Phymatous Rosacea and Rhinophyma — Ablative Laser Treatment

Phymatous rosacea is the subtype where the skin thickens and overgrows. It most often affects the nose — where it is called rhinophyma — but can also involve the chin, forehead, ears or eyelids. It develops slowly, over years, on a background of long-standing rosacea, and is considerably more common in men. ^(1,3)

This is a different problem from redness or bumps, and it needs a different solution. The most important thing to understand is that once the tissue has thickened, creams and tablets cannot undo it — the excess tissue has to be physically removed and the nose reshaped. Done well, the results can be genuinely life-changing.

What is happening in the skin

Rhinophyma is the end stage of phymatous change: enlarged oil (sebaceous) glands, extra connective tissue and fibrosis build up until the nose becomes enlarged, bumpy and irregular, sometimes with dilated pores and a bulbous shape. ^(1,2)

Two points matter clinically:

• the change is structural, not just inflammatory — which is why anti-inflammatory creams and antibiotics do not reverse it
• rhinophyma can occasionally conceal a skin cancer (such as a basal cell carcinoma) within the thickened tissue, so proper assessment — and sending removed tissue for pathology where appropriate — is part of treating it responsibly ⁽²⁾

Can medical treatment help at all?

Yes, but with realistic expectations. Medical therapy has two roles:

• calming the underlying rosacea — redness, flushing and inflammatory bumps respond to the usual topical and oral rosacea treatments, and settling this is worthwhile in its own right
• slowing early phymatous change — in selected patients, oral isotretinoin can reduce sebaceous gland activity and may slow progression of early, still-soft phyma ^(1,3)

What medical therapy cannot do is remove tissue that has already become thickened and fibrous. For established rhinophyma, that requires a physical (ablative) treatment.

The main treatment — ablative erbium (Er:YAG) laser resurfacing

For established rhinophyma, the mainstay of treatment is ablative laser resurfacing — using a laser to precisely remove the excess tissue and re-sculpt the nose back toward a normal contour, while leaving enough of the deeper skin structures for the surface to heal over. ^(4,5,6)

We use a 2940 nm Er:YAG (erbium) laser for this. There are two ablative lasers commonly used for rhinophyma — CO2 and Er:YAG — and both are effective. ⁽⁴⁾ The reason we favour erbium is how its light behaves in skin:

• erbium light is very strongly absorbed by water, so it ablates tissue in thin, precise layers with less residual heat spreading into the surrounding skin ⁽⁴⁾
• in the published reviews, that lower thermal footprint is associated with faster healing and a lower risk of scarring and permanent lightening (hypopigmentation) than CO2 ⁽⁴⁾
• the trade-off is a little more surface bleeding during the procedure, because erbium does not seal small vessels as aggressively as CO2

Device choice is always individualised — but for reshaping the rhinophymatous nose while protecting the final cosmetic result, erbium is a strong, well-evidenced option.

What the published evidence shows

Ablative erbium resurfacing for rhinophyma has been studied with encouraging results:

• In a 2020 study of patterned ablative 2940 nm Er:YAG laser (16 patients, four sessions), around three-quarters achieved good-to-excellent outcomes at three months, patient satisfaction was high (no dissatisfied patients), average downtime was only a few days, and recurrence was low. ⁽⁵⁾
• A 2019 series reported that Er:YAG resurfacing restored both normal function and cosmesis in patients with severe rhinophyma. ⁽⁶⁾
• A 2024 comprehensive review comparing CO2 and Er:YAG concluded both are effective, with erbium offering less thermal damage and fewer complications. ⁽⁴⁾

Before and after — from the published literature

The photographs above are from the published research cited on this page — they are patients treated in that study, not patients of The Skin Doctor, and are shown so you can see the kind of change ablative erbium resurfacing can achieve. ⁽⁶⁾

What treatment involves

Phymatous laser treatment is doctor-led and planned by Dr Chris. In practice:

• treatment is done under local anaesthetic
• the excess tissue is ablated and the nose re-contoured, preserving the deeper structures the skin heals back from
• larger rhinophyma is often staged across more than one session for a safer, more controlled result
• afterwards the surface crusts and re-epithelialises over roughly one to three weeks, with redness settling over the following weeks to months
• you receive specific aftercare — wound care, ointment and strict sun protection — and we review you through healing

Because phyma sits on a background of rosacea, we usually also treat the underlying redness, flushing and bumps medically and with vascular laser as needed, so the whole picture is addressed rather than just the bulk.

When surgery is the better option

Very severe or extensive rhinophyma — or cases where function (such as nasal breathing) is significantly affected — is sometimes better managed with surgical (plastic surgery) reduction, on its own or combined with resurfacing. We will tell you honestly if a surgical referral would give you a better outcome. ^(2,4)

Assessment and booking

The right plan starts with an assessment: confirming the diagnosis, checking for anything suspicious within the tissue, staging the phyma, and setting realistic expectations about downtime and results. No referral is required.

Where this fits

Adjacent reads in the rosacea library:

• Rosacea condition page — diagnostic overview and the four-subtype map
• Erythematotelangiectatic rosacea — redness, flushing and broken capillaries
• Papulopustular rosacea plan — bumps and pustules
• Ocular rosacea — dry, gritty eyes, blepharitis and styes

If thickening of the nose or another area is affecting your comfort or confidence, a doctor-led assessment is the place to start.