Treatment of rhinophyma with Er:YAG laser

Novel Management of Rhinophyma by Patterned Ablative 2940nm Erbium:YAG Laser

Introduction

Rhinophyma is a cosmetic disorder that causes emotional distress if the symptoms are extensive or obvious enough. Treatment options range from topical antibiotics or isotretinoin, surgical resection, cryosurgery, electrocautery, dermabrasion and more recently laser therapy. With the limitations of surgical techniques, lasers gained popularity for treating rhinophyma. However, laser ablation is invasive and can lead to side effects and prolonged downtime. Fractional photothermolysis (FP) was introduced to overcome the limitations posed by conventional ablative lasers. To the best of our knowledge, there are no previous studies to evaluate the use of Er:YAG in an ablative mode with a fractional handpiece for the treatment of rhinophyma.

Aim of the Work

The goal of this study was to evaluate the efficacy and safety of fractional ablative 2940 nm Er:YAG laser for the treatment of mild to moderate rhinophyma.

Patients and Methods

Sixteen patients having mild to moderate rhinophyma were treated with fractional ablative 2940 nm Er:YAG laser. All patients received 4 laser treatments and were followed up over the following 3 months. An additional follow-up appointment 6 months after the last session was arranged to detect any signs of recurrence.

Outcome Measures

Patient questionnaire was used to evaluate patient subjective satisfaction. Objective evaluation was performed by a blind assessment of clinical photographs that were taken before and 3 months after the final treatment by two independent blinded evaluators.

Results

Patient questionnaire taken 3 months after last treatment revealed that 8 patients (50%) were “very satisfied”, 4 patients (25%) were satisfied, and 4 patients (25%) were somewhat satisfied. None of the patients assessed their results as not satisfying.

Conclusion

In conclusion, the use of patterned ablative Er:YAG laser with a PS01 handpiece and parameters used in this study comprise an effective tool for treatment of mild to moderate rhinophyma with rapid postoperative recovery compared with conventional surgical procedures and other ablative lasers.

Consensus on the therapeutic management of rosacea - Brazilian Society of Dermatology

BACKGROUND

Rosacea is a chronic inflammatory disease of the skin, relatively more frequent in women over 30 with a low phototype and proven genetic predisposition. Although its etiology is unknown and possibly multifactorial, the immunological abnormality, associated with neurovascular dysregulation and triggering factors, are important elements in its pathophysiology, which lead to the main changes of inflammation, vasodilation, and angiogenesis that are responsible for the clinical manifestations. Despite the lack of cure, numerous therapeutic options are available for the different clinical presentations of the disease, with satisfactory responses.

OBJECTIVE

To reach a consensus, with recommendations from experts, on the therapeutic management of rosacea suitable to the Brazilian setting.

METHODS

The study was conducted by five specialized dermatologists from university centers, representatives of the different Brazilian regions, with experience in rosacea, who were appointed by the Brazilian Society of Dermatology. Based on the adapted DELPHI methodology, the experts contributed through an updated bibliographic review of the scientific evidence, combined with personal experiences.

RESULTS

The group of experts reached a consensus on the relevant aspects in the therapeutic management of rosacea, providing information on epidemiology, pathophysiology, triggering factors, clinical condition, classification, quality of life, and comorbidities. Consensus was defined as approval by at least 90% of the panel.

CONCLUSION

Despite the impossibility of cure, there are several therapeutic alternatives specific to each patient that provide excellent results, with chances of total improvement and long periods of remission, promoting a positive impact on quality of life. This consensus provides detailed guidance for clinical practice and therapeutic decisions in rosacea.

