Plastic Surgeon Provides Valuable Information on Rosacea Treatment

I’ve wanted to do a dedicated blog post on #Rhinophyma for a while, but needed to make sure I was sharing information that actually added something to the conversation first. I don’t have personal experience of this form of #rosacea, so I asked the wonderful Naveen Cavale to help me. Naveen is a Consultant Plastic, Reconstructive & Cosmetic Surgeon, and very kindly fielded all of the questions I received in a recent call-out on my #Instagram Stories. My usual disclaimer: I am not medically trained in any way, but I have had rosacea for over 17 years, have access to a lot of incredible experts, and use this platform to raise awareness, give support, and provide information. As well as Naveen’s helpful answers below, I’ve included some links to further reading as well as additional information where I think it’s useful. I’ve tried to make it clear which parts are Naveen’s answers (italics) and which parts are my additional information (regular font) but if anything’s unclear, just let me know!
What does #Rhinophyma mean? It comes from the Greek for nose (‘rhis’) and growth (‘phyma’). It’s pronounced ry-no-fy-ma.
What is Rhinophyma? What causes it? “Rhinophyma is the thickening of the skin on the nose and tends to happen as you get older. It is more likely to affect those with thicker and oilier skin. It gives the appearance of a thicker, more bulbous nose and can sometimes look raised in some areas, but not in others.“ Patient.info lists some additional factors present in Rhinophyma that can cause significant distress and physical changes: “disruption of the nasal architecture, airway obstruction, [as well as] disfigurement of the nose.” According to the British Association of Dermatologists (BAD), it is not thought to be genetic, but this is disputed by some.
How common is Rhinophyma? “It’s a fairly rare condition. I don’t see it very often, but when I do it’s usually more common in men as they tend to have thicker, oilier skin generally.“
What are the early signs of Rhinophyma? “Early signs would include skin starting to look/feel thicker and also a slight increase in size. Some people find their skin becomes oilier too.“ According to the (BAD)1, diagnosis can be made by your GP/Dermatologist from a simple visual examination. If necessary, a skin biopsy can be taken under general anaesthetic.
Is Rhinophyma a progression of other rosacea subtypes? “No, it’s a standalone issue.“ This was the most common question, so I wanted to give a little more information on this. According to the BAD, Rhinophyma can develop in anyone, including people who don’t have rosacea. In the cases of people with rosacea who do develop Rhinophyma, it typically occurs after many years of rosacea. As Rav mentioned above, it’s more common in men and – according to the BAD – it’s more common in men aged 50-70.
How can I prevent Rhinophyma? “Unfortunately it’s not something that can be prevented.“
If my flushing is concentrated to my nose, does that mean I’ll definitely get Rhinophyma? “Potentially, but there’s no concrete evidence to suggest this. There’s not a lot of research into this specific area of rosacea at present.“
Is the thickening skin linked to cancerous growths? “Potentially. There is a small link between rhinophyma and basal cell carcinoma – the milder of the three main types of skin cancer. If you were to undergo surgery for it, we’d send what we take away to histology to check for skin cancer.“
Is Rhinophyma related to alcoholism? “No, it’s a myth that rhinophyma is related to alcoholism. Rhinophyma is a genetic condition and typically isn’t influenced by environmental factors.“ This myth is perpetuated by references to ‘whisky nose’ or ‘gin blossom nose’ which are nicknames for the swollen and red noses often associated with alcoholism. Rosaceans of all subtypes will empathise with the damage caused by this ignorant and widespread misconception. Alcohol consumption can exacerbate the symptoms of Rhinophyma, in the same way that alcohol can trigger flare ups in those of us with other rosacea subtypes, but alcohol alone is not a causal factor in the development of rosacea2.
