dioxide, or CO2, laser. That became the mainstay of what all of us used in the laser world. For me, lasers have always been a mainstay.

Today, we have microneedling devices with radiofrequency (RF), which has become more popular. Microneedling pens are not going to do much, but microneedling with RF can definitely make an impact. Overall, more people are coming in earlier for treatment.

The Dermatologist: How can clinicians examine the condition in a way that puts patients at ease?

Dr Gold: There is a whole spectrum of dermatologists, and we need to understand that, as a group, there are things we can do to make our patients better. We have the tools at hand to be able to take care of these patients, and if you are not skilled in a specific modality, you can find somebody in the fi eld who is. It is best to make sure the entire dermatology community knows that there are treatments for rhinophyma. If we communicate that we have treatments available, it will be good for our patients.

The Dermatologist: What key factors should physicians keep in mind when examining patients with rosacea for rhinophyma?

Dr Gold: For those who have not seen a lot of it, or are not comfortable with it, the first thing is not to freak out when you walk into the room. Patients have concerns and they are there get your expert opinion on what to do, but understand that there is no medicine to make rhinophyma get better. Patients need a surgical, laser, or microneedling RF procedure if they want to get their rhinophyma resolved.

Remember that we are not curing this, but we are treating it. With rhinophyma, we are treating what we have, so we must make sure the patient understands that every so often it may recur, but we want to get it really quickly if it does. If we are honest with patients and address their concerns, there is a lot that can be done.

The Dermatologist: Are there any other tips you would like to share with your colleagues regarding rhinophyma in patients with rosacea?

Dr Gold: For a dermatologist, we are never going to miss rhinophyma. Once you see the nose, there is nothing else that it could be. Obviously, there are bizarre diseases that you need to keep in the back of your mind, but 99.9% of the time it is going to be rosacea-related rhinophyma. We need to understand that we have good treatments. We can treat these patients, and we do not need to be afraid to treat them.