Rhinophyma: Prevalence, Severity, Impact and Management

Rhinophyma is an advanced stage of rosacea affecting the nasal soft tissues and resulting in disruption of the nasal architecture, airway obstruction, and disfigurement of the nasal aesthetic units. Rhinophyma presents with hypertrophy of the nasal soft tissues, erythema, telangiectasias, nodules, and lobules with a bulbous appearance. Significant psychosocial morbidity is associated with the disease. Understanding of this disease has improved and multiple treatment options exist. The article is a review of the literature to evaluate the pathophysiology, clinical presentation, and epidemiology of keywords “rhinophyma” and “rosacea” using an OVID Medline and PubMed search along with a systematic review of outcomes pertaining to treatment of rhinophyma with laser therapy, scalpel excision, and the subunit method using an OVID Medline search. The subunit method has the highest complication and revision rates followed by carbon dioxide laser therapy. Outcomes between carbon dioxide laser and scalpel therapy and electrocautery are equivalent. Scalpel excision is a more cost-effective treatment modality with less post-operative complications; however, it risks poor hemostasis intraoperatively. Patient satisfaction is common post-therapy regardless of the treatment method. Over 89% of patients would recommend undergoing treatment for rhinophyma irrespective of treatment type. Treatment options vary, and choice of treatment can be dependent on practitioner and patients’ treatment goals.

Laser Ablation Electrospray Ionization Time-of-Flight Mass Spectrometry for Direct Analysis of Biological Tissue

Direct analysis and identification of biological tissue is significant for clinical applications. In this study, porcine liver and kidney have been analyzed using laser ablation electrospray ionization time-of-flight mass spectrometry (LAESI-TOFMS). This method showed good reproducibility for the same types of tissue and is capable of distinguishing different tissue species. The margin assessment was also performed using porcine renal tissue, and the response time was less than 6 s. Furthermore, human hepatocarcinoma tissue and normal tissue were identified using this method. Our results indicate that LAESI-TOFMS is a feasible approach for direct identification of tumor tissue and potential for assessment of the resection margin.

Rhinophyma Treatment by Copper Vapor Laser With the Computerized Scanner

Introduction: Rhinophyma is recognized as a common and severe skin disease manifested as progressive thickening of the nasal skin due to hypertrophy of the soft tissue. The most severe complication of rhinophyma is telangiectasis. So far the pathogenetic approach for the treatment of rhinophyma should be based on the removal of the dysplastic vessels to provide the appropriate revascularization of the involved skin area. Case Report: This study presented the experience of the treatment of rhinophyma with the copper vapor laser (CVL) designed with the computerized scanner device. A 52-year-old elderly Caucasian male patient with typical clinical signs of rhinophyma was successfully managed during three sessions of CVL treatment. CVL emits light with a wavelength of 578 nm, exposure time of 0.2 seconds. The settings used for the CVL in scanner mode were set at 1.2 W. The scanner device has a hexagonal frame with a maximum width of 12 mm with the distance of 1 mm between centers of laser spots. The CVL treatment resulted in a restoration of the natural appearance of the nose without side effect during 18 months after treatment. Conclusion: The described clinical case demonstrates excellent results of the management of rhinophyma by means of the scanned CVL. CVL treatment was associated with the removal both of dysplastic superficial skin vessels, the solution of the inflammation, decline of the sebum production and the disappearance of the nasal hypertrophy.

Treatment of rhinophyma using a copper vapor laser

Background. Rhinophyma is considered to be the most severe stage of rosacea, associated with the proliferation of the nose skin epithelium, hyperproduction of the sebaceous glands and telangiectasia.The treatment of rhinophyma remains a difficult task. One of the problems associated with rhinophyma is thickened and lumpy skin, penetrated with telangiectasias. The use of laser radiation in the treatment of rhinophyma seems to be promising, since this method allows blood vessels to be selectively heated.For the first time, we describe the treatment of rhinophyma using a copper vapour laser (CVL) equipped with a computerized scanner.Patient description. A 63-year-old male with Fitzpatrick skin type II was treated using an CVL (‘Yakhroma-med' model, RaS P. N. Lebedev Physical Institute). The clinical manifestations of the disease were typical of the phymatous or hypertrophic rhinophyma type, including significant thickening of the tissues and an uneven roughness of the skin surface. The treatment was carried out using a radiation wavelength of 578 nm, exposure duration of 0.2 s and energy exposure (fluence) of 15-30 J/cm2. Operational parameters used for the CVL in the scanner mode were the average power of 0.6-1.2 W and the focusing size of the light spot on the skin of 0.6 mm. The hexagonal mode of the scanning head was used with a maximum size of 12 mm and 1 mm distance between the centres of the laser spots. The treatment resulted in the restoration of the natural nose shape without redness. No side effects were noted.Conclusion: CVL radiation provided a selective photodisruption of the vessels with increased diameter.Due to the remodelling of the vasculature, the described method showed excellent results in the treatment of rhinophyma without side effects.

