  rhinophyma , exuberant hypertrophic acne , with tumoral aspect of the skin of nasal pyramid is characterized by large , bulbous , erythematous appearance of the nose .
there were incriminated several factors such as : the excess of steroid hormones ( androgens ) , the presence of a parasite ( demodex folicolorum)[1 , 3 ] , and vitamin deficiency .
it is said that alcoholism was a trigger for rhinophyma , because a lot of alcoholics have erytherma of the face , but alcoholism does not cause rhinophyma .   
histological , besides sebaceous hyperplasia , it can also be observed an abnormal vascular development ( telangiectasis ) , hypertrophy of subcutaneous tissue and atrophy of dermis .
  a 56-year - old patient , from urban area , chronic alcohol consumer known with chronic hepatitis presented a giant rhinophyma with a slowly progressive development of approximately 10 years .
because of his unaesthetic aspect , the patient was excluded from his group of friends .    at the clinical examination
it was found :    in the glabellar and malar region , the tegument was changed , the skin being fibrous , crossed by red , purple , dilated follicular orifices - fig.1 .   
the nasal tumor was crossed by glandular orifices from which , at pressure , sebum flows .    this nasal tumor ,
because of its size , caused the obstruction of external nasal orifices and difficulty in eating due to the ptosis through lips .   
the diagnosis of rhinophyma was established on the clinical aspect . in order to confirm it a biopsy
was performed fig.2 .    the surgical treatment consisted in the excision of the nasal tumor , with preservation of the cartilages , perichondrium and periosteum .
hemostasis was done by injecting saline and adrenaline peritumoral - fig.3 .    in the same operatory time , there were covered the skin defect , the cartilage , the perichondrium and the periosteum and then the graft suture and a  tie over  bandage were realized .   
the histopathological exam helps to establish a precise diagnosis and can point some modifications bounded on injury progression . in our patients case
we encounter the next histopathological features : in rhinophyma , the hyperplasia of sebaceous glands came over so obvious and sebaceous ducts are enlarged and filed with keratin and sebum .
was observed a vasodilatation in the upper and the middle part of derma , presenting a perivascular and perifollicular inflammatory infiltrate with lymphocytes and histiocytes fig.6 .
dermal infiltrates are gathering in little nodular formations and creating granulomas , observing epithelioid histiocytes and , occasionally , can be identified multinucleate giant cells fig.7 .  
he , enlarged sebaceous ducts filed with keratin and sebum , he , x10 lymphocytes and histiocytes perivascular and perifollicular , he , x10 dermal infiltrates formations creating granulomas , he , x10   under pre and post - operative antibiotic therapy the evolution was good and the patient was discharged 12 days after the intervention .    after the surgical intervention , the respiratory problems and the discomfort in eating disappeared .
furthermore , due to the good aesthetic aspect the patient was reintegrated into society -fig.8 .  
  acne rosacea is a chronic or long term facial skin disorder and rhinophyma is the most advanced form of this disease .    in the evolution of acne rosacea
there are 4 stages :    stage i ( vascular )  it appears around the age of 20 years and it is characterized by sudden reddening of the face and neck , with sensation of intense heat .
the factors responsible for these facts are : the change of temperature , ingestion of hot drinks , alcohol or spicy food    stage ii  it appears around the age of 30 years and it is clinically characterized by permanent facial redness associated with telangiectasia located on the nose , cheek and forehead .   
stage iii- it appears around the age of 40 years and it is characterized by inflammatory papules and pustules on an erythematous background .
the lesions are spread to areas around the eyes and mouth , without scars and the skin is sensitive , with intolerance at application of local cream .   
stage iv  appears around the age of 50 years and it is clinically characterized by thick red skin , with purple striae and nodules located on the nose , ear and zygomatic region    the diagnosis is easy to establish even in the first stage .
the clinical examination reveals an enlarged nose , with erythematous and thick skin and tumors of different sizes located on the external nose .
histopathological changes can differ considerably from case to case , reflecting the clinical aspect on presentation .
is observed vasodilatation in upper and middle part of derma , and generally , is present in all cases a perivascular and perifollicular inflammatory infiltrate with lymphocytes and hystiocites and , occasionally , plasmocytes . can be present a dilatation of lymphatic vases .
can be observed epithelioid hystiocites in a tuberculoid pattern and , occasional , can be identified multinucleated giant cells .
can be constituted unfamiliar body granulomas around necrotic material storages and around materials resulted after lacerating and destructing the follicles .
concerning follicular involving can differ also from the infundibular spongiosis and exocytosis , to severely alterations type superficial pustular folliculitis . in rhinophyma ,
sebaceous glands hyperplasia becomes obvious sand sebaceous ducts are enlarged and filled with keratin and sebum .
it can be dermal fibroplasia and the amount of the quantity of conjunctive tissue .   
the tumor is painless and while pressing it can appear an increased quantity of whitish sebum with fetid smell .    in gigantic forms
can be associated with a suborbital region lymphedema , having as a result blepharitis , conjunctivitis and keratitis [ 2 , 7 ] . in this situations
the differential diagnosis is made with : angiosarcomas , squamous carcinoma , basocellular carcinoma , sebaceous carcinoma , dermal carcinoma , skin metastasis especially in pulmonary neoplasm , eozinophilic facial granuloma , hemangioma , nasal keloid scars , lymphoma , . in this context
the therapeutically possibilities in rhinophyma are [ 7 , 9 , 10 , 11 , 12 ] :    laser ( co2 , argon , nd : yag ) ;    hydrodissection ( versajet system ) ;    mechanical dermabrasion ;    laser treatment , hydrodissection and dermabrasion are used in small dimensioned lesions , at the beginning of the disease .
the excision is performed in monobloc ; the covering of skin defect can be performed in the same operatory time like in the presented case or after granulation in almost 14 - 16 days from the first intervention .
the skin graft is gathered in all its thickness from hairless areas and face skin - like coloration .    the principal complication that can appear is represented by the nasal cartilages chondrolysis ; to avoid this complication it must be not used the electrical scalpel and the electrocoagulation that will compromise the perichondral vascularization .   
to avoid the appearing of postoperatory chondritis must be administrated antistaphylococcal antibiotheraby on systemic as on local way .
  rhinophyma represent stage iv of rosacea acne , that give an inaesthetic aspect sometimes monstrous of nose and of face too that required a radically surgical treatment in cases where tumoral mass is big , obtaining an satisfactory aesthetic and functional aspect dissipating the respiratory obstruction and also the alimentation discomfort .
 the aim of the article is to present an update on the pathophysiology , clinical features and treatment of rhinophyma . a 56 years old patient , living in urban area , presented with a giant rhinophyma which caused him not only upper airways obstruction and difficulty in eating , but also aesthetic and psycho - social disadvantages.the treatment of the patient was a surgical intervention consisting in removal of the nasal tumor and split - thickness skin grafting of the defect . 
 the aesthetic result after surgical intervention was very good , there were no postoperative complications or recurrences.rhinophyma represents the most advanced form of acne rosacea . 
 the diagnosis is easy to establish based on the clinical features of the disease . in advanced forms of rhinophyma , when the tumor is giant , 
 the main method of treatment is surgery . 
Introduction
Matherial and Method
Discussion
Conclusions