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Evidence-based management of rhinophyma according to disease severity and clinical grade

Published online by Cambridge University Press:  10 July 2026

Nuray Bayar Muluk Open the ORCID record for Nuray Bayar Muluk [Opens in a new window]
Nuray Bayar Muluk*
Affiliation:
Otorhinolaryngology Department, Kırıkkale University, Faculty of Medicine, Kırıkkale, Türkiye
*
Email: nuray.bayar@yahoo.com
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Abstract

Objectives

This review evaluates contemporary therapeutic strategies for rhinophyma, emphasising evidence-based treatment selection according to disease severity and clinical grading.

Methods

A structured literature search of PubMed/Medline, Scopus, Embase and Web of Science was performed for studies published between 1990 and 2025 evaluating medical, surgical and laser-based rhinophyma treatments.

Results

Medical therapy, including doxycycline and isotretinoin, is primarily beneficial in early inflammatory disease (Clark Grade I). Established fibrotic rhinophyma (Grades II–IV) generally requires surgical intervention. Current Level III–IV evidence supports partial-thickness sharp excision combined with adjunctive laser contouring using CO₂, Er:YAG and emerging blue laser technologies to improve haemostasis, tissue preservation and cosmetic outcomes. Histopathological assessment remains essential because occult malignancies may coexist within rhinophymatous tissue.

Conclusion

Treatment should be individualised according to clinical severity. Combined excisional and laser-based approaches currently provide the most favourable functional and aesthetic outcomes, although prospective comparative studies remain limited.

Keywords

laser therapylevel of evidencerhinophymarosaceasurgical therapeuticstreatment outcome

Information

Type
Review Article
Information
The Journal of Laryngology & Otology , Volume 140 , Issue 9 , September 2026 , pp. 963 - 967
Creative Commons
Creative Common License - CCCreative Common License - BYCreative Common License - NCCreative Common License - ND
This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (http://creativecommons.org/licenses/by-nc-nd/4.0), which permits non-commercial re-use, distribution, and reproduction in any medium, provided that no alterations are made and the original article is properly cited. The written permission of Cambridge University Press or the rights holder(s) must be obtained prior to any commercial use and/or adaptation of the article.
Copyright
© The Author(s), 2026. Published by Cambridge University Press on behalf of J.L.O. (1984) LIMITED.

Introduction

Rhinophyma is a profoundly disfiguring, progressive condition representing the severe, end-stage manifestation of phymatous rosacea. Clinically, patients present with an enlarged, bulbous nasal profile characterised by soft tissue overgrowth, nodular formations and prominent telangiectasias.Reference Chauhan, Loewenstein and Hassanein1 Beyond the severe aesthetic alteration, the progressive tissue hypertrophy can cause the lower third of the nose to droop (ptosis), ultimately leading to critical obstruction of the nasal passages.Reference Lian and Thompson2

While the precise cause of rhinophyma remains multifactorial, it is fundamentally driven by chronic inflammation, vascular dysfunction and matrix degradation.Reference Two, Wu, Gallo and Hata3 Elevated localised blood flow and upregulated vascular endothelial growth factor (VEGF) lead to vascular hyperpermeability, stimulating fibrotic tissue deposition.Reference Two, Wu, Gallo and Hata3, Reference Cuevas and Arrazola4 Additionally, oxidative tissue injury driven by reactive oxygen species (ROS) and abnormally elevated antimicrobial peptides, specifically cathelicidin (LL-37), play significant roles in pathological angiogenesis and subsequent fibrosis.Reference Jones5–Reference Schauber and Gallo7

To standardise reporting and guide treatment, various clinical grading systems are utilised. The most widely recognised is the Clark classification, which stages the disease based on anatomical extent and severity: Grade I (mild, restricted to the nasal tip), Grade II (moderate with early nodular changes), Grade III (severe with distinct lobules) and Grade IV (widespread disease extending to the nasal dorsum with significant functional impairment).Reference Clark and Hanke8

Because rhinophyma primarily involves established fibrotic and glandular hypertrophy rather than transient inflammation, surgical correction remains the definitive management strategy.Reference Lian and Thompson2 The objective of this review is to evaluate modern therapeutic interventions for rhinophyma, strictly emphasising the level of evidence and treatment selection based on disease severity and clinical grading.

Materials and methods

Search strategy and databases

To conduct this comprehensive review, an extensive literature search was performed across major recognised scientific databases, including PubMed/Medline, Scopus, Embase and Web of Science. Non-specific search engines and general internet resources were strictly excluded to ensure academic rigor. The literature search encompassed articles published from 1990 up to 2025.