Procedural management of rhinophyma: A comprehensive review

BACKGROUND

Rhinophyma is a cosmetically deforming disease characterized by nodular overgrowth of the lower 2/3 of the nose and is considered the end stage of acne rosacea.

AIMS

Review the spectrum of procedural techniques for treatment of rhinophyma with a focus on the advantages and disadvantages of each modality.

METHODS

A comprehensive literature search was conducted using the search terms "rhinophyma," "treatment," and "surgery" in PubMed. Case reports, case series, and small retrospective trials using procedural techniques for management of rhinophyma were included for review. Animal studies, non-English articles, and reports of medical treatment of rhinophyma were excluded.

RESULTS

There are currently no prospective, randomized controlled studies evaluating procedural management of rhinophyma. The most commonly employed treatments include scalpel excision, resection with heated knives, dermabrasion, electrosurgery and lasers, specifically carbon dioxide (CO₂ ) and erbium:yttrium-aluminum-garnet (Er:YAG). The main complication associated with complete excision of rhinophymatous tissue is excessive scarring. To correct for this adverse effect, partial or tangential excision with preservation of underlying adnexal structures is now the accepted technique, irrespective of the chosen modality.

CONCLUSION

There is no accepted gold standard for management of rhinophyma, and each modality succeeds in maintaining hemostasis, reducing scarring and achieving satisfactory cosmesis to different degrees. There is a conflicting data on the theoretical risk of recurrence with partial excision due to incomplete removal of tissue. Further studies evaluating this risk and alternate methods of prevention are required.

Early Cosmetic Results and Midterm Follow-up Findings of Rhinophyma Patients Treated With High-Frequency Electrosurgery and a Discussion on the Severity Assessment of the Disease

BACKGROUND

Different methods can be used in the surgical treatment of patients with rhinophyma. There are limited numbers of reports on high-frequency electrosurgery treatment. In addition, an efficient scoring system is required to evaluate severity of the disease in clinical progress and recurrence after treatment.

OBJECTIVES

We evaluated patients with rhinophyma who were treated with high-frequency electrosurgery and discussed the methods used to assess severity of the disease.

METHODS

Data and photos of 13 patients were retrospectively evaluated and scored via 2 different forms of the rhinophyma severity index.

RESULTS

Median rhinophyma severity index scores of patients at first visits were significantly higher than those at second and third visits ( P = .002 and P = .002, respectively). Likewise, median modified rhinophyma severity scores of patients at first visits were significantly higher than those at second and third visits ( P = .001 and P = .001, respectively). Also, there was a strong positive correlation between these 2 assessment methods ( r = 0.838, P < .001).

CONCLUSIONS

The rhinophyma severity assessment methods used in this study are positively correlated. High-frequency electrosurgery seems to be a procedure that is safe, effective, and relatively cost-effective in the treatment of rhinophyma lesions.

Update on the Management of Rosacea

Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Update on the management of rosacea

Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Fractionated carbon dioxide laser therapy as treatment of mild rhinophyma: report of three cases

Rhinophyma is a bothersome condition of the nose that is regarded as a manifestation of rosacea (subtype 3). Whereas the efficacy of medical treatments, including antibiotics and retinoids, is often dissatisfying, conventional invasive procedures are limited by their unfavorable side effect profile. We present three patients who were treated by a minimally invasive approach using fractionated carbon dioxide (CO2) laser therapy, showing variable response. We observed that fractionated CO2 laser therapy may improve patient-reported outcome in some patients with mild rhinophyma and is associated with a relatively favorable side effect profile compared with conventional surgical techniques.

