The use of the fractional CO2 lasers for the treatment of rhinophyma

Dr. Matt Mahlberg is a board-certified and fellowship-trained dermatologic surgeon in Centennial, CO. He’s been using CO₂ lasers for a decade for procedures like skin resurfacing and surgical scar repair. Learn how Dr. Mahlberg employs the CO₂RE laser for successful treatment of rhinophyma. Scott Kober hosts The Dermatology Times Podcast Series. It is brought to you by Candela, a global leader in the aesthetic medical device marketplace.

Scott: My name is Scott Kober with Dermatology Times and today we’ll be talking about the use of fractional CO₂ lasers in the treatment of rhinophyma.

I’m happy to be joined today by Dr. Matt Mahlberg, a board-certified dermatologist and fellowship-trained dermatologic surgeon at Colorado Center for Dermatology & Skin Surgery in Centennial, CO. 

Dr. Mahlberg is a consultant and speaker for Candela.

Welcome Dr. Mahlberg, and thank you for joining me.

Dr. Mahlberg: Thank you for having me.

Scott: When and why did you first explore acquiring a CO₂ laser for your current practice?

Dr. Mahlberg: I’ve worked with CO₂ lasers for about a decade, initially during my training and residency when the first fractional lasers were coming to market. I have and continue to use them for a variety of purposes such as skin resurfacing and surgical scar repair.

When I decided to start my own practice 2 years ago, I felt it was important to obtain a fractional CO₂ laser to round out the laser-based therapy armamentarium in our practice.

Scott: What were some of the features that were important to you when you were assessing the CO₂ lasers that were on the market?

Dr. Mahlberg: Certainly, one of the top priorities was to obtain a CO₂ laser with fractional capabilities so that energy can be delivered in a short pulse duration. There are a number of devices on the market that don’t have that capability and therefore create a substantial amount of bulk heating. That’s not something I wanted.

I also wanted a laser that would provide me with the flexibility to perform fully ablative as well as fractional CO₂ resurfacing. It was also important that the laser be fairly light and mobile since I don’t have a lot of empty space in our clinical areas. I didn’t want a laser that sat in one spot and took up a lot of space when it wasn’t in use.  

Lastly, I wanted a laser that was flexible in terms of its settings so that we would be able to create a variety of wounds in the tissue to obtain optimal clinical results.

There were only a small handful of lasers that checked all of those boxes, among them the CO₂RE fractional laser. I had used the CO₂RE in my previous practice, so I knew its capabilities and I didn’t find anything that I thought would be a better fit for my current practice.

Scott: Let’s talk specifically about rhinophyma, one of the indications for which the CO₂RE laser is cleared by the U.S. Food and Drug Administration. How commonly do you see patients in your practice presenting with rhinophyma?

Dr. Mahlberg: It’s something I see on a daily basis. Rhinophyma is a condition of sebaceous gland overgrowth. It’s often considered the end stage of acne rosacea. It presents as a bulbous lower half of the nose where the sebaceous gland is really overgrown. Rhinophyma literally means nose growth in Greek.

In Caucasian populations, particularly those of Northern and Eastern European descent, it’s quite common. Rhinophyma appears most often in men ages 25 to 50.

In the earliest stages of rhinophyma, you’ll see enlarged oil glands. Some patients will have papules or the pustular type of rosacea accompanying the excessive oil formation.

Scott: How is rhinophyma initially treated?

Dr. Mahlberg: In the pre-rhinophyma phase when it’s mainly inflammatory acne rosacea, we’ll typically start with topical agents such as tretinoin or another topical retinoid to help reduce oil production and prevent pores from getting clogged. Oral and topical antibiotics are also an option.

But once sebaceous gland overgrowth becomes present, topical agents are largely unsuccessful and you need to move onto physical treatment modalities.

Scott: Such as what?

Dr. Mahlberg: Once a patient develops the classic rhinophyma symptom of the very large bulbous nose, there are a whole host of physical and surgical modalities available. You can perform surgical excision with a scalpel. You can do hot loop cautery, which is essentially taking a heated wire loop and shaving off parts of the skin tissue using heat. You can use manual dermabrasion, which is essentially taking either a spinning wheel or a manually dermablade and sanding down the affected area. Or you can use a CO₂ laser either in classic mode, fully-ablative mode, or fractional mode.

What I like about the use of the CO₂RE laser in patients with rhinophyma is that you can start treatment in a conservative fashion, which means that you can treat earlier phases of rhinophyma surgically before you get the progression to those large, bulbous W.C. Fields noses that we commonly associate with rhinophyma.

