Rhinophyma treatment. Rhinophyma: causes, symptoms, diagnosis, treatment

• unfavorable environmental conditions (high dust content, high air humidity, abrupt temperature changes, hypothermia, prolonged exposure to high temperatures (for example, in the sun));
• alcohol abuse;
• chronic diseases of the gastrointestinal tract;
• endocrine diseases (hormonal disorders caused by diseases of the thyroid, pancreas, etc.);
• chemotherapy (for cancer);
• autoimmune diseases (diseases that develop as a result of pathological production of antibodies (protective cells of the human immune system) against healthy tissues; healthy tissues are perceived as foreign and destroyed by their own immune system);
• gender (the disease is typical for men over 40 years old);
• hypovitaminosis;
• stressful situations;
• dietary errors.

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Symptoms and course of the disease

Outwardly, rhinophyma looks like a growth, this is due to hypertrophy and hyperplasia of the skin of the nose. The growth can be single or in the form of nodes, then nodular rhinophyma is diagnosed. Due to dilated vessels, the color of hypertrophied nodes can vary from red to dark brown and purple.

Large sebaceous glands and follicles are clogged with keratin, the area affected by rhinophyma is a lymphatic interfollicular inflammatory infiltrate. If the rhinophyma progresses, then granulomas are observed and often the giant sebaceous glands are emptied into the normal sinus.

With rhinophyma, it is clearly seen that most of the hypertrophied tissue consists of dilated vessels with thin walls. Skin affected by rhinophyma is more susceptible to the development of neoplasms.

Rhinophyma occurs in several varieties.

1. Granular (glandular) forms are diagnosed more often, the growths of the skin of the nose in this case outwardly look like rough knots. The consistency of the nodes is soft, and the surface of the area affected by rhinophyma is glossy greasy with a bluish and less often purple tint. The fibrous form of rhinophyma is less common, with this form the skin layers are also hypertrophied, but the skin is dense, which retains the configuration of the nose. The surface is smooth, shiny from enlarged pores, sebum may be released, which, when interacting with air, acquires an unpleasant odor. On palpation, pronounced hyperplasia of the sebaceous glands of various densities is felt.
2. Fibroangiomatous rhinophyma is clinically similar to the fibrous form of rhinophyma, but the nodes are more elastic and soft on palpation. Due to the large number of telangiectasias, the surface of the nose has a dark red color. This form of rhinophyma is differentiated from the rest by the presence of a large number of superficial and deep pustules. The content of the pustules is bloody-purulent, which shrinks into crusts as it is evacuated. Patients, in addition to shortness of breath, complain of itching, soreness and paresthesia.
3. Fibrous: the affected skin of the nose is smooth, thickened, enlarged (swollen), bluish-violet. The skin takes on a rough appearance.
4. The actinic form of rhinophyma has a more benign course, the layers of the dermis thicken evenly and slightly, the nose acquires a cyanotic color, telangiectasias are localized mainly on the wings of the nose. With this form of rhinophyma, there are no pustules, and the mouths of the sebaceous glands are slightly dilated, as a result of which sebum is separated moderately without the formation of crusts on the surface of the nose. The main pathogenetic component of actinic rhinophyma is actinic elastosis.

The course of rhinophyma is long, with a series of stages of remission of the process and stages of active growth. As a rule, active growth of rhinophyma is observed in the first years of the disease, after a few years the growth may completely stop, but the reverse development of rhinophyma is not observed.

Rhinophyma makes nasal breathing difficult, and with a huge size and food intake, despite the fact that the pathological process does not affect the cartilage, the pressure from the overgrown rhinophyma on them is so great that the nasal cartilages are deformed or undergo complete destruction.

The disorders caused by rhinophyma are mainly reduced to a cosmetic defect. Hypertrophic growths noticeably disfigure the patient's face, so it is important to treat a characteristic ailment at an early stage, trying to preserve your usual face. If this is not done, then among the possible complications it is worth highlighting the psychological trauma, which is directly related to the acquired external deformities.

As a rule, the disease is benign in nature, and only in isolated cases is the degeneration of this disease into a malignant formation described.

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Treatment of the disease

Conservative treatment

With the diagnosis of "rhinophyma" an integrated approach to the problem is required, which will slow down the course of the pathological process. So, they distinguish not drug and drug treatment, but also surgical intervention, which is appropriate strictly according to indications. The doctor can determine the treatment regimen only on a purely individual basis, based on the characteristics of the course of inflammation in the affected organism.