Rosacea and rhinophyma

Rosacea is a common and chronic inflammatory cutaneous disease with unknown etiology. The pathophysiology of rosacea is still poorly understood. Epidemiological studies indicate a genetic component, but a rosacea gene has not been detected yet. Recent molecular studies propose that an altered innate immune response is involved in the pathogenesis of the rosacea disease. Signs of rosacea are indicated by the presence of characteristic facial or ocular inflammation involving both the vascular and tissue stroma. A wide range of drug options is available for the treatment of rosacea, including several topical ones (metronidazole, antibiotics, azelaic acid, benzoyl peroxide, sulfacetamide/sulfur, retinoids) and oral ones (mainly tetracyclines, metronidazole, macrolides, isotretinoin). This review highlights the recent clinical and pathophysiological developments concerning rosacea.

Rhinophyma: Excision and Reconstruction with Local Nasolabial Flap

Rhinophyma is a rare disease which causes disfiguring soft tissue hypertrophy of the nose. Various medical and surgical treatment modalities have been proposed and tried with varying degree of success. We report a case where we adopted excision of the rhinophymatous tissue and reconstructed with the local nasolabial flap. The result was cosmetically good enough and the procedure technically simple.

Rhinophyma: Carbon dioxide laser with computerized scanner is still an outstanding treatment

The cosmetic deformity produced by rhinophyma is characterized by nodular hypertrophy of the nasal skin. A retrospective review and analysis of nine consecutive patients with moderate and major rhinophyma treated with scanned carbon dioxide laser was performed. A particular method of continuous scanner use is described. This report demonstrates excellent cosmetic results and no major postoperative complications or recurrence of the condition after 1 year of follow up for seven patients. Two more patients had been followed up for 1 month at the time this paper was written. Scanned carbon dioxide laser is safe and highly effective treatment for rhinophyma.

Gnatophyma and Otophyma

Background:

Phymas are slowly progressive, disfiguring disorders of the face and ears that represent the end stage of rosacea. The most common phyma is rhinophyma, yet similar swellings may occur on the chin (gnatophyma), forehead (metophyma), one or both ears (otophyma), and eyelids (blepharophyma).

Objective: Unlike rhinophyma, otophyma is rarely seen. We report two rare phymas:

a case of gnatophyma and a case of otophyma.

Methods:

A 56-year-old African American man presented with a history of bumps on his chin that had begun about 7 years earlier. Physical examination was remarkable for lobulated plaques on the chin, coalescing into hypertrophic nodules and dilated pores. A 73-year-old African American male presented with bilateral cauliflower-like earlobe growths for the past 17 years.

Results:

A skin biopsy was performed for each patient demonstrating cystic follicular dilatation with keratin plugging, dermal scarring, psoriasiform epidermal hyperplasia, and chronic inflammation of some of the follicles.

Conclusion:

This case report describes a relatively rare gnatophyma and otophyma. Surgical management is well accepted as the best mode of therapy to treat rhinophyma and is becoming a first-line treatment for all phymas.

Combined carbon dioxide laser and bipolar electrocoagulation: another option to treat rhinophyma

Rhinophyma is a progressive and disfiguring disorder of the nose characterized by hyperplasia of the sebaceous glands and dermal tissue, representing the end-stage of rosacea. Four male patients affected by a moderate-severe rhinophyma were treated using a combined therapy with carbon dioxide laser and bipolar electrocoagulation. All patients achieved marked cosmetic results with minimal scarring. Various surgical approaches have been described to treat this condition but as yet there is no agreement in the literature on the ideal treatment. This combined method provides a bloodless operative field which allows the sculpting of the hypertrophic areas, leading to a good cosmetic outcome and a pain-free postoperative recovery.

Lasers and optical technologies in facial plastic surgery

Lasers and optical technologies play a significant role in aesthetic and reconstructive surgery. The unique ability of optical technologies to target specific structures and layers in tissues to effect chemical, mechanical, or thermal changes makes them a powerful tool in cutaneous rejuvenation, hair removal, fat removal, and treatment of vascular lesions such as port-wine stains, among many other procedures. With the development of adjunct techniques such as epidermal cooling, lasers and optical technologies have become more versatile and safe. The constant improvement of existing applications and the emergence of novel applications such as photodynamic therapy, nanoparticles, spectroscopy, and noninvasive imaging continue to revolutionize aesthetic medicine by offering a minimally invasive alternative to traditional surgery. In the future, therapies will be based on individualized, maximum, safe radiant exposure to deliver optimal dosimetry. Lasers and optical technologies are headed toward safer, easier, more quantifiable, and more individualized therapy.