What is the treatment for Rhinophyma? Are there any topicals that can help? “CO2 laser can be used for milder cases, but for quite severe cases, surgery is often the route. We would put a patient under general anaesthetic as it involves shaving away the excess tissue which form the bulbous parts of the nose. The procedure is fairly quick: 2 hours at most, depending on the severity.“ An article on the BJGP states that “the early stages of rhinophyma may respond to topical treatments such as metronidazole, azelaic acid, and topical retinoids, and oral antibiotics such as tetracycline, doxycycline, and metronidazole can also be used. More severe cases should be referred to a specialist, who may consider using topical ivermectin and brimonidine, or oral isotretinoin.”3 Patient.info has some interesting information about patient satisfaction after treatment: “Outcomes between carbon dioxide laser and scalpel therapy and electrocautery were equivalent. Patient satisfaction was common post-therapy regardless of the treatment method. The review found that over 89% of patients would recommend undergoing treatment for rhinophyma irrespective of treatment type.” 4 / 5
Is Rhinophyma surgery a ‘one-and-done’ or will the thickening/swelling come back? “Unfortunately, there’s no guarantee even if you have surgery that it will stay away. We can’t stop the root cause of the thickening that occurs. If it did reoccur, it wouldn’t likely be for a very long time – 10 years or so I would say.“
What is the downtime after Rhinophyma surgery? “After surgery, the nose will be dressed and will need to be kept very clean to avoid infection. This means regular dressing changes while it starts to scab over. In terms of downtime, the minimum required would be a week, but please note that there will be a very big scab that is healing which might mean you may wish to take longer off work etc. Everyone’s surgery will be different, it’s very much a case-by-case surgery depending on the severity.“
Is the Rhinophyma healing painful? “The good thing is once you get rid of the surface of the skin as we do in this surgery, a lot of the nerves have gone. It’s more changing the dressing that can be sore, but soaking in the shower first before removing the bandage can help.“
What will my nose look like afterwards? Will it look as it did before rhinophyma? “It won’t go exactly how it used to look [before the Rhinophyma developed], but your nose will look in proportion to the face again and there won’t be any obvious bulbous areas. It’s worth noting that this surgery cannot be combined with a rhinoplasty procedure – it would be too risky on the skin.“
Can I be referred for surgery by my GP or do I have to see a dermatologist? “The first port of call would be speaking with your GP. From there, they should be able to refer you to a plastic and reconstructive surgeon to discuss in more detail. Alternatively, for those able to do so, you could book a consultation with a private plastic surgeon.“
How to care for Rhinophyma: Many of the tips for caring for Rhinophyma will be familiar if you have any of the other rosacea subtypes, but I thought it was worth sharing them here for ease. Sunscreen. Exposure to the sun is the most common rosacea trigger so finding a sunscreen that suits you is really important. This rule goes for cloudy days, cold days, when you’re in the car… it’s not just for sunny days and holidays! Try to find a sunscreen that suits your skin type, that’s at least SPF30, apply it generously, reapply if outside for more than 2 hours, and choose a broad spectrum sunscreen (providing protection from UVA and UVB). Gentle skincare. There is a prevailing myth that oily skin doesn’t need to be moisturised – this is untrue. In fact sometimes your skin produces more oil to try to keep your skin comfortable and hydrated, so by skipping skincare you could be making your skin more oily! Try to find a gentle and simple skincare routine: cleanser, moisturiser, sunscreen is the holy grail.