Among non-drug methods of treatment, it is worth highlighting electrocoagulation, which can rapidly destroy telangiectasia, papular and papular-pustular structures. A more modern method of treating rhinophyma is a long-wave laser, which has a sparing effect on the focus of pathology.

Drug treatment is appropriate at an early stage of the disease, when medications that improve skin microcirculation show a tangible therapeutic effect. In addition, they are complemented by drugs that eliminate the process of digestion, and hormone therapy in particularly difficult clinical pictures. Among the medicines for topical use, it is worth highlighting the Antineoderm S-A phyto-ointment and boric baths.

Surgery

However, the conservative method of treatment is not always highly effective, and in the absence of positive dynamics of the disease, immediate surgical intervention is indicated.

Among the most relevant procedures, surgeons distinguish the following:

• laser electroscalpel surgery;
• The radio wave method in the treatment of rhinophyma allows you to quickly and effectively eliminate all clinical manifestations and restore the shape of the nose. With this treatment, there is practically no blood loss, no swelling, the likelihood of postoperative complications is minimal, and the rehabilitation process is short;
• dermabrasion, where the epidermis and papillary dermis are removed. Dermabrasion of the skin area affected by rhinophyma gives good results with minor tissue growths and in the initial periods of the disease;
• decortication consists in cutting off all hypertrophied parts with a sharp knife or narrow razor. Cut off only the hypertrophic parts. The sebaceous glands must be spared so that after the operation, a cover is formed from the epithelium of their excretory ducts for the surface exposed after the operation. If this precaution is not observed, it would be necessary to resort to artificial epithelialization of the wound surface by means of flaps transplanted along Tiersch, which is much more difficult;
• plastic surgery of the affected area of ​​the nose;
• wedge-shaped excision of affected tissues followed by suturing is indicated for deep lesions of the nasal skin and when it is impossible to use other methods of surgical treatment of rhinophyma. Wedge-shaped excision consists in the following: wedges are cut out from the wings of the nose in the entire thickness of the wings and then the edges of the incisions are sutured. The septum of the nose is first separated from the wings in a bloody way, then the necessary wedges are cut both along the wings of the nose and across it, and finally, the edges of the wound are sutured, the septum is sewn to its former place.The disadvantage of this method is the possibility of stenosis of the nasal openings. In addition, the method is not always applicable, but only in the presence of individual lobed growths;
• subcutaneous extirpation of the newly formed connective tissue - a transverse incision is made from the point of attachment of one wing of the nose to the corresponding place of the opposite side. A longitudinal incision along the midline of the nose is attached to this incision. Three flaps with wide bases are obtained: two lateral and one lower. Hypertrophied connective tissue is carefully extirpated from under these flaps, after which the edges of the incisions are sutured;
• complete removal of abnormal nodes.

The essence of the operation is to eliminate tuberosity and remove excess glandular tissues that caused the patient's external deformity. However, after such surgical actions, a long-term rehabilitation is shown, which allows you to partially restore the naturalness of your appearance.

It is important to understand that the success of the clinical outcome is relevant only in those clinical pictures where the course of the pathological process was detected at the initial stage. Neglected external deformities and cosmetic defects are not even subject to surgical treatment, but remain with the patient until the end of life. Form loading..." data-toggle="modal" data-form-id="42" data-slogan-idbgd="7308" data-slogan-id-popup="10614" data-slogan-on-click= "Calculate treatment cost AB_Slogan2 ID_GDB_7308 http://prntscr.com/merhh7" class="center-block btn btn-lg btn-primary gf-button-form" id="gf_button_get_form_171824">Calculate treatment cost

Large, bumpy, atypical, growing with time and far from aesthetic appearance, the noses were previously considered a punishment of God, in fact, this is nothing more than a disease called rhinophyma. Rhinophyma develops on the skin of the nose, in rare cases it passes to the cheeks, ears or chin. Due to the increase in the sebaceous glands and blood vessels, the nose is covered with peculiar tubercles, which grow over the years, causing itching and forming unpleasant outgrowths. It is not excluded the allocation of pus. Some severe cases lead to loss of the ability to breathe and see.

