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Phenotype 5 Phymatous Explained


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"Phymatous rosacea is most commonly associated with rhinophyma, an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma). Telangiectasias may be present." Wikipedia

Phenotype 5 - Phymatous (Rhinophyma)

Phenotype 5 used to be classified as Subtype 3 - [Rhinophyma] (red, enlarged nose). This phenotype responds to treatment very well. Phymatous rosacea is uncommon. The most frequent phymatous manifestation is rhinophyma (known familiarly as "whiskey nose" "brandy nose" or "rum blossom"). In its severe forms, rhinophyma is a disfiguring condition of the nose resulting from hyperplasia of both the sebaceous glands and the connective tissue. Rhinophyma occurs much more often in men than in women (approximate ratio, 20:1), [1] and a number of clinicopathologic variants have been described. [2]

Although rhinophyma is often referred to as "end-stage rosacea," it may occur in patients with few or no other features of rosacea. The diagnosis is usually made on a clinical basis, but a biopsy may be necessary to distinguish atypical, or nodular, rhinophyma from lupus pernio (sarcoidosis of the nose); basal-cell, squamous-cell, and sebaceous carcinomas; angiosarcoma; and even nasal lymphoma. [3]

Older papers usually mention how rosacea progresses in stages and ends up in subtype 3 (now called Phenotype 5), but recent studies indicate that this is not necessarily true. One can develop subtype 3 without going through any 'stages.' [read this post]

One report says, "It can affect nose (rhinophyma), chin (gnatophyma), forehead (metophyma), ears (otophyma) and eyelids (blepharophyma). Rhinophyma is the most frequent location..." [15]

For images of phymatous click below:

http://goo.gl/BI2lf; 28 Images of Rhinophyma

A classic example of Subtype 3 is WC Fields (the rosacea poster boy😞


Another classic example is this painting in the Louvre, "The Old Man and His Grandson" by Ghirlandiao around the year 1480.


There are Five Variants of Rhinophyma:
Rhinophymous leishmaniasis

This is a great thread to read about what was referred to as Subtype 3 (now called Phenotype 5)


There are a number of different treatments for rhinophyma, including surgery, but it is better to treat the rosacea before it reaches the advance stage of rhinophyma. However, once rhinophyma has developed it can usually be corrected by surgery using either laser, scapel, or dermabrasion. The good thing about rhinophyma is that though this condition is generally regarded as a severe form of rosacea it is a relatively rare disorder involving thickening of the skin on the nose and the presence of many oil glands and this condition can usually can be corrected. Accutane is usually the drug of choice, but your physician may use other prescription drugs such as antibiotics if you have this skin disorder. Other treatment may involve cryosurgery, dermashaving and electrosurgery.

"Coblation of rhinophyma is an effective treatment with few side effects." [4]

""...Initially, the mass was thought to be rhinophyma, but biopsy of the mass revealed noncaseating granulomata consistent with sarcoidosis. The mass resolved following several steroid injections..." [5]

Radiofrequency is used to treat rhinophyma. [6]

Rhinophyma treated with kilovoltage photons {7]

Treatment of rhinophyma with ultrasonic scalpel: case report [8]

Radiosurgical excision of rhinophyma. [9]

"Surgery is indisputably the treatment of choice for rhinophyma." [10]

This report said, "Despite many advances in fundamental understanding, surgical techniques, and related technologies, no single method has been universally embraced and employed as the "gold standard." " [11]

Smoothbeam laser [13]

Surgical Management [14]

Another report says, "Both tangential excision and carbon dioxide laser are well-established, reliable procedures for rhinophymaplasty that preserve the underlying sebaceous gland fundi allowing spontaneous re-epithelialization without scarring with similar outcomes and high patient satisfaction. The original nose shape and nearly normal skin surface texture are preserved by quickly removal of the hypertrophic tissue sparing the pilosebaceous tissue. The CO(2) laser is more capital intensive and results in higher fees compared with the simpler cold blade tangential excision. In our experience the ease of use, accuracy and precision of the lasers offer is not justified by the increased costs." [16]

