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Giant rhinophyma
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  1. Stuti Chowdhary and
  2. Arun Alexander
  1. ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
  1. Correspondence to Dr Stuti Chowdhary; stuti.9894{at}gmail.com

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Description

A 68-year-old man presented with a painless bulbous growth arising from the tip of his nose for 4 years that had gradually progressed to the current size.

On examination, the lesion was bulbous, firm, rubbery, non-tender, extending from the dorsum of the nose to the alae bilaterally and projected anteriorly about 3 cm from the nasal tip (figure 1). The skin pores over the nose appeared prominent and gentle pressure on the swelling caused a yellow cheesy material to be expressed. It was clinically diagnosed as a rhinophyma. The lesion was accorded 6 points according to the Rhinophyma Severity Index and was graded as a giant rhinophyma.1

Figure 1

The front view of the patient, showing the benign-appearing rhinophyma or ‘potato nose’.

The lesion was excised by shaving it off from the underlying cartilage without damaging alar cartilages. The wound was allowed to granulate and healed by secondary intention. The patient was followed up and no recurrence of the lesion was observed after the initial excision.

Rhinophyma, also known as ‘potato nose’, is a rare, chronic, benign, clinical entity forming the fourth and terminal stage of acne rosacea. It is usually found in elderly Caucasians and is rarely reported in men of Asian descent.2 Though the incidence of acne rosacea is commoner in the Caucasian population, the chance of seeing a giant rhinophyma like the present case is more likely in the third world countries like India, with a majority of cases affecting darker Fitzpatrick skin types.3 A variety of theories have been proposed for its causation, such as exacerbation of rosacea and dermal interstitial oedema due to immunologically mediated vasodilatation.4 There is empirical evidence of exacerbation of the disorder after alcohol or caffeine intake and presence of the skin mite Demodex folliculorum.5 It preferentially affects the nasal skin over the tip and alae and spares the osteocartilaginous framework.

It is a disfiguring and distressing disorder due to the cosmetic unsightliness and nasal obstruction, although, in some parts of India, it is allowed to grow unchecked and untreated as the elongated trunk shaped nose is considered auspicious as the patient resembles the elephant God ‘Ganesh’ (figure 2).

Figure 2

The elongated, bulbous growth as shown resembles the elephant God ‘Ganesh’.

Diagnosis of the condition is clinical, with the confirmation by histology of the excised specimen. Histopathological examination demonstrates dermal and epidermal thickening, sebaceous gland hypertrophy and a myxoid stroma, with admixed mast cells (figure 3). An associated inflammatory infiltrate is seen in reaction to the keratin, composed of lymphocytes, plasma cells and foreign body giant cells.

Figure 3

Low-power scanning view of the histopathology of the excised lesion shows dermal and epidermal thickening (marked with a hollow arrow), sebaceous gland hypertrophy and myxoid stroma admixed with lymphocytes and plasma cells (marked with an asterisk). Stained with H&E.

A range of surgical treatments have been adopted, which include dermal shaving or paring with re-epithelialisation, full-thickness excision with a free flap or skin graft, partial-thickness debulking, cryosurgery, electrocoagulation and lasers.2 Carbon dioxide and Nd:YAG lasers have also shown good results.6 The postoperative results in terms of the colour match of the skin are probably best if the wound is allowed to heal by secondary intention.

Patient’s perspective

I was not much concerned about the growth on my nose until it became bigger. I am glad it has been removed and my nose looks much better now.

Learning points

  • Rhinophyma is characterised by a bulbous painless enlargement of the tip of the nose.

  • The lesion involves the skin and subcutaneous tissue of the tip of the nose and spares underlying cartilage.

  • Shaving of the lesion while sparing underlying cartilage gives the best results cosmetically.

Acknowledgments

The authors acknowledge Dr Pampa Ch. Toi, from the Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, for her suggestions and help for the histopathology image.

References

Footnotes

  • Contributors SC: Contibuted in drafting the article and acquisition of data. AA: Contibuted in interpretation of data and revising it critically for important intellectual content and final approval of the version being published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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