Search terms and algorithms

Boolean operators (AND, OR) were utilised to combine specific keywords and Medical Subject Headings (MeSH) terms. The primary search string included: (“rhinophyma” OR “phymatous rosacea”) AND (“treatment” OR “surgery” OR “laser ablation” OR “radiofrequency” OR “therapeutics”).

Inclusion and exclusion criteria

To ensure the synthesis of high-quality evidence, strict selection criteria were applied. Inclusion criteria consisted of: (1) peer-reviewed original research articles, including clinical investigations, retrospective reviews and meta-analyses; (2) real-world clinical studies evaluating surgical, ablative and laser-based treatment outcomes; and (3) articles published in the English language. Exclusion criteria included non-peer-reviewed preprints, studies in languages other than English and articles lacking specific outcome data for rhinophyma treatments.

Data synthesis

Priority was given to peer-reviewed clinical studies and comparative trials. The extracted literature was categorised by therapeutic modality. Outcomes were analysed based on the kevel of evidence (using standard Oxford Centre for Evidence-Based Medicine guidelines) and the efficacy of treatments concerning specific clinical grades of rhinophyma.

Results

A comprehensive synthesis of the literature reveals that the management of rhinophyma relies heavily on the clinical grade of the disease. Due to the progressive, structural nature of the condition, randomised controlled trials (RCTs) comparing surgical interventions are scarce. Consequently, current clinical guidelines and treatment algorithms are predominantly derived from Level III (case–control and retrospective cohort studies) and Level IV (large case series) evidence. The literature demonstrates a clear consensus: pharmacological interventions are restricted to early-stage inflammatory disease, whereas surgical and energy-based modalities are required for established fibrotic hypertrophy.

The quality of evidence varies considerably among treatment modalities, with most available data derived from retrospective cohorts and case series rather than prospective randomised trials.

Medical management (Grade I rhinophyma)

For actively inflamed, early-stage rhinophyma (Clark Grade I), characterised by primary vascular hyperpermeability and early glandular hyperplasia without gross architectural distortion, medical therapies demonstrate Level I and II evidence for halting disease progression. Oral doxycycline and isotretinoin are the mainstays of conservative management.Reference McClellan and Noble9, Reference Somogyvári, Battyáni, Móricz and Gerlinger10 A sub-antimicrobial dose of doxycycline (40 mg) provides potent anti-inflammatory effects by inhibiting neutrophil-derived reactive oxygen species and matrix metalloproteinases, with a favourable side-effect profile compared to higher dosesReference Chauhan, Loewenstein and Hassanein1, Reference Tüzün, Wolf, Kutlubay, Karakuş and Engin11 (Table 1).

Table 1.

Evidence-based treatment strategies according to rhinophyma severity and clinical grade

Rhinophyma care escalates from oral anti-inflammatory drugs in mild disease to laser and surgical debulking for severe, obstructive, or recurrent cases, with evidence mostly low. See long description.
Table 1 Long description

Rhinophyma severity by Clark clinical grade is linked to dominant pathology, recommended treatments, evidence level, and key pros and cons. Grade I, driven by inflammation and early sebaceous hyperplasia, is treated with oral isotretinoin or sub-antimicrobial doxycycline and has the strongest support, with benefits in reducing inflammation but frequent relapse after stopping. Grade II adds early nodular fibrosis and glandular hypertrophy and shifts to device-based approaches such as Er:YAG laser, blue laser, radiofrequency surgery, electrosurgery, or coblation, offering precise contouring and haemostasis but with thermal injury risk and operator-dependent cosmetic results. Grade III, marked by fibrotic overgrowth and lobular deformity, recommends partial-thickness sharp excision with optional electrocautery or laser resurfacing for rapid debulking and tissue sampling, balanced against bleeding and scarring risk if too deep. Grade IV, with diffuse giant disease and functional obstruction, uses combined surgical debulking plus carbon dioxide or Er:YAG laser contouring to restore contour and airway function, but requires advanced expertise and longer healing. Recurrent or refractory disease may need dual-modality revision surgery and experimental anti-fibrotic options such as tamoxifen, with limited supporting data. Across grades, evidence strength generally decreases as disease severity and procedural complexity increase, and much of the surgical evidence comes from non-randomized studies.

Note: Most currently available evidence for surgical rhinophyma management is based on retrospective cohort studies and case series (Oxford CEBM Levels III–IV).