Another report, which says, "a surgical "gold standard" for treating the distorting phymatous skin alterations has not yet been established," it goes on to state, "the combination of a bovine collagen-elastin with simultaneous autologous non-meshed split-thickness skin grafting" was used in a surgery, and "may ultimately avoid the recurrence of rhinophyma and contribute to a full skin repair leading to satisfactory functional and aesthetic outcome." [17]

"This report describes a simple, safe, efficient, and cost-effective approach to the treatment of severe rhinophyma using a scalpel and the electroscalpel, instruments readily available in every operating room." [18]

Scalpel Excision and Wire Loop Tip Electrosurgery [19]

One reports says, "The CO2 laser is more capital intensive and results in higher fees compared with the simpler cold blade tangential excision. In our experience the ease of use, accuracy and precision of the lasers offer is not justified by the increased costs." [20]

"Electrosurgery is one of the simplest and most cost-effective techniques currently available for the treatment of rhinophyma by dermatologists." [21]

" It is suspected that many different factors may induce rhinophyma development. In our opinion, mechanical repetitive trauma is one of the most important.: [22]

Salicylic acid 30% • Jojoba oil • Glycolic acid 70% • Baking Soda • Dawn Ultra

Anecdotal Reports 

Nose Swelling, big pores, phymous tissue--please post!

Another treatment has been reported, coblation. The report says, "A hand-held coblation ‘wand’ emits a slow stream of saline solution – sterilised salt water – from the end that comes into contact with the nose. At the same time, it emits waves of radiofrequency energy to excite the molecules in the solution which ‘sands’ down the tissue. It also uses a low heat to cauterise (clot) any bleeding blood vessels." [12]

Fractionated Carbon Dioxide Laser Resurfacing as an Ideal Treatment Option for Severe Rhinophyma: A Case Report and Discussion.

End Notes

[1] Roberts JO, Ward CM. Rhinophyma. J R Soc Med 1985;78:678-681.[iSI] [Medline]

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jun 15.
Dick MK1, Patel BC2.

[2]  J Am Acad Dermatol 2000;42:468-472.[CrossRef][iSI] [Medline]
The clinicopathologic spectrum of rhinophyma
Aloi F, Tomasini C, Soro E, Pippione M.

[3]  J Am Acad Dermatol 1998;38:310-313.[iSI] [Medline]
Cutaneous presentation of nasal lymphoma: a report of two cases
Murphy A, O'Keane JC, Blayney A, Powell FC.

[4] Coblation of rhinophyma.
Timms M, Roper A, Patrick C.
J Laryngol Otol. 2011 Apr 27:1-5.

[5] Sarcoidosis of the external nose mimicking rhinophyma. Case report and review of the literature.
Goldenberg JD, Kotler HS, Shamsai R, Gruber B.
Ann Otol Rhinol Laryngol. 1998 Jun;107(6):514-8.

[6] Management of mild to moderate rhinophyma with a radiofrequency.
Erisir F, Isildak H, Haciyev Y.
J Craniofac Surg. 2009 Mar;20(2):455-6.

[7] Rhinophyma treated with kilovoltage photons.
Skala M, Delaney G, Towell V, Vladica N.
Australas J Dermatol. 2005 May;46(2):88-9.

[8] Treatment of rhinophyma with ultrasonic scalpel: case report.
Tenna S, Gigliofiorito P, Langella M, Carusi C, Persichetti P.
J Plast Reconstr Aesthet Surg. 2009 Jun;62(6):e164-5. Epub 2008 Dec 12.

[9] Radiosurgical excision of rhinophyma.
Somogyvári K, Battyáni Z, Móricz P, Gerlinger I.
Dermatol Surg. 2011 May;37(5):684-7. doi: 10.1111/j.1524-4725.2011.01965.x. Epub 2011 Apr 1.

