Amyloidosis Complicating Rhinophyma

Aesth. Plast. Surg. 28:98–99, 2004 DOI: 10.1007/s00266-004-3104-8

Amyloidosis Complicating Rhinophyma V. Nanda, B. K. Garg, R. Chittoria, G. Biswas, and R. K. Sharma Chandigarh, India

Abstract. Rhinophyma is the advanced stage of acne rosacea and a source of embarrassment for the patient. Secondary localized cutaneous amyloidosis complicating rhinophyma is not reported in the literature. A patient with rhinophyma was treated by excision and primary closure. The histologic examination showed amyloidosis. Key words: Rhinophyma—Secondary amyloidosis.

Introduction Amyloid deposits may occur throughout many organs of the body (systemic amyloidosis), or may be restricted to a single tissue site (localized amyloidosis). Amyloidosis secondary to chronic inflammatory conditions such as rheumatoid arthritis, Reiter’s syndrome, and systemic lupus erythromatosus is well known. Local amyloidosis secondary to rhinophyma is largely unreported. We present the case of a patient who underwent excision and primary closure of rhinophyma, with histopathologic examination showing amyloidosis of the nose.

markable. He was offered either excision and resurfacing with split-skin graft or dermabrasion with the attendant risk of delayed healing. The patient refused both options, expressing that only the downward projecting growth of the nasal tip was a major embarrassment for him. The patient was treated with surgery under local anesthesia with sedation. The pattern of skin enlargement was found amenable to excision and primary closure. Two lateral dorsal nasal flaps were raised, and both flaps were conservatively undermined. The palecolored hypertrophied tissue under the skin and above the cartilage was excised. Excessive skin was trimmed, and primary closure was performed. Postoperatively, the patient had marginal superficial necrosis of one lateral flap, which was managed by dressings. He healed fully by 2 weeks. At the 1year follow-up assessments, the tip was well-defined. At this writing, the scar is barely perceptible and the patient is fully satisfied (Figs. 3 and 4). Histopathologic examination showed marked hypertrophy–hyperplasia of the sebaceous glands, fibrovascular proliferation of the dermis, and a subcutaneous deposit of amyloidosis (Congo Red stain– positive). The patient was screened by the internist for systemic amyloidosis, and no abnormality was detected.

Case Report A 40-year-old healthy Sikh gentleman presented to us reporting enlargement of his nose that had gradually increased for the preceding 5 years. He had a bulbous enlargement of the nasal tip area, (Figs. 1, and 2). The skin of the nose and the adjoining cheek showed enlarged pores attributable to hypertrophied sebaceous glands. The man’s medical history was unreCorrespondence to V. Nanda, Department of Plastic Surgery, Postgraduate Institute of Medical, Education and Research, Chandigarh 160012 India; email: vipulnanda@ rediffmail.com

Discussion Rhinophyma is recognized clinically by bulbous enlargement of the nose with erythematous skin containing grossly hyperplastic sebaceous glands. Rhinophyma is 12 times more common among men than among women [1]. Partial-thickness excision of rhinophyma was suggested by Stromeyer [5]. This was later termed ‘‘decortication’’ by Ollier [3,4], and included sparing of the perichondrium and cartilage. Dermabrasion is one of the established treatment methods. However, the patient’s occupation did not allow a prolonged break from work. We therefore,

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Fig. 1. Preoperative anterior view. Fig. 2. Preoperative lateral view. Fig. 3. Anterior view 1 year after operation. Fig. 4. Lateral view 1 year after operation.

planned excision and primary closure using two lateral flaps. The pattern of enlargement was found amenable to such excision. The key is to avoid thinning the skin flaps because the vascularity of the nasal skin in such cases is less than ideal. The histologic picture of rhinophyma is one of marked hypertrophy-hyperplasia of sebaceous glands, fibrovascular proliferation in the dermis, and acanthosis of the epithelium [4]. Histologic examination of nasal skin in the reported patient showed amyloid deposits, which were confirmed with Congo-red dye. The authors suggest that the plastic surgeon should keep the possibility of this rare diagnosis in consideration, and further emphasize the importance of routine histopathologic examination for essentially benign conditions. Deposition of localized amounts of amyloid in relation to a variety of cutaneous lesions is the most common type of localized cutaneous amyloidosis. The predisposing conditions that have been reported include intradermal nevi, sweat gland tumors, pilo-

matrixoma, dermatofibroma, seborrheic keratosis, solar elastosis, Bowen’s disease, basal cell carcinoma, and pulsed ultraviolet actinotherapy [2]. Secondary localized cutaneous amyloidosis complicating rhinophyma is largely unreported. References 1. Barton FE Jr, Byrd HS: Acquired deformities of nose In: Mcarthy JG ed Plastic surgery Philadelphia, WB Saunders, 1990 2. Breathnach SM, et al.: Amyloidosis of skin In: Fitzpatrick BT eds Dermatology in general medicine McGraw-Hill, New York, 1993 3. Oilier L: Application de I’osteoolastic a la re’stauration du nezi transplantation du perioste frontal. Bulk Gen Therapeut 61:510, 1861 4. Oilier L: Technique of rhinoplasty. Bill Mean Soc Chis (Paris) 3:184, 1875 5. Stromeyer: Quoted in Joseph J: Naruplastic Lwipzig. Kabitzsch 1931, 1864