My sister (38 years old) has been diagnosed with rhinophyma. It is a small but growing lump on the point of her nose. She is distressed about this and is quite anxious. What is it? Is it viral? Can it be surgically removed, or are there any creams that might work?

B.K.

Rhinophyma is an overgrowth of the sebaceous glands -- the tiny glands that give skin its oily quality. It most commonly arises from nasal skin. In its mild form, rhinophyma has a red, raised or nodular appearance and involves only a small portion of the nose. In its more severe form, these skin changes can affect the whole nose, leading to a marked distortion of the normal nasal shape, and even leading to nasal airway obstruction. The comedian W.C. Fields' trademark bulbous nose was almost certainly a case of rhinophyma.

Rhinophyma is considered an extreme form of acne rosacea, a chronic skin condition that primarily afflicts middle-aged adults. It is fairly common, affecting 13 million people in the United States alone. Acne rosacea affects facial skin, but it can also affect the neck and upper chest and back. More than half of the people with acne rosacea will also develop a variety of eye problems, such as conjunctivitis.

Prominent flushing of the central face (in response to strong sunlight, a variety of foods or alcohol) is an early manifestation of acne rosacea. Eventually, the flushed appearance persists and acne develops. Papules (red bumps) and pustules (pus-filled red bumps) develop, though the classic "whiteheads and blackheads" of teenage acne are conspicuously absent. Spider-like capillaries (telangectasias) may also appear. Rhinophyma occurs later in the course of acne rosacea.

The causes of acne rosacea and rhinophyma are mysterious. They do not appear to be caused by a virus, but there has been considerable speculation about bacterial infection and/or infestation with the skin mite Demodex folliculorum. Antibiotics are the mainstay of treatment for acne rosacea; this suggests that bacterial infection is the cause. However, antibiotics do not cure rosacea; the rosacea patient must continue to use oral antibiotics or a topical antibiotic, metronidazole gel (Metrogel), to prevent recurrence.

Oral isotretinoin (Accutane) can be used to treat severe acne rosacea and rhinophyma, but it is essential to point out that Accutane causes SEVERE birth defects, and so should be used with extreme caution by women in their reproductive years.

Another important point: Not all bumps on the nose that look like rhinophyma ARE rhinophyma. Skin cancers, sebaceous gland cancers, systemic chronic infections (such as tuberculosis), systemic lupus erythematosus and sarcoidosis are some of the other possible problems that can masquerade as rhinophyma. If there is any doubt as to the diagnosis, skin biopsy is essential.

Surgical treatment of rhinophyma can lead to rapid cosmetic improvement, although scarring and recurrence are two important considerations. Rhinophyma can be "shaved off" with a scalpel, "sanded off" (this is known as dermabrasion) or removed with an electrical cautery tool or even a carbon dioxide laser. Cryotherapy (freezing the lesion with liquid nitrogen) has also been used to treat rhinophyma. Scarring (as well as other complications) may occur with any of these techniques; there is no clear evidence that one technique is better than another. The surgeon's comfort and experience with the chosen technique is the most important consideration.

More information on acne rosacea can be found on the Web site of the National Rosacea Society.