Why is my nose so large and red?
If you’ve been living with rosacea, you’re probably accustomed to looking in the mirror and seeing rosy cheeks, a telltale symptom of the inflammatory skin condition that affects 16 million people. Rosacea often begins with persistently pink cheeks or flushing, in which your face gets suddenly hot and red. People with rosacea may also have what looks like acne, known as rosacea acne, on their face.
If your nose is red, as well, it could be you have what’s known as rhinophyma.
Some people with rosacea develop will begin to grow excess skin tissue—a type known as phymatous rosacea. It’s this growth that can lead to a large, bulbous nose (rhinophyma) though the growth can occur on the ears, chin, forehead, or even the eyelids. “This is considered the end stage of rosacea,” says Lauren Fine, MD, a dermatologist at Chicago Cosmetic Surgery and Dermatology. “It is rare and can be disfiguring.”
What is phymatous rosacea?
A common misconception is that this large red nose is caused by too much alcohol consumption, a stigma that can make the condition even more difficult to live with. Rhinophyma may even affect breathing through the nose.
Fortunately, phymatous rosacea—one of four types of rosacea—isn’t common. “Patients who have fixed redness of the face due to rosacea, or who have papules and pustules [aka pimples] of rosacea will not necessarily progress to have phymatous changes,” says Yolanda Helfrich, MD, a dermatologist and associate professor of dermatology at the University of Michigan. “Many patients worry most about developing these types of changes, but most will never develop a phyma.”
Even if it happens, though, there are surgical methods for phymatous rosacea that are effective. “It can be a challenging condition to treat, but there are multiple options that can improve the overall appearance of the area,” Dr. Fine says. “Close management by a board-certified dermatologist can best determine treatment options.”
Here’s what you need to know about the rare skin condition.
What does phymatous rosacea look like?
“Phymatous rosacea looks like thickened, irregular skin,” Dr. Helfrich says. “Often the pores look larger. Sometimes phymatous rosacea can be redder in color than normal skin; however, sometimes it has a normal skin color.” A rhinophyma also may appear waxy or yellow.
Phymatous rosacea most commonly involves the nose, but doctors also see phymas of other areas like the forehead, chin, cheeks, or even the ears, she says. These phymas are one of the diagnostic criteria of rosacea, according to a study published in 2018 in the Journal of the American Academy of Dermatology (JAAD). Once your doctor spots one, a diagnosis of rosacea can be made right away.
Who gets phymatous rosacea?
Women are much more likely to get rosacea than men, but it tends to be more severe in men. In a survey of 2,000 rosacea patients, men were more than twice as likely to experience rhinophyma than women. “Phymatous changes are rarer in women,” Dr. Helfrich says. But, “it is not known why men are more likely to develop phymas than women.”
One hypothesis suggests male hormones may play a part. In both men and women, rosacea tends to affect people in middle-age with fair skin, but dark-skinned people can also have rosacea.
What causes phymatous rosacea?
The underlying causes of rosacea aren’t well understood. But they have to do with inflammation in the skin and hyperactive blood vessels that dilate, allowing more blood in and causing the redness. Rosacea may be caused by a combination of genetic factors and “triggers” in the environment, which may include spicy foods, alcohol, temperature changes, strong emotions, or sunlight.
As for the phymatous growths themselves, “these changes are due to enlargement of the oil glands, or sebaceous glands, and increased amounts of connective tissue, or collagen, in the skin,” Dr. Helfrich says. “Inflammation in the skin likely drives this process.”
Phymatous rosacea is usually thought of as an advanced form of the condition, but that might not necessarily be the case, suggests a study published in a 2017 issue of JADD. “Though the changes in the skin associated with phymatous rosacea are similar to changes of more inflammatory rosacea, it’s not clear that there is a progression from other forms of rosacea to phymatous rosacea,” Dr. Helfrich says.
Phymatous rosacea and alcohol
There’s a myth about phymatous rosacea and alcohol. One of the fallacies with the bulbous nose is that “people think that means you drink too much,” says Mona Gohara, MD, a dermatologist in Connecticut and an associate clinical professor in the department of dermatology at Yale School of Medicine. “So if you have a glass of wine, people feel like, ‘I’m going to get that bulbous nose, and that means people are going to say I’m an alcoholic.’ There’s a stigma to it.”