Causes and background

What are the specific causes of the disease? There is no single point of view: some believe that rhinophyma is neglected rosacea, others interpret it as a separate disease.

Based on practice and statistics, the risk group is:

• people whose age ranges from 40 to 60 (often men), fair-skinned and fair-haired;
• people suffering from endocrine diseases, as well as those whose relatives have experienced rosacea.

What are the prerequisites?

1. Firstly, these are living conditions: frequent weather changes, excessive hypothermia.
2. Secondly, insufficient concentration of moisture or its excess in the air.
3. Thirdly, chemotherapy, as well as diseases associated with the gastrointestinal tract.
4. Another favorable factor for the development of rhinophyma is alcoholism.

The disease itself is sluggish in nature, but sometimes it can develop quite quickly. Usually for several years the nose is covered with growths, deformation occurs.

Dilated vessels can contribute to the appearance of various shades of the skin of the nose: crimson, pink, bright red, purple.

Rhinophyma is divided into types:

• glandular;
• actinic;
• fibrous;
• fibrous-angiectatic.

They are distinguished by the increase in certain tissues and the color that the nose eventually acquires.

Diagnostics

It is recommended to consult a dermatologist. Medical diagnosis of the disease is usually easy, as it has visual signs. After a general examination, a biopsy follows, and after a histological examination, aimed at identifying the type of rhinophyma.

Remember that rhinophyma can become malignant.

Treatment of rhinophyma

There are several types of treatment for rhinophyma, depending on the stage.

Please note that traditional medicine is useless.

At first, the disease manifests itself weakly, but noticeably. A characteristic roughness appears on the skin, accompanied by vasodilation, therefore, at this stage, the treatment is carried out by medication. Prescribe drugs that improve skin microcirculation, medicinal solutions. In addition to them, you need to adjust your lifestyle and nutrition, use phototherapy.

The last stages are characterized by a pronounced outgrowth, which implies direct cosmetic intervention.

Depending on the size, different methods of removal are offered:

1. Dermabrasion. This method is good for minor neoplasms on the nose. It consists in mechanical grinding of the fabric, so that instead of the old layer that is removed, a new one appears. The disadvantages of this method are a long postoperative period aimed at recovery.
2. laser surgery. The main tool is a laser, which helps shape the shape of the nose by evaporating tissue. A week later, active skin recovery begins.
3. radio wave surgery. The treatment is carried out using radio waves. This method is remarkable in that it eliminates blood loss, and is also a procedure that takes place without complications. Signs of recovery appear within a week.
4. Conventional surgery. Previously, this method of solving the problem of rhinophyma was in demand and popular, but with new technologies it is becoming a thing of the past.

Other methods of destruction: cryosurgery, ultrasound.

It is best to get rid of rhinophyma under internal anesthesia, as the operation will be accompanied by unpleasant irritants.

Rhinophyma removal (video)

Prevention of rhinophyma

For prevention, you must follow a few simple rules:

• Sun exposure should be kept to a minimum and sunscreen should be avoided.
• Long stay in places where there is a risk of a sharp increase or decrease in temperature is prohibited.
• It is advisable to give up alcohol.
• In order to avoid the appearance of rhinophyma, it is better to engage in timely treatment of gastrointestinal diseases, hormonal disorders and skin inflammation.

The likelihood of recurrence of signs of the disease is low if the treatment was carried out correctly.

Rhinophyma is a rather unpleasant disease that can disfigure a person’s face, therefore, at the first signs, it is better to consult a dermatologist, since at the beginning of the disease you can solve the problem without resorting to destruction. Rhinophyma provokes inconvenience, and can also develop into malignant neoplasms on the skin. The sooner treatment begins, the better. The best prevention is to constantly monitor your body and stay in a healthy ecological environment.

Rhinophyma classification

Etiology of rhinophyma

Clinic of rhinophyma

Diagnosis of rhinophyma

Treatment of rhinophyma

Non-drug treatment

Medical treatment

Surgery

This is a benign change in the skin of the nose of a tumor-like form, which leads to an increased accumulation of sebaceous secretions in the skin ducts of the nose, causes an unpleasant odor, or can even disfigure a person's face.

By its nature, the disease is a serious complication of rosacea and observed in men over 40 years of age(but there are exceptions when the disease manifests itself in young people).

