Treatment options

Historically, a multitude of treatment methods have been used to treat rhinophyma, including both medical and surgical treatments. In the past, medical measures have included non-invasive procedures such as dietary changes, herbs, mercury vapour, combinations of vitamins, injection of fibrinolysin, and the use of steroids; X-ray therapy was abandoned owing to its association with secondary skin malignancies4,17. Oral and topical antibiotics and isotretinoin have been widely used to treat rosacea, and their use has been extrapolated to treating rhinophyma; nevertheless, they have not been shown to conclusively halt the progression from rosacea to rhinophyma or cause a regression of existing rhinophyma4. Therefore, despite the advances in medical therapy, it is generally accepted that surgery offers the only chance of cure by removing the hypertrophied tissue.

Surgical treatment includes total eradication (full thickness excision) or subtotal eradication (partial thickness excision or ‘decortications’) of the diseased tissue. The total eradication is considered in cases of infiltrating rhinophyma -— the fibrous variant or rhinophyma with underlying skin cancer — and usually requires flap coverage or skin grafts27. In 1845, Dieffenbach excised rhinophymatous skin and closed the nose primarily. Later, in 1851, von Langenbeck performed full-thickness excision of nasal skin and allowed the surface to heal secondarily. Total excision techniques are now less favoured because they are associated with significant scarring, poor colour and texture match, and poorer cosmetic results19.

Subtotal eradication

In 1864, Stromeyer performed a subtotal eradication of involved skin, allowing re-epithelialisation from retained sebaceous glands4. Subtotal eradication by tangential excision of diseased tissue preserves the underlying sebaceous glands and allows a spontaneous re-epithelisation and complete healing in 2–3 weeks27. Although a low risk of recurrence remains, it guarantees better aesthetic results, reduces the complexity of the surgical procedure, and reduces the discomfort to the patient, while total excision necessitates a second procedure of skin graft or flap harvesting with added morbidity28. Furthermore, the advantage of decortication is the preservation of the original nose shape. However, a number of disadvantages of the decortication technique include: excessive intraoperative blood loss (because of the hypervascular nature of rhinophyma) that frequently obscures the operating field, leading to imprecise removal of tissue, poor cosmetic outcome, and postoperative pain and bleeding19.

Decortication has been performed using cryosurgical techniques, dermaplaning with a dermatome, dermabrasion, chemical peels, the cold scalpel , the Shaw knife, ultrasonic scalpels, the Bovie® (Bovie Medical Corporation, St. Petersburg, FL), hot wire loops, electrocautery, argon and CO2 laser ablation, radiofrequency blade vapourisation and the VersajetTM Hydrosurgery System20,29. Nevertheless, most demonstrate specific disadvantages:

  • Scalpel excision and dermabrasion cause bleeding during operation and leave a large wound on the nose. Furthermore, dermabrasion produces significant blood aerosol
  • Electrocautery, the Bovie, and radiofrequency blade vapourisation may damage underlying cartilage owing to the intense thermal heat generated during the procedure, and scarring may be worse
  • Cryosurgery is not capable of effectively controlling the depth and contour
  • CO2 laser seems to be effective yet slow
  • Chemical peels, the argon laser, the Shaw Knife and Versajet seem to provide only minimal destruction and are not suitable for large and deep lesions30.

For the reasons mentioned above, a number of authors recommend a combined use of these techniques rather than a single technique alone.

The scalpel in association with electrocautery is an inexpensive and useful method to control bleeding. It allows a sharp and accurate removal of rhinophymatous tissue with minimal thermal injury to the underlying surrounding tissues, avoiding the risk of scarring, and preserving the underlying fundi of the sebaceous glands for spontaneous re-epithelialisation27.

The combination of dermaplaning with scalpel followed by dermabrasion for final contouring and CO2 laser for additional haemostasis, seems to be a simple and reproducible method4.

Cravo et al31 described a combined CO2 laser and bipolar electrocoagulation for the treatment of rhinophyma. Indeed, the CO2 laser was first described in 1980 for treating this disease and offers a range of advantages. These include limited thermal effect reducing the risk of scarring, excellent selectivity in tissue destruction, low complication rates, high patient acceptability, precise control of the depth and extent of vapourisation7,29,31, and good haemostasis during resection that could be further increased by combining it with bipolar electrocoagulation31.

Recently, the modulated erbium laser or combined erbium and CO2 lasers seem to be the treatments of choice. This laser technique combines the advantages of the Er:YAG laser as an efficient vapourising tool and the CO2 coagulation laser to provide good haemostasis for accurate sculpting of the nose that quickly and efficiently produces cosmetically acceptable results19.