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Treatment for Phenotype 5


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Phymatous (Rhinophyma) [aka Subtype 3

No current consensus exists on the ideal surgical treatment as the option chosen largely depends on the combined decision of the patient and provider based on cost, disease severity, and experience of the provider. We list the treatments being used below for your consideration.  

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," [30] "fourth stage rosacea," [30] "stage III rosacea," [29] or "the most advanced stage of rosacea" [27], 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 (Phenotype 5), but recent studies indicate that this is not necessarily true. One can develop phenotype 5 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 phenotype 5 (formerly Subtype 3) click below:

http://goo.gl/BI2lf; 

28 Images of Rhinophyma

A classic example of Phenotype 5 is WC Fields (the rosacea poster boy)
wcfields.gif

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

There are Five Variants of Rhinophyma:
Glandular
Fibrous
FibroangiomatousActinic
Rhinophymous
leishmaniasis
 

This is a great thread to read about Subtype 3.

Otophyma

Treatment

"No current consensus exists on the ideal surgical treatment as the option chosen largely depends on the combined decision of the patient and provider based on cost, disease severity, and experience of the provider." [32]

"At present, the treatment of this pathology presents great difficulties. Despite the many surgical methods, rhinophyma is poorly treatable, often relapses and leaves no less noticeable disfigurement of the face in the postoperative period. In this regard, there is a constant search for new surgical methods, which has not only medical but also important social significance." [33]

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.

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]

Other treatment may involve cryosurgery, dermashaving and electrosurgery. Below is a list you can consider and ask your physician about: 

Acellular dermal matrix [26]

Autologous Melanocyte Transplantation for those with Fitzpatrick skin type IV-VI

CO2 Laser (or other laser)
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]

1064 nm Q-Switched Neodymium:Yttrium Aluminum Garnet Laser

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]

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

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]

Fractional ablative CO2 laser treatment

ultra plus CO2 laser

Fractional ablative 2940 nm Er:YAG laser [31]

Fractional or fully ablative CO2 laser alone or in combination with oral isotretinoin is a very effective treatment modality.

Copper Vapor Laser With the Computerized Scanner [27]

Laser-assisted surgery and bioscaffold

Erbium-doped Yttrium Aluminium Garnet (Er:YAG) Laser

Cryotherapy
Cryotherapy is listed among other treatments for phenotype 5. [23]

Dermabrasion
"Our technique combining dermabrasion, decortication and application of fibrin glue has given very good results." [21]

Electrocautery
Electrocautery  [28]

Electrocautery [34]

Excison
Excision and repair with bilateral pedicled nasolabial flaps [25]

Microdebrider-assisted excision

Surgical Excision and Amniotic Membrane [24]

Hydrosurgery

Low Dose Isotretinoin

Ordinary Bur

Radiofrequency is used to treat rhinophyma. [6]

Radiosurgical excision of rhinophyma. [9]

Rhinophyma treated with kilovoltage photons [7]

Scapel
Scalpel Excision and Wire Loop Tip Electrosurgery [19]

"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]

Shave excision [34]

Shave excision and Electrocautery

"Surgery is indisputably the treatment of choice for rhinophyma." [10]  [28]

Five-blades scratcher surgery

"We conclude that the microdebrider is an excellent surgical tool for treating rhinophyma lesions." [22]

Steroid Treatment
"...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]

Smoothbeam laser [13]

Surgical Management [14] [28]

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

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]

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

Anecdotal Reports 

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

End Notes

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

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

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

[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):231-7Authors: Little SC, Stucker FJ, Compton A, Park SS

[12] How salt-blasting surgery cured my disfiguring condition called 'drinker's red nose'
By ROGER DOBSON
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.
Source
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] Rhinophyma: Our experience based on a series of 12 cases.
Eur Ann Otorhinolaryngol Head Neck Dis. 2017 Sep 21;:
Clarós P, Sarr MC, Nyada FB, Clarós A

[22] Use of the microdebrider in the surgical management of rhinophyma.
Ear Nose Throat J. 2018 Jan-Feb;97(1-2):E42-E45
Chow W, Jeremic G, Sowerby L

[23] Aesthetic Plast Surg. 2004 Dec 23; The Gold Standard for Decortication of Rhinophyma: Combined Erbium- YAG/CO(2) Laser.
Goon PK, Dalal M, Peart FC.
Department of Plastic Surgery, University Hospital Birmingham, Selly
Oak, West Midlands, Birmingham, United Kingdom

Rhinophyma is a benign condition of the nose that often is severely disfiguring and occasionally causes functional problems. A considerable proportion of the patients, with rhinophyma are elderly with chronic medical problems. Electrocautery, heated scalpel, carbon dioxide (CO(2)) laser, argon laser, Weck blade, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel have been used either alone or in
combination. All these techniques have disadvantages that are resolved by using the combined erbium:yttrium-aluminum-garnet (YAG)/CO(2) laser. The authors present their technique and the results from decortication of rhinophyma using a combined erbium:YAG/CO(2) laser. The technique requires only local anesthesia with a vasoconstrictor. The combination of an efficient vaporization tool consisting of the erbium:YAG laser and the CO(2) coagulation laser provides a nearly bloodless field for accurate sculpting of the nose and produces cosmetically pleasing results.

[24] J Craniofac Surg. 2019 Apr 10;:
Treatment of Rhinophyma With Surgical Excision and Amniotic Membrane.
Yoo JJ, Thaller SR

[25] J Craniofac Surg. 2019 Apr 12;:
Surgical Treatment Strategy for Severe Rhinophyma With Bilateral Pedicled Nasolabial Flaps.
Cui MY, Guo S, Wang CC, Lv MZ, Jin SF

[26] Int J Surg Case Rep. 2019; 59: 120–123.
Acellular dermal matrix for rhinophyma: Is it worth it? A new case report and review of literature
Matteo Torresetti, Alessandro Scalise, and Giovanni Di Benedetto

[27] J Lasers Med Sci. 2019 Spring; 10(2): 153–156.
Rhinophyma Treatment by Copper Vapor Laser With the Computerized Scanner
Igor V. Ponomarev, Sergey B. Topchiy, Svetlana V. Klyuchareva, Alexandra E. Pushkareva 

[28] Case Rep Surg. 2019; 2019: 2395619.
Large Rhinophyma Treated by Surgical Excision and Electrocautery
Nabeel K. Al Hamzawi and Salih M. Al Baaj

[29] Case Rep Otolaryngol. 2019;2019:4915416
Microdebrider-Assisted Rhinophyma Excision.
Abushaala A, Stavrakas M, Khalil H

[30] Does Rosacea Progress In Stages?

[31] Clin Cosmet Investig Dermatol. 2020; 13: 949–955.
Novel Management of Rhinophyma by Patterned Ablative 2940nm Erbium:YAG Laser
Ashraf Badawi, Mai Osman, and Ahmed Kassab

[32] StatPearls [Internet].
Rhinophyma
Mary K. Dick; Bhupendra C. Patel.

[33] The rhinophyma through the prism of time

[34] BMJ Case Rep. 2020; 13(1): e232973.
Severe rhinophyma treated by shave excision and electrocautery
Manish Gupta, Gurchand Singh, and Monica Gupta

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