Oral isotretinoin (0.5–1.0 mg/kg) represents the most effective systemic agent for reducing sebaceous gland volume, perivascular lymphohistiocytic infiltrates and erythema.Reference Jansen and Plewig12, Reference Rebora13 However, literature strongly confirms that while isotretinoin successfully suppresses active sebum output, it fails to induce apoptosis in established fibrotic tissue, rendering it ineffective for Grades II–IV.Reference Hampton, Berth-Jones, Duarte Williamson, Hay, Leslie and Porter14 Furthermore, multiple cohort studies highlight a high relapse rate within one year of cessation if used as a standalone therapy for advanced disease. Crucially, active isotretinoin therapy must be discontinued prior to any ablative or surgical intervention to prevent severe delays in post-operative re-epithelialisation and atypical scarring.Reference Hampton, Berth-Jones, Duarte Williamson, Hay, Leslie and Porter14 Topical agents (e.g., metronidazole, azelaic acid) show negligible efficacy for phymatous changes and are generally contraindicated due to severe skin irritation in hypervascular rosacea.Reference Dick and Patel15

Surgical excision (Grades II–IV rhinophyma)

For established, nodular and structurally deforming rhinophyma (Clark Grades II–IV), partial-thickness surgical resection remains a cornerstone of treatment, supported by strong Level IV evidence.Reference Dick and Patel15, Reference Payne, Ko, Anspaugh, Wheeler, Wright and Robson16 Retrospective studies favour the use of a cold scalpel or razor blade for rapid, cost-effective debulking. The primary advantage of this physical excision is the preservation of deep adnexal structures to facilitate secondary intention healing, alongside the acquisition of tissue for histopathological analysis. Pathological screening is imperative, as large case series report a notable incidence (up to 3–10%) of occult malignancies—predominantly basal cell carcinoma—concealed within the nodular phymatous stroma.Reference Tüzün, Wolf, Kutlubay, Karakuş and Engin11, Reference Dick and Patel15 The major limitation of sharp excision is profound intra-operative bleeding, which obscures the surgical field and often necessitates adjunctive electrocoagulation. Alternatively, the use of a heated Shaw scalpel (operating at 160–200°C) provides simultaneous excision and thermal haemostasis, though it carries a slightly higher risk of thermal diffusion compared to cold instruments.Reference Dick and Patel15

Ablative and laser modalities (Grades II–IV rhinophyma)

Ablative technologies are utilised either as primary monotherapy for moderate (Grade II) disease or as a secondary refinement tool following cold excision for severe (Grades III–IV) disease.

Electrosurgery and Coblation: Electrosurgery (electrocautery and radiofrequency) provides highly cost-effective, bloodless ablation (Level IV evidence). However, literature reports a higher incidence of post-operative complications, including hypertrophic scarring and deep cartilaginous necrosis, resulting from unpredictable, excessive thermal spread.Reference Dick and Patel15 To mitigate this, coblation (cold ablation) technology is increasingly utilised. By exciting electrolytes in a conductive medium, coblation dissolves tissue at significantly lower temperatures (<90°C), drastically minimising collateral thermal injury.Reference Sadick, Goepel, Bersch, Goessler, Hoermann and Riedel17

Laser Therapy: Energy-based lasers currently represent the most sophisticated and well-supported modalities in the literature (Level III and IV evidence).Reference Sadick, Goepel, Bersch, Goessler, Hoermann and Riedel17–Reference Miranda, Villarreal, Arenas and Plaza23 The carbon dioxide (CO₂) laser (10,600 nm) is highly absorbed by tissue water, allowing for precise vaporisation. It generates a controlled thermal coagulation zone extending approximately 0.5 mm beyond the ablation site, ensuring exceptional haemostasis and a bloodless surgical field.Reference Fink, Lackey and Grande18, Reference Madan, Ferguson and August21 The Erbium:YAG (Er:YAG) laser (2,940 nm) is an alternative with an even higher water absorption coefficient, producing a very narrow thermal injury zone (<50 μm). While this results in faster re-epithelialisation, its haemostatic capacity is notably inferior in highly vascular lesions.Reference Mancini24 More recently, blue laser systems have emerged as a promising minimally invasive modality. Miranda et al.Reference Miranda, Villarreal, Arenas and Plaza23 reported favourable cosmetic and functional outcomes in two rhinophyma cases treated with blue laser therapy, highlighting effective tissue remodelling with minimal collateral thermal damage. However, current evidence remains limited to small case reports and further prospective clinical studies are required to validate long-term efficacy and recurrence rates.