A detailed study of clinical analyzes and observation by specialists of many patients in stationary conditions has not yet yielded results in terms of determining the main causes of the onset and further course of the disease.

Human Risk Factors

There are associated factors and risks that can lead to the development of rhinophyma with a high degree of probability:

Causes

Factors that increase the risk of developing a disease are the effects on the human body of sharp temperature fluctuations and frequent exposure to dusty areas. Also, the cause of the disease can be microscopic demodex mites, which are located in a person in the subcutaneous layer.

The whole difficulty lies in the fact that it is impossible to identify the presence of ticks, they appear only when adverse factors affect the body.

Chronic inflammatory skin is another cause of rhinophyma in humans. Doctors recommend that patients give up bad habits and engage in an active lifestyle.

Symptoms

Due to the increased size of the nose, the skin loses its natural beauty and other aesthetic characteristics, therefore it is an ugly growth.

Depending on the localization of the disease on the nose, a diagnosis can be made - nodular rhinophyma(the growth is a collection of numerous nodules), or single rhinophyma(single localization).

There is dilation of the blood vessels on the nose, so the nodules may have a red, purple, or even dark brown tint. The growth of the skin is a benign formation, which is formed from small vessels interconnected.

Here are several forms of rhinophyma that can be diagnosed in a patient:

Unfortunately, rhinophyma is a long-term and rather complex disease, which, if not properly treated, can be accompanied by exacerbations and further remissions.

The main growth of the skin is observed at the initial stage of the disease and may continue in some categories of patients up to several years.

Regression of rhinophyma is impossible, so all treatments must be prescribed in a timely manner!

Diagnostics

Diagnosis of the disease by an experienced doctor takes a short time. The first thing that draws attention is the change in color and relief of the skin on the nose, as well as the presence of pain when touching it.

The doctor necessarily clarifies with the patient all the features of the appearance of the problem, its duration and prescribes some clinical studies to identify disorders in the gastrointestinal tract or endocrine problems.

In controversial cases, an instrumental biopsy (skin sampling) is prescribed, followed by a histological examination to establish the good quality of the neoplasm. A dermatologist can provide advice on this matter..

Treatment

In practice, cases of therapeutic and drug treatment of the disease are known. Patients are prescribed the following drugs:

• drugs that improve the patency of the intestinal tract and microcirculation of the skin (in order to increase the supply of oxygen);
• preparations for the normalization of hormonal levels;
• medicinal solutions and ointments to get rid of acne and nodules on the surface of the skin.

Unfortunately, there are few cases of positive drug treatment, so more radical methods of treatment are required. If treatment is carried out in a timely manner, dermabrasion of the skin can help, but the patient must be examined by specialized doctors and have test results in hand.

The most effective solution to the problem is surgery (with the need for hospitalization of a person). Deep forms of skin lesions require wedge-shaped excision or subcutaneous excision of affected skin areas.

Laser surgery can be used to obtain the maximum aesthetic effect, but it will only be effective if a small area of ​​the skin is affected.

In some patients who undergo surgery, the shape of the nose may remain deformed. In this case, it comes to the rescue radio wave treatment of rhinophyma. Patients assure that this procedure is painless and without further complications, which often occur after surgery.

The most difficult cases may require plastic surgery to create the correct shape of the nose. Remember that a properly performed operation almost completely eliminates the occurrence of the disease in the future.

Folk remedies

As mentioned above, drug treatment, and even more so, treatment with folk remedies for rhinophyma is practically does not give positive results, and with the wrong approach, it can only aggravate the situation and complicate further treatment.

Prevention

Following the simple tips that we give below will allow each person to reduce the risk of rhinophyma:

As you can see, the tips are simple and somewhat banal, but they allow you to almost completely rid yourself of such an unpleasant disease as rhinophyma.

In this article:

Rhinophyma is the growth of the skin of the nose, which has a tumor-like benign character. The growth of the skin leads to hypertrophy of the ducts and hyperfunction of the sebaceous glands themselves. As a result, fat accumulates in enlarged pores, decomposes and becomes a source of an unpleasant odor.

Rhinophyma is not only a pronounced cosmetic defect, but also a disease that worsens the quality of life. Enlargement of the nose in size is accompanied by difficulty in nasal breathing, and sometimes eating. In addition, there is a high probability of malignant degeneration of the affected skin cells. The diagnosis is not difficult, the treatment is carried out by surgical methods.

