Pictorial Case Study - rhinophyma

THE CASE 
This 64-year-old man was becoming embarrassed by the appearance of his nose. Friends were remarking on it and suggesting that he was imbibing too much alcohol - an accusation that he strongly denied. He had no other health problems. On examination, his nose was red with a bulbous appearance. Because of sebaceous gland hyperplasia, the skin was thickened with prominent pores, and it had a waxy yellow, 'bumpy' surface. His face was flushed and there were some telangiectases on the cheeks, suggesting that there was a problem of rosacea. What is the diagnosis, management and differential diagnosis?

DIAGNOSIS AND MANAGEMENT
The diagnosis of rhinophyma seemed clear, especially in view of the additional feature of rosacea on his cheeks. Antibiotics such as tetracycline or erythromycin do not usually have much effect on rhinophyma but in view of the rosacea he was prescribed a course of lymecycline.He was referred to a plastic surgeon who agreed to perform a surgical reshaping of the patient's nose but warned him that subsequent recurrence of the condition was possible. One year later, all is well.

POSSIBLE DIFFERENT DIAGNOSIS

  • Lupus pernio (sarcoidosis).
  • Acne vulgaris.
  • Photodermatitis.
  • Drug eruptions.

 

DIFFERENTIAL DIAGNOSIS
Lupus pernio

  • Is a cutaneous manifestation of sarcoidosis.
  • Large bluish red or purple, infiltrated nodules may be seen on the nose, cheeks, ears, fingers and toes.
  • Diagnosis confirmed by biopsy of a lesion.
  • Papules and nodules resolve spontaneously over months/years.
  • May or may not have other manifestations of sarcoidosis in the eye, liver, heart or nervous system.

Dr Jean Watkins, a GP in Ringwood, Hampshire 

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