Emerging non-surgical therapies

Recent molecular research (Level V evidence) has identified fibrotic cytokines, particularly transforming growth factor (TGF) -β1 and TGF-β2, as primary drivers of progressive rhinophyma thickening.Reference Wetzig, Averbeck, Simon and Kendler25 In vitro investigations reveal that tamoxifen, a nonsteroidal anti-estrogen, downregulates TGF-β2 expression and suppresses fibroblast activity in cultured phymatous tissue.Reference Payne, Ko, Anspaugh, Wheeler, Wright and Robson16 While clinical trials are pending, this represents a crucial step towards targeted pharmacological therapy aimed at preventing post-operative recurrence.

Discussion

The therapeutic paradigm for rhinophyma has undergone a significant evolution over the past few decades. Historically, the surgical landscape was dominated by highly aggressive, full-thickness resections that frequently required full-thickness skin grafting or local flap reconstruction. These approaches were largely abandoned due to high donor-site morbidity, severe scarring and notoriously poor cosmetic colour-matching.Reference Dick and Patel15 A comprehensive review of current clinical evidence indicates that modern rhinophyma management must be strictly governed by the clinical severity of the disease, moving towards tissue-sparing, partial-thickness interventions.

The critical distinction in the treatment algorithm lies between active inflammation and established fibrosis. For patients presenting with Clark Grade I disease (erythema, telangiectasia and minimal hypertrophy without structural deformity), medical management with oral isotretinoin is highly efficacious. As supported by robust Level II evidence, isotretinoin downregulates sebocyte proliferation and significantly decreases nasal volume in the early stages.Reference McClellan and Noble9, Reference Schaller, Almeida, Bewley, Cribier, Dlova and Kautz26 However, as the disease progresses into Grades II, III and IV, the hyperplastic sebaceous glands and dense fibrous stroma become entirely refractory to pharmacological agents. At these advanced stages, where patients frequently suffer from profound aesthetic disfigurement and functional nasal airway obstruction, surgical intervention transitions from an elective cosmetic procedure to a medical necessity.Reference Lian and Thompson2, Reference Rohrich, Griffin and WP27

Current literature increasingly supports a dual-modality surgical approach as one of the most effective strategies for moderate-to-severe rhinophyma (Level III–IV evidence). This modern technique leverages the unique advantages of both cold instrumentation and high-energy devices.Reference Fink, Lackey and Grande18, Reference Krausz, Goldberg, Ciocon and Tinklepaugh19 The initial phase involves gross surgical debulking using a cold scalpel or surgical loop. This achieves two critical objectives: rapid removal of the bulk of the disease to restore functional nasal airflow and the acquisition of uncharred tissue specimens. Given that phymatous rosacea creates a chronic inflammatory microenvironment that can mask the nodular growth of basal cell or squamous cell carcinomas, routine histopathological evaluation of the excised tissue is an absolute clinical requirement.Reference Tüzün, Wolf, Kutlubay, Karakuş and Engin11, Reference Dick and Patel15

Following the physical excision, the surgery transitions to the refinement phase, where energy-based devices are utilised to achieve meticulous haemostasis and aesthetic contouring. The CO₂ and Er:YAG lasers have revolutionised this phase. The CO₂ laser is often preferred as the “workhorse” due to its 0.5 mm thermal coagulation zone, which perfectly seals the hypervascular dermal bed of the rhinophymatous nose, providing a completely bloodless field for the surgeon to sculpt the delicate nasal subunits (alar lobules, tip and dorsum).Reference el-Azhary RA, Roenigk and Wang20, Reference Madan, Ferguson and August21 The Er:YAG laser, with its extremely shallow penetration profile, is increasingly used in combination with the CO₂ laser for the final superficial passes, minimising thermal damage and accelerating wound healing.Reference Mancini24

A critical element frequently emphasised in laser safety literature is the intra-operative utilisation of “sebum extrusion” as a reliable clinical endpoint. During laser vaporisation or dermabrasion, manual compression of the treated nasal skin will cause sebum to extrude from the hyperplastic glands. The abrupt cessation of this sebum extrusion serves as a physiological marker indicating that the surgeon has reached the fundus (base) of the sebaceous glands. Halting ablation at this precise depth is paramount; it ensures the preservation of the deep follicular adnexa, which act as the regenerative epithelial islands required for secondary intention healing. Violating this depth risks exposing the underlying alar cartilages and invariably leads to catastrophic complications, including hypertrophic scarring, hypopigmentation and alar retraction.Reference Sadick, Goepel, Bersch, Goessler, Hoermann and Riedel17, Reference Fink, Lackey and Grande18