I’ve wanted to do a dedicated blog post on Rhinophyma for a while, but needed to make sure I was sharing information that actually added something to the conversation first. I don’t have personal experience of this form of rosacea, so I asked the wonderful Naveen Cavale to help me. Naveen is a Consultant Plastic, Reconstructive & Cosmetic Surgeon (you can read more about him and his work HERE) and very kindly fielded all of the questions I received in a recent call-out on my Instagram Stories.

My usual disclaimer: I am not medically trained in any way, but I have had rosacea for over 17 years, have access to a lot of incredible experts, and use this platform to raise awareness, give support, and provide information. As well as Naveen’s helpful answers below, I’ve included some links to further reading as well as additional information where I think it’s useful. I’ve tried to make it clear which parts are Naveen’s answers (italics) and which parts are my additional information (regular font) but if anything’s unclear, just let me know!

What does Rhinophyma mean?

It comes from the Greek for nose (‘rhis’) and growth (‘phyma’). It’s pronounced ry-no-fy-ma.

What is Rhinophyma? What causes it?

Rhinophyma is the thickening of the skin on the nose and tends to happen as you get older. It is more likely to affect those with thicker and oilier skin. It gives the appearance of a thicker, more bulbous nose and can sometimes look raised in some areas, but not in others.

Patient.info lists some additional factors present in Rhinophyma that can cause significant distress and physical changes: “disruption of the nasal architecture, airway obstruction, [as well as] disfigurement of the nose.” According to the British Association of Dermatologists (BAD), it is not thought to be genetic, but this is disputed by some.

How common is Rhinophyma?

It’s a fairly rare condition. I don’t see it very often, but when I do it’s usually more common in men as they tend to have thicker, oilier skin generally.

What are the early signs of Rhinophyma?

Early signs would include skin starting to look/feel thicker and also a slight increase in size. Some people find their skin becomes oilier too.

According to the (BAD)1, diagnosis can be made by your GP/Dermatologist from a simple visual examination. If necessary, a skin biopsy can be taken under general anaesthetic.

Is Rhinophyma a progression of other rosacea subtypes?

No, it’s a standalone issue.

This was the most common question, so I wanted to give a little more information on this. According to the BAD, Rhinophyma can develop in anyone, including people who don’t have rosacea. In the cases of people with rosacea who do develop Rhinophyma, it typically occurs after many years of rosacea. As Rav mentioned above, it’s more common in men and – according to the BAD – it’s more common in men aged 50-70.

How can I prevent Rhinophyma?

Unfortunately it’s not something that can be prevented.

If my flushing is concentrated to my nose, does that mean I’ll definitely get Rhinophyma?

Potentially, but there’s no concrete evidence to suggest this. There’s not a lot of research into this specific area of rosacea at present.

Is the thickening skin linked to cancerous growths?

Potentially. There is a small link between rhinophyma and basal cell carcinoma – the milder of the three main types of skin cancer. If you were to undergo surgery for it, we’d send what we take away to histology to check for skin cancer.

Is Rhinophyma related to alcoholism?

No, it’s a myth that rhinophyma is related to alcoholism. Rhinophyma is a genetic condition and typically isn’t influenced by environmental factors.

This myth is perpetuated by references to ‘whisky nose’ or ‘gin blossom nose’ which are nicknames for the swollen and red noses often associated with alcoholism. Rosaceans of all subtypes will empathise with the damage caused by this ignorant and widespread misconception. Alcohol consumption can exacerbate the symptoms of Rhinophyma, in the same way that alcohol can trigger flare ups in those of us with other rosacea subtypes, but alcohol alone is not a causal factor in the development of rosacea2.

What is the treatment for Rhinophyma? Are there any topicals that can help?

CO2 laser can be used for milder cases, but for quite severe cases, surgery is often the route. We would put a patient under general anaesthetic as it involves shaving away the excess tissue which form the bulbous parts of the nose. The procedure is fairly quick: 2 hours at most, depending on the severity.

An article on the BJGP states that “the early stages of rhinophyma may respond to topical treatments such as metronidazole, azelaic acid, and topical retinoids, and oral antibiotics such as tetracycline, doxycycline, and metronidazole can also be used. More severe cases should be referred to a specialist, who may consider using topical ivermectin and brimonidine, or oral isotretinoin.”3

Patient.info has some interesting information about patient satisfaction after treatment: “Outcomes between carbon dioxide laser and scalpel therapy and electrocautery were equivalent. Patient satisfaction was common post-therapy regardless of the treatment method. The review found that over 89% of patients would recommend undergoing treatment for rhinophyma irrespective of treatment type.” 4 / 5

Is Rhinophyma surgery a ‘one-and-done’ or will the thickening/swelling come back?

Unfortunately, there’s no guarantee even if you have surgery that it will stay away. We can’t stop the root cause of the thickening that occurs. If it did reoccur, it wouldn’t likely be for a very long time – 10 years or so I would say.