The late comedian W.C. Fields was famous for his red, bulbous nose, which was due to rosacea—and for enjoying alcohol. That may have fueled the cause-and-effect perception. Fields reportedly called the red bumpiness on his nose “gin blossoms.” Rhinophyma has also been called “whiskey nose,” “rum nose,” or “drinker’s nose.” Even further back, authors Shakespeare and Chaucer featured characters with bumpy red noses who liked to imbibe alcohol.
But phymatous rosacea does not indicate alcoholism: “A phyma does not mean you drink too much—it’s just that sometimes alcohol is a trigger,” Dr. Gohara says. A small observational study of 52 phymatous rosacea patients, published in 2019 in JAAD, found that excessive drinking was linked with more severe cases of rosacea. Although this doesn’t prove a direct effect, it could suggest that alcohol makes phymatous rosacea worse.
Phymatous rosacea treatments
Treating phymatous rosacea with topical or oral medications is very difficult, Dr. Helfrich says. “Oral antibiotics like doxycycline may have a minimal effect, due to their anti-inflammatory effects,” she says. “Isotretinoin [known by the discontinued brand Accutane] has been used and has been noted to occasionally be helpful.”
This oral medication works by shrinking the oil (sebaceous) glands, but only works for as long as you take it, according to a study in a 2017 issue of Dermato-Endocrinology. Plus, isotretinoin can only prevent phyma from getting worse; it can’t get rid of what already exists. “Medical treatments are unlikely to alter the thickened collagen or the more sebaceous look of the skin,” Dr. Helfrich says. In addition, “we do not know of any treatments that can prevent these changes.”
However, “if there are pimple-like bumps overlying the [phymatous] rosacea, medical treatments could potentially address those changes,” Dr. Helfrich says.
“The best treatments are surgical remodeling, including aggressive dermabrasion, CO2 laser, or other surgical techniques,” Dr. Helfrich says. Depending on the type of treatment, recovery typically takes several weeks, she says.
“Scalpel excision and electrosurgery using high-frequency current are often the most effective modalities of treatment,” Dr. Fine says. “Electrosurgery is a procedure under local anesthesia that uses a high-frequency current to remove the thickened portions of tissue. Scalpel excision involves using a surgical blade to manually remove the tissue under local anesthesia. These are procedures that are usually done as a series of multiple treatments.”
A quick word about surgery
Before attempting surgery, your doctor will probably make sure your overall rosacea is being addressed. “While these [surgical] procedures can offer permanent solutions, it is imperative that the underlying rosacea is under control so the condition does not progress,” Dr. Fine says. “This can be done with oral medications such as doxycycline and isotretinoin at varying doses.”
Recovery from surgery can take anywhere from days to weeks of downtime depending on the type of procedure, Dr. Fine says. And it may be a bit rough. “Treated areas can be painful and recovery often involves extensive wound care of the areas,” she says. But, it may help restore your appearance. “In some cases, the skin will never return to normal. However, these treatments can make dramatic improvements.”
There isn’t too much you can do at home to prevent or treat phymatous rosacea specifically. However, there are some things that may make rosacea better in general. Avoiding triggers is perhaps the most important: If you have flare-ups when you eat spicy food or drink alcohol, for example, limit those. You should also wear sunscreen daily to prevent the sun’s rays from irritating the skin.
In addition, a gentle skin care routine for rosacea is important. For men with rosacea, shaving also presents a challenge. The National Rosacea Society suggests switching to an electric razor to avoid the irritation from dull razor blades. Also, be careful with shaving products as they could be bothersome to the skin, and moisturize after shaving.
If you have already been diagnosed with rosacea, follow your doctor’s treatment plan to keep the condition under control. And stick with your medications to slow the development of skin thickening, says Lisa Anthony, MD, a dermatologist at Westmed Medical Group in Westchester, New York. “Treating rosacea when it is milder with prescription medicines, including oral antibiotics, can prevent these chronic phymatous changes,” Dr. Anthony says. “Once the thickening is present, one may consider laser resurfacing or even surgery to improve the appearance.”