Letter: radiosurgical excision of rhinophyma.
Niamtu J 3rd.
Dermatol Surg. 2012 May;38(5):816-7. doi: 10.1111/j.1524-4725.2012.02383.x.

[10] Rhinophyma in rosacea : What does surgery achieve?
Sadick H, Riedel F, Bran G.
Hautarzt. 2011 Oct 19.

[11] Nuances in the management of rhinophyma.
Facial Plast Surg. 2012 Apr;28(2):231-7
Authors: Little SC, Stucker FJ, Compton A, Park SS

[12] How salt-blasting surgery cured my disfiguring condition called 'drinker's red nose'
Mail Online / Health
PUBLISHED: 16:07 EST, 12 May 2012 | UPDATED: 17:23 EST, 12 May 2012
Read more: http://www.dailymail...l#ixzz1uvARY8Et

[13] J Dermatolog Treat.
2012 Apr;23(2):153-5. Epub 2010 Oct 22.
Moderate rhinophyma successfully treated with a Smoothbeam laser.
Chou CL, Chiang YY

[14] Conn Med. 2014 Mar;78(3):159-60.
Surgical management of rhinophyma: a case report and review of literature.
Ferneini EM, Banki M, Paletta F, Ferneini CM.

[15] An Bras Dermatol. 2012 Dec;87(6):903-5.
Gnatophyma: a rare form of rosacea.
Macedo AC, Sakai FD, Vasconcelos RC, Duarte AA.

[16] J Craniomaxillofac Surg. 2012 Dec 8. pii: S1010-5182(12)00248-X. doi: 10.1016/j.jcms.2012.11.009.
Surgical correction of rhinophyma: Comparison of two methods in a 15-year-long experience.
Lazzeri D, Larcher L, Huemer GM, Riml S, Grassetti L, Pantaloni M, Li Q, Zhang YX, Spinelli G, Agostini T.

[17] Int J Surg Case Rep. 2012 Nov 10;4(2):200-203. doi: 10.1016/j.ijscr.2012.11.003. [Epub ahead of print]
The surgical treatment of rhinophyma-Complete excision and single-step reconstruction by use of a collagen-elastin matrix and an autologous non-meshed split-thickness skin graft.
Selig HF, Lumenta DB, Kamolz LP.

Aesthetic Plast Surg. 2013 Jan 8. [Epub ahead of print]
Optimizing Cosmesis with Conservative Surgical Excision in a Giant Rhinophyma.
Lazzeri D, Agostini T, Spinelli G.
[18] Aesthetic Plast Surg. 2013 Mar 1. [Epub ahead of print]
Management of Severe Rhinophyma With Sculpting Surgical Decortication.
Husein-Elahmed H, Armijo-Lozano R.
[19] Dermatol Surg. 2013 Apr 5. doi: 10.1111/dsu.12193. [Epub ahead of print]
Treatment of Severe Rhinophyma Using Scalpel Excision and Wire Loop Tip Electrosurgery.
Prado R, Funke A, Brown M, Ramsey Mellette J.

Northeast Dermatology Associates, Andover, Massachusetts.

[20] J Craniomaxillofac Surg. 2013 Jul;41(5):429-36. doi: 10.1016/j.jcms.2012.11.009. Epub 2012 Dec 8.
Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience.
Lazzeri D1, Larcher L, Huemer GM, Riml S, Grassetti L, Pantaloni M, Li Q, Zhang YX, Spinelli G, Agostini T.

[21] Actas Dermosifiliogr. 2017 Aug 9. pii: S0001-7310(17)30385-X. doi: 10.1016/j.ad.2017.02.033. [Epub ahead of print]
Electrosurgery for the Treatment of Moderate or Severe Rhinophyma.
González LF, Herrera H, Motta A.
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