While standard electrosurgery and loop cautery remain globally accessible and cost-effective alternatives to expensive laser systems, surgeons must exercise extreme caution. The unpredictable deep thermal diffusion associated with monopolar electrocautery drastically increases the risk of deep cartilaginous necrosis compared to the highly controlled photothermal ablation of modern lasers or the low-temperature ionic fields of helium-plasma radiofrequency devices.Reference Krausz, Goldberg, Ciocon and Tinklepaugh19, Reference Gentile22 Therefore, in severe Grade IV cases where functional nasal valve collapse is present, a specialised, subunit-based approach combining cold scalpel excision and precise CO₂ laser contouring provides the optimal balance of structural preservation and aesthetic reconstruction.

Despite these significant surgical advancements, the existing literature is limited by a lack of large-scale, multicentre randomised controlled trials comparing specific surgical techniques, largely due to ethical considerations and the heterogeneous presentation of the disease. Furthermore, while surgical debulking effectively eradicates the immediate architectural deformity, it does not arrest the underlying pathophysiological mechanisms of rosacea. Consequently, post-operative recurrence remains a clinical challenge. Future research must prioritise the development of standardised objective scoring systems (such as the Rhinophyma Severity Index [RHISI]) to better evaluate long-term outcomes and further investigate targeted molecular therapies. The promising in vitro success of tamoxifen in downregulating TGF-β2 mediated fibrosis suggests that the future of rhinophyma management may lie in a hybrid approach: surgical restoration of nasal anatomy coupled with targeted maintenance pharmacotherapy to permanently alter the fibrotic trajectory of the disease.Reference Payne, Ko, Anspaugh, Wheeler, Wright and Robson16

Despite technological advances in laser and radiofrequency systems, no universally accepted treatment algorithm currently exists for rhinophyma. Treatment selection remains largely dependent on surgeon experience, equipment availability, disease severity and patient-specific cosmetic expectations. Consequently, individualised treatment planning continues to represent a central principle in contemporary rhinophyma management.

  • • Rhinophyma is a progressive phymatous subtype of rosacea characterised by sebaceous gland hypertrophy, fibrosis and progressive nasal deformity

  • • Treatment selection should be guided by disease severity and clinical grading systems such as the Clark classification

  • • Medical therapy, including isotretinoin and doxycycline, is mainly effective in early inflammatory disease (Grade I)

  • • Established fibrotic rhinophyma (Grades II–IV) generally requires surgical or ablative intervention

  • • Partial-thickness excision combined with CO₂ or Er:YAG laser resurfacing currently represents the most supported treatment strategy for advanced disease

  • • Histopathological evaluation of excised tissue is essential because occult malignancies may coexist within rhinophymatous tissue

  • • Preservation of deep adnexal structures is critical to ensure proper re-epithelialisation and minimise post-operative scarring

  • • Most currently available evidence is based on retrospective studies and case series, highlighting the need for prospective randomised clinical trials

Conclusion

Rhinophyma is a progressive fibro-inflammatory disorder requiring individualised management according to disease severity and anatomical involvement. While medical therapy may provide benefit in early inflammatory stages, advanced rhinophyma generally necessitates surgical intervention. Current evidence suggests that combined partial-thickness excision and adjunctive laser resurfacing provide favourable functional and cosmetic outcomes while preserving critical adnexal structures required for secondary healing. Nevertheless, the literature remains limited by the predominance of retrospective studies and the absence of large prospective comparative trials. Future research should focus on standardised severity assessment systems and the development of targeted anti-fibrotic therapies to improve long-term disease control and reduce recurrence.

Funding sources

None.

Competing interests

Author Nuray Bayar Muluk declares that she has no conflict of interest. There are no financial disclosures of the authors.

Ethical approval

There was no need to obtain ethical approval, because this is a review paper.

Informed consent

There was no need to take informed consent, because this is a review paper.

Author contributions

Nuray Bayar Muluk: Planning, designing, literature survey, evaluation of literature search, writing, submission

Availability of data and materials

All data for this review are presented in this paper.

Acknowledgments

N/A.

Consent for publication

The author gave consent for publication

Footnotes

Nuray Bayar Muluk takes responsibility for the integrity of the content of the paper

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Figure 0

Table 1. Evidence-based treatment strategies according to rhinophyma severity and clinical gradeTable 1 long description.