Surgical management of extensive gnathophyma

Rhinophyma is an uncommon disease of the nose characterized by irregular skin thickening and nodular deformation. The extensive growth causing 'whisky nose' is due to hyperplasia of the sebaceous glands and the surrounding connective tissue. Other facial regions may concomitantly be affected. We present a case of extensive gnathophyma accompanying minor lesions of the nose. Surgical treatment led to an excellent cosmetic result.

Rosacea and its management: an overview

BACKGROUND

Rosacea is a chronic inflammatory disorder that affects 10% of the population. The prevalence of rosacea is highest among fair-skinned individuals, particularly those of Celtic and northern European descent. Since a cure for rosacea does not yet exist, management and treatment regimens are designed to suppress the inflammatory lesions, erythema, and to a lesser extent, the telangiectasia involved with rosacea.

OBJECTIVES

This review outlines the treatment options that are available to patients with rosacea.

METHODS

Published literature involving the treatment or management of rosacea was examined and summarized.

RESULTS

Patients who find that they blush and flush frequently, or have a family history of rosacea are advised to avoid the physiological and environmental stimuli that can cause increased facial redness. Topical agents such as metronidazole, azelaic acid cream or sulfur preparations are effective in managing rosacea. Patients who have progressed to erythematotelangiectatic and papulopustular rosacea may benefit from the use of an oral antibiotic, such as tetracycline, and in severe or recalcitrant cases, isotretinoin to bring the rosacea flare-up under control. Treatment with a topical agent, such as metronidazole, may help maintain remission. Patients with ocular involvement may benefit from a long-term course of an antibiotic and the use of metronidazole gel. A surgical alternative, laser therapy, is recommended for the treatment of telangiectasias and rhinophyma. Patients with distraught feelings due to their rosacea may consider cosmetic camouflage to cover the signs of rosacea.

CONCLUSIONS

With the wide variety of oral and topical agents available for the effective management of rosacea, patients no longer need to feel self-conscious because of their disorder.

The gold standard for decortication of rhinophyma: combined erbium-YAG/CO2 laser

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.

Use of a Dual-Mode Erbium:YAG Laser for the Surgical Correction of Rhinophyma

Rhinophyma is a cosmetically deforming disorder characterized by nodular hypertrophy of the nasal soft tissue. Treatment of rhinophyma usually consists of laser ablation or surgical excision for correction of the associated tissue deformity. We describe 6 patients with mild to severe rhinophyma who were treated with a dual-mode erbium:YAG (Er:YAG) laser, which provides the advantages of controlled ablative energy for tissue reduction and excellent intraoperative hemostasis. Outcome measures included patient satisfaction, clinician observer ratings, and an assessment of complications, including scarring, pigment abnormalities, and postoperative bleeding. All patients were satisfied with their outcomes, and no complications were detected during follow-up. All treatment outcomes were rated as very good to excellent at a 3-month follow-up visit. The flexibility of the dual-mode Er:YAG laser provides both controlled ablation and hemostasis, making it an ideal laser for the surgical treatment of rhinophyma.

Laser treatment of rosacea

Rosacea is a common condition often resulting in persistent erythema and telangiectasia as well as rhinophyma in a number of patients. Over the last two decades lasers have been increasingly used in the treatment of these permanent changes. The literature is reviewed in terms of the different laser systems, side-effects and comparison with other surgical techniques. Laser studies on rosacea-associated telangiectasia and erythema are limited. Copper-bromide, krypton and KTP lasers have been used with good to excellent results. However, the most commonly applied system is the flash lamp-pumped pulsed dye laser. Rhinophyma can be treated with a variety of different surgical methods, including laser resurfacing. CO(2) lasers are the most widely used lasers, others are the Er:YAG and Nd:YAG lasers. Cosmetic end results are comparable to partial excision with a scalpel or electrosurgery. There does not appear to be an increased risk of infection or scarring, but the conventional surgical methods are quicker to perform and more cost effective.