Scott: Do you use the CO₂RE laser in most of your rhinophyma patients?

Dr. Mahlberg: Yes, once sebaceous gland overgrowth has set in and the patients are interested in addressing it, the CO₂RE laser is my go-to treatment modality, although the way that we use it often depends on the stage of the patient’s disease.

In patients with mild or early stages of rhinophyma, I typically perform high percentage fractional ablative treatments with the CO₂RE that vaporize some of the sebaceous oil glands. The goal is to shrink down the quantity and the size of those oil glands.

Patients typically have approximately 5-7 days of minor wound healing following the procedure and some erythema for the final half of that healing period. During that time, I have them apply moisturizer to the affected area.

As we progress to more moderate or severe cases -- or as some people call it, mid-to-late stage rhinophyma – I’ll often use a combined modality of a scalpel and the fully-ablative CO₂RE laser. Wound healing in those cases can take 7 to 10 days, and in some cases even longer than that. There will also sometimes be bleeding during the actual procedure itself that needs to be managed.

Scott: How do you utilize the CO₂RE laser during the treatment of rhinophyma? What does the overall procedure look like?

Dr. Mahlberg: Because it is a surgical procedure, I like to have patients come in for a consultation prior to the surgery to discuss and set proper expectations, and to go through the expected amount of down time and the healing process following the procedure. At this time, I also take a medical history to uncover any allergies and document if they’ve had a history of herpes simplex virus or other high-risk infections.

In the perioperative period, I’ll typically prescribe an oral antibiotic such as cephalexin to start one day before and then for about a week after the surgery. I also prescribe an antiviral medication such as valacyclovir to reduce the risk for a herpes simplex super-infection while the patient is healing.

On the day of the procedure, if the patient has only mild or early stage rhinophyma, we may use topical anesthesia, but more often we will offer a local infiltration of lidocaine with epinephrine so that we can treat without the patient feeling discomfort.

We always do a block around the nose, and then prep the patient sterilely with Hibiclens or chlorhexidine wash so that there is as little fluid as possible on the skin. In some cases, we’ll use alcohol or acetone to reduce the amount of oil so that it isn’t affecting the tissue interaction with the CO₂ laser.

In patients with mild-to-moderate rhinophyma, we’ll typically use the Mid mode of the CO₂RE with about 40% coverage, though in some cases we will use the Fusion mode to contour areas of sebaceous gland overgrowth and to just reduce the overall tissue bulk.

For patients with more severe rhinophyma, we’ll typically use either a scalpel or hot loop cautery to remove the initial bulk. We’ll then use the CO₂RE in Classic mode, going down to about a 3-5 mm depth to contour that last bit. You don’t want to penetrate too deeply with either the scalpel or hot loop cautery. While you can debulk things pretty easily with either of those methods, to refine things and contour the tissue the way you want it, the CO₂RE is really much more useful.

Scott: Is the full treatment completed in one procedure, or are there patients who will need multiple visits?

Dr. Mahlberg: That’s a great question. In patients with mild to moderate rhinophyma, this is almost considered part of a maintenance routine. Many people with rhinophyma are genetically prone to sebaceous gland overgrowth, and while they’ll only need one or two treatments at a time to manage their condition, they may then need to come back every few years to taper down the affected region.

For patients with more severe rhinophyma, that’s where we’re really resculpting things and hoping for a dramatic change much more quickly. With the combined approach of a scalpel or hot loop cautery in addition to the CO₂RE laser, we can affect the necessary improvement typically in just one sitting.

Scott: How would you characterize your rhinophyma patients’ overall satisfaction after use of the CO₂RE laser?

Dr. Mahlberg: In patients with severe rhinophyma whose nose may have grown 4 or 5 times normal size, the procedure is a life changer. Not only is their physical appearance improved, but often their nasal valve function will become markedly better.

I had a recent patient who for years had needed a CPAP machine at night and had very high blood pressure. His rhinophyma had become so severe that he was trouble even using the CPAP machine; it became a dangerous situation. We were able to treat his rhinophyma with the CO₂RE laser as part of a combined modality approach, and it has made a huge difference. Not only is his blood pressure down but he’s been able to discontinue use of the CPAP machine entirely.

Now, his improvement is certainly more significant than most, but that’s the impact we’re able to have on these patients with the tools available to us.

Scott: Great. I think this has been an insightful discussion regarding new technologies that offer opportunities for dermatologists to better serve the needs of their patients.

Please click here for more information about the CO₂RE Intima laser.