What is the downtime after Rhinophyma surgery?

After surgery, the nose will be dressed and will need to be kept very clean to avoid infection. This means regular dressing changes while it starts to scab over. In terms of downtime, the minimum required would be a week, but please note that there will be a very big scab that is healing which might mean you may wish to take longer off work etc. Everyone’s surgery will be different, it’s very much a case-by-case surgery depending on the severity.

Is the Rhinophyma healing painful?

The good thing is once you get rid of the surface of the skin as we do in this surgery, a lot of the nerves have gone. It’s more changing the dressing that can be sore, but soaking in the shower first before removing the bandage can help.

What will my nose look like afterwards? Will it look as it did before rhinophyma?

It won’t go exactly how it used to look [before the Rhinophyma developed], but your nose will look in proportion to the face again and there won’t be any obvious bulbous areas. It’s worth noting that this surgery cannot be combined with a rhinoplasty procedure – it would be too risky on the skin.

Can I be referred for surgery by my GP or do I have to see a dermatologist?

The first port of call would be speaking with your GP. From there, they should be able to refer you to a plastic and reconstructive surgeon to discuss in more detail. Alternatively, for those able to do so, you could book a consultation with a private plastic surgeon.

How to care for Rhinophyma:

Many of the tips for caring for Rhinophyma will be familiar if you have any of the other rosacea subtypes, but I thought it was worth sharing them here for ease.

  • Sunscreen. Exposure to the sun is the most common rosacea trigger so finding a sunscreen that suits you is really important. This rule goes for cloudy days, cold days, when you’re in the car… it’s not just for sunny days and holidays! Try to find a sunscreen that suits your skin type, that’s at least SPF30, apply it generously, reapply if outside for more than 2 hours, and choose a broad spectrum sunscreen (providing protection from UVA and UVB).
  • Gentle skincare. There is a prevailing myth that oily skin doesn’t need to be moisturised – this is untrue. In fact sometimes your skin produces more oil to try to keep your skin comfortable and hydrated, so by skipping skincare you could be making your skin more oily! Try to find a gentle and simple skincare routine: cleanser, moisturiser, sunscreen is the holy grail. I have some recommendations HERE and HERE.
  • Triggers. Finding your individual rosacea triggers is so important but requires some trial and error. Luckily, I have designed a free downloadable digital worksheet so you can track your triggers easily.
  • Detergents. Your skin comes into contact with fabric multiple times a day (bedding, towels, clothes), so it makes sense to wash with a detergent that is suitable for sensitive skin. I love the Fairy No-Bio range (I’ve worked with them in the past but this is not an ad!)
  • Make up. If you would like to use make up to minimise the redness of the skin on the nose, there are some recommendations and tips below:
    • Changing Faces offer some wonderful support in camouflage make up. You can find more information HERE.
    • Because Rhinophyma affects the pores and oil production on the nose, it may cause longevity issues with your make up. Things that might help: a primer designed for oily skin to prepare the skin; gently tapping your foundation/concealer onto the skin with your fingers (rather than using a brush or wiping with your fingers); and making sure to set your make up with a small make up brush and loose powder.
    • Please note that make up will reduce the redness of the skin, but the texture and uneven appearance of the skin will still be visible (and perhaps exaggerated) by make up.

I hope you found this post useful.

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LINKS TO FURTHER READING

1 https://www.bad.org.uk/pils/rhinophyma/

2 https://www.rosacea.org/blog/2019/september/severity-rosacea-rhinophyma-linked-alcohol-intake-291846

3 Rhinophyma: when Red Nose Day is no laughing matter. Alison Liu, Ali Al-Lami and Karan Kapoor. British Journal of General Practice 2019; 69 (680): 137.

4 Surgical management of rhinophyma: a case report and review of literature. Conn Med. 2014 Mar78(3):159-60.

5 Management of Rhinophyma: Outcomes Study of the Subunit Method. J Craniofac Surg. 2017 May28(3):e247-e250. doi: 10.1097/SCS.0000000000003467.

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