Wound Excision and Closure by Secondary Intention and Growth Factor Application in the Management of Rosacea Complicated by Giant Rhinophyma

Rosacea is a chronic skin disease that occurs in the middle face and is centered on the external nose; it is marked by flushing of the skin, dilated capillaries, papules, and pustular rhinophymas.¹ It is mostly seen in middle-aged people. The etiology is not clear, although Demodex folliculorum infection is hypothesized as a potential cause of this disease. Clinically, rosacea is divided into the erythematous stage, papule pustular stage, and rhinophyma stage. Giant rhinophyma is the end-stage lesion of rosacea, and it mainly results from perennial chronic inflammatory stimulated tissue proliferation.² Giant rhinophyma has negative effects both on behaviors such as breathing and eating and also on physical appearance—effects that significantly reduce patients’ quality of life.³ 

Rosacea must be distinguished from diseases such as acne (acne-like substances are often visible in skin lesions), seborrheic dermatitis (lesions often occur in areas with abundant sebaceous glands), contact dermatitis (marked by acute onset and history of contact), and hormone-dependent dermatitis (long-term history of hormone use). Typically, rosacea is classified as either mild or severe, and management is tailored accordingly. For patients with mild rosacea, anti-inflammatory drugs such as doxycycline or minocycline can be used externally or orally. For those with obvious capillary dilation, carbon dioxide laser treatment or intense pulsed light therapy can also be used. For patients with severe rosacea in the proliferative phase, surgery or laser treatment is mainly used to remove proliferative tissue.⁴ Studies have shown that carbon dioxide laser ablation can effectively treat hypertrophic rosacea.⁵ Authors have successfully treated several cases of hypertrophic rosacea with surgical resection combined with skin grafting.^6,7 

A 67-year-old male presented to the authors’ hospital in July 2021 with severe progressive enlargement of the external nose. He had experienced diffuse flushing and capillary dilation on the tip of his nose for 20 years. Starting approximately 5 years prior to this presentation, a bulky growth occurred on his nose that slowly developed outward with increased oily discharge and hypertrophy of the nasal wings. Large nodules then gradually formed. In the 6 months prior to presentation in July 2021, the nasal redundancy had sagged significantly, affecting facial, ventilatory, and perioral function as well as feeding. On physical examination, a large, red, nodular bulge measuring approximately 8 cm × 6 cm × 6.5 cm, with an uneven surface and strawberry-like appearance, was observed on the tip of the patient’s nose. The follicular opening of the nasal bulge was significantly enlarged, and cheese-like secretion was visible on squeezing (Figure 1). The clinical diagnosis was determined to be rosacea with giant dermatophyte formation.

An external nasal redundancy excision was performed in which a circumferential incision was made at the root of the redundancy. The nasal tip form was excised and trimmed, and the nasal redundancy was removed, preserving the normal nasal shape. Oil sand was placed on the wound surface and bandaged under pressure. Postoperative pathology findings confirmed the presence of dermal fibrous tissue hyperplasia with epidermal-like cysts, foreign body granulomas, and microabscess formation. 

The postoperative wound underwent iodophor disinfection, followed by the application of topical growth factors (rn-bFGH, Gaifu, Nanhai Langtide Pharmaceutical Co, Ltd, CN). The patient employed these growth factors during dressing changes, which occurred every 2 to 3 days, until the wound fully healed within 1 month. On postoperative day 30, the wound was healed (Figure 2A). Two months postoperatively, healing was achieved, the nasal shape had returned to normal, and ventilation, feeding, and perioral functions were restored. At the 6-month follow-up evaluation, no recurrence of the lesions was observed, and only a slight scar remained at the area of nasal trauma at the tip of the nose (Figure 2B).

In the current case, the nasal vegetations were large and exogenous, and lobulated with multiple protrusions—findings that are rarely seen clinically. The treatment approach involved surgically removing the overgrown section of nasal tissue, followed by wound excision and closure by secondary intention and growth factor application. 

Wound excision and closure by secondary intention and growth factor application, which is akin to open placement surgery. In this procedure, the skin tumor is removed without the primary suturing or immediate repair of the incision. Instead, the wound gradually healed through the innate self-healing capabilities of the skin and subcutaneous tissue, with the primary aim of facilitating natural tissue repair.

This approach entails regular disinfection and dressing changes and may include the use of growth-promoting medications to enhance the healing process. Notably, in the current case this method not only led to a marked improvement in the aesthetic appearance of the patient’s nose, characterized by minimal scar hypertrophy and linear scars, but also resulted in significant enhancements in breathing, feeding, and perioral functions. 

In addition, the treatment plan involved the application of recombinant human basic fibroblast growth factor to aid in the healing process. These growth factors stimulate cell growth, proliferation, and tissue repair. 

Wound contraction is a natural phenomenon in wound healing, and adequate wound contraction ensures that the healing tissue maintains a relatively normal appearance and function. Such contraction may be facilitated by a combination of wound excision and closure by secondary intention and growth factor application to minimize excessive contraction that might otherwise compromise aesthetic and functional outcomes. 

In the current case, subsequent postoperative assessments revealed only minor nasal scarring and pigmentation, with no instances of skin tag recurrence. The patient expressed high levels of satisfaction with the achieved outcomes. 

Rosacea is a chronic skin condition that can be managed using various methods. Comorbidities associated with rosacea include eye problems, Demodex infestation, anxiety and depression, gastrointestinal issues, and cardiovascular diseases. One common treatment is laser or light ablation therapy. Prior to rosacea diagnosis, treatments such as topical or oral medications, avoidance of triggers, and skincare routines may be prescribed.

Surgical resection is the most direct and effective treatment for nasal tumors, so the repair of postoperative wounds is of great significance in the management process.⁸ Currently, the repair methods for patients with nasal non-melanin skin cancer mainly include open placement, skin flap transfer, and skin grafting, among others. Nasal defects have a high degree of complexity, have substantial individual differences, and are quite difficult to repair.^8,9 Wound excision and closure by secondary intention and growth factor application for rosacea has potential side effects, such as temporary swelling or infection; however, these are rare with proper antiseptic techniques. Importantly, in the current case the application of growth factors and wound excision and closure by secondary intention contributed to natural wound closure without the need for sutures, thereby reducing the risk of unsightly scar formation. 

To manage the nasal defect wound in this patient, skin flap transfer or skin transplantation could have been performed. For the former, the large wound area with no available skin resource around it precluded transfer of a surrounding skin flap. Skin grafting would have had 2 associated problems. First, additional surgical incision would have been necessary, and second, the texture and color of the transplanted skin are significantly different from the original skin of the nose. Considering the strong self-renewal ability of nasal skin tissue,¹⁰ the authors of the current case report chose to perform wound excision and closure by secondary intention and growth factor application to repair the nose. In this case, the large nasal defect was treated with open surgery, which not only achieved a more natural-looking repair effect but also simplified the surgical method and reduced the patient’s medical burden. 

This case report has limitations. Open placement surgery has disadvantages, such as a 4- to 8-week recovery period, an increased risk of infection, and the need for more frequent dressing changes. Further studies are needed to explore the benefit of wound excision and closure by secondary intention and growth factor application in patients with large nasal defects that cannot be effectively managed using a transfer flap or skin graft.

In patients with large nasal defects and in cases in which neither transfer flaps nor implants can achieve good results, wound excision and closure by secondary intention and growth factor application can obtain clinical benefits.