Causes

Rhinophyma in most diagnosed cases is a complication of such a dermatological disease as. It is characterized by a persistent expansion of the capillary network in the T-zone of the face, thickening and redness of the skin, and the appearance of a pustular rash. However, if the patient has no history of rosacea, which happens quite rarely, rhinophyma is defined as an independent pathology.

Figure #1. Rosacea complicated by rhinophyma

The exact cause of its development has not yet been identified, however, a number of factors have been established that contribute to the onset of the pathological process:

• Exposure to the skin of excessively low or high temperatures, their frequent fluctuations. Most often this is associated with professional activities - work on the street.
• Constant inhalation of too dry or polluted air.
• Pathologies of the endocrine system, provoking changes in the hormonal background.
• Diseases of the digestive system that prevent the normal absorption of food. As a result, beriberi develop, metabolism is disturbed.
• Intense psycho-emotional overstrain, especially of a chronic nature. The neurogenic factor is not decisive, but it enhances the action of others.
• Hereditary predisposition in the form of congenital anomalies in the structure of capillaries, their increased fragility.
• A nevus is a benign pigmented spot on the nose that can transform and lead to a characteristic overgrowth of tissues.

Alcoholism is often mentioned as one of the most likely causes of rhinophyma. However, the abuse of alcohol in itself cannot provoke a benign degeneration of skin cells. However, the vasodilating effect of ethanol contributes to the disruption of capillary activity, especially against the background of other risk factors.

Figure #2. Rhinophyma: usually affects men from 40 to 50 children

Symptoms

The main clinical sign of the disease is an enlarged, fleshy nose. The surface of the skin becomes bumpy, often knotty, hypertrophied sebaceous glands are clearly visible on it.

Figure #3. Signs of rhinophyma: damage to the wings and tip of the nose

The color of the skin of the organ also changes: the color can be different, from red to bluish-purple and brown. This symptom depends on the specific type of rhinophyma, of which there are several.

Figure #4. Skin coloration in rhinophyma

Another characteristic feature of the pathology is the presence of an unpleasant odor. This phenomenon is due to the decomposition of sebum, which constantly accumulates in enlarged pores. One of the widows of the disease is accompanied by the formation of pustules with purulent-bloody contents. Difficulty in nasal breathing is also a common symptom.

Types of pathology

Depending on the individual characteristics of the organism, etiology, the presence of concomitant diseases and other factors, rhinophyma can develop in different ways. Despite the general symptoms, including an increase in size, enlargement of the pores and increased secretion of sebum, several forms of the disease are distinguished according to a number of specific signs.

Grandular

The most frequently diagnosed variant of the pathological growth of the skin of the nose, which occurs according to the glandular type. The skin in this case acquires a nodular structure, and the nodes themselves have a fairly soft texture.

Figure #5. Glandular rhinophyma

The affected surface becomes glossy due to excess sebum, hypertrophied pores are clearly visible. The color changes from healthy to cyanotic, sometimes there is a more intense lilac color of the skin.

Fibrous

This type of rhinophyma is less common than rhinophyma and differs in the type of tissue growth. The nose, as in the previous case, significantly increases in size, but its structure remains dense and smooth, without knots. In the enlarged mouths of the sebaceous ducts, sebum constantly accumulates and decomposes, due to which a persistent unpleasant odor is observed. The skin for the same reason is glossy, with its palpation, significantly enlarged sebaceous glands are felt.

Fibroangiomatous

According to the main clinical symptoms, this form of the disease is similar to the previous one: the nose is enlarged, its surface is smooth, and excess sebum is clearly expressed. However, the glands themselves are less dense to the touch. The hallmarks of fibroangiomatous rhinophyma are skin color and the presence of pustules.

The dark red color with the so-called spider veins is due to the expansion of the capillary network - telangiectasia. And multiple pustular rashes with purulent-bloody contents form characteristic crusts after opening. In addition, patients often complain of sensory disturbances, soreness and itching.

actinic

They are the most benign type of pathological process. Integuments grow moderately and evenly, without forming knots. The orifices of the ducts of the sebaceous glands are also moderately hypertrophied, and sebum secretion is slightly higher than normal. Therefore, intense glossy sheen, crusts and unpleasant odors are usually absent. The general color of the skin of the organ is cyanotic, and damaged capillaries are visible only on the wings of the nose. Pustule is also not observed.

Figure No. 6. Actinic form of rhinophyma

Course of the disease

Pathology is chronic irreversible, with alternating periods of remissions and exacerbations. For most cases of rhinophyma, a dynamic onset of the disease is characteristic, when the tissues grow rapidly in a short time. Then, as a rule, the pathological process stops for a while or forever. In the first case, after the “calm” stage, the pathology progresses again with an increase in symptoms. In the second, the process stops completely, but the reverse development does not occur, that is, the nose remains hypertrophied.

Diagnostics

Already at the initial examination, without additional research, the doctor accurately determines rhinophyma. The external clinical manifestations of the pathology are so specific that further examination is carried out only for differentiation with demodicosis (this disease is considered a frequent complication of the main one). Some oncological diseases such as sarcoidosis, lymphomas are also manifested by the growth of the skin. In this case, a biopsy is prescribed to exclude or confirm the primary diagnosis.

The examination begins with a questioning of the patient, finding out the conditions of his life, collecting an anamnesis. On physical examination, white contents of a pasty consistency are released from hypertrophied pores when pressed. Additionally, microscopy is performed, revealing a large amount of sebum, desquamated epithelium and saprophytic flora. Cytological examination is used to finally confirm the initial diagnosis.

Treatment

The process of growth of the skin of the nose with rhinophyma is irreversible. It can be stopped by eliminating provoking factors, including through the treatment of diseases of the gastrointestinal tract and the endocrine system.

The affected tissues themselves can only be removed using the following methods:

• Dermabrasion - is used in cases where the skin is slightly hypertrophied. It is a grinding of the surface with a special cutter that removes the surface layer. It belongs to the group of deep peels, therefore, in terms of trauma, it is comparable to surgical intervention.
• Laser removal is also indicated in the initial stages of the disease. It allows you to restore the anatomical shape of the nose by laser excision of the deformed dermis. The healing process usually takes about a week.
• The radio wave method is also applicable at more severe stages of the pathological process. At the same time, it is less traumatic, is not accompanied by postoperative edema, blood loss is minimal. Rehabilitation also does not take much time.
• A complete operation for subcutaneous excision of hypertrophied areas is indicated when the skin lesion is extensive and other methods are not applicable. Tissues are removed, intradermal sutures are applied.

After significant surgery, the patient may need a rhinoplasty. This type of operation is carried out according to indications, in order to restore the shape of the organ.

At-risk groups

The vast majority of patients diagnosed with rhinophyma are men over the age of forty. This fact is due to the way of life and the peculiarities of the professional activity of the representatives of the stronger sex. Men are more likely to work in harsh weather conditions, in hazardous production, which over the years has a negative impact on the state of blood vessels and the whole organism as a whole.

In addition, members of this population group are often malnourished. Irregular meals, especially fatty ones, provoke the development of gastroenterological diseases, metabolic disorders, hypovitaminosis. Of great importance is also the abuse of alcoholic beverages, which adversely affect the tone of the capillaries and eventually lead to their increased fragility.

Effects

Since the growth of the skin in rhinophyma is irreversible, the disease is a serious cosmetic defect. It can be eliminated only by surgical methods, and the possibility of relapse is not excluded. In addition to aesthetic inconvenience, pathology causes significant physical discomfort. Patients complain of difficulty breathing through the nose. In especially neglected cases, an enlarged organ even interferes with eating. The most dangerous consequence of rhinophyma is the malignant degeneration of skin cells with the formation of a cancerous tumor.

Forecast and prevention

Prospects directly depend on the stage of the pathological process at which treatment is started, although in some cases it fades by itself. Minor tissue hypertrophy can be easily and without consequences corrected by sparing surgical methods. The functions and appearance of the nose are restored almost completely. Severe stages require more extensive intervention and subsequent plastic reconstruction of the organ. However, in general, rhinophyma does not pose a threat to life. However, if the tumor transforms into malignant, the prognosis may be poor.

There are no specific methods for preventing the disease. You can only reduce the risk of its occurrence if you identify and treat rosacea in a timely manner. You should also be responsible for your own health, not triggering diseases of the digestive system and the endocrine system. Prevention of recurrence of rhinophyma is to eliminate (as far as possible) provoking factors. If the cause of the pathology was professional activity, a job change is desirable.