This paper explores the different problems that may be causing flushing. The list of possible reasons other than rosacea is extensive. It is worth consider what other conditions may be causing your red face before embarking on any treatment regime. Treatments that are good for some of the conditions listed here may make your rosacea worse, so read as widely as you can.
The author was kind enough provide a full copy of this paper, so contact me if you’d like to read it.
If you would like some ideas about about how to treat a red face, see another popular article I wrote titled how to treat a red face
The flushing patient: Differential diagnosis, workup, and treatment, Journal of the American Academy of Dermatology, Volume 55, Issue 2 , August 2006, Pages 193-208. Leonid Izikson MD, Joseph C. English III MD and Matthew J. Zirwas MD, Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Abstract: Cutaneous flushing—a common presenting complaint to dermatologists, allergists, internists, and family practitioners—results from changes in cutaneous blood flow triggered by multiple conditions. Most cases are caused by very common, benign diseases, such as rosacea or climacterum, that are readily apparent after a thorough taking of history and physical examination. However, in some cases, accurate diagnosis requires further laboratory, radiologic, or histopathologic studies to differentiate several important clinicopathologic entities. In particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma, mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid, pancreatic cell tumor, renal carcinoma, and others, should be considered.
Learning objective: At the completion of this learning activity, participants should be familiar with the mechanisms of flushing, its clinical differential diagnosis, the approach to establish a definitive diagnosis, and management of various conditions that produce flushing.
Abbreviations: CS, carcinoid syndrome; 5-HIAA, 5-hydroxyindoleoacetic acid; 5-HT, 5-hydroxytryptamine; MCT, medullary carcinoma of the thyroid; NSAID, nonsteroidal anti-inflammatory drug; TMEP, telangiectasia macularis eruptiva perstans; VIP, vasoactive intestinal polypeptide
…
When evaluating patients with rosacea, it is important to exclude the diagnoses of polycythemia vera, photosensitive eruption, lupus erythematosus, mixed connective tissue disease, carcinoid syndrome, systemic mastocytosis, or side effects from long-termfacial application of topical steroids. Since rosacea is typically limited to the face, extra facial erythema is generally an exclusionary sign. Rosacea flushing is associated with burning or stinging but not sweating, lightheadedness, or palpitations. Erythematotelangiectatic rosacea, while considered by many to represent a separate entity, may in fact be difficult to distinguish from simple benign cutaneous flushing and sun-damaged skin. In attempting this distinction, it may be useful to assess the extent of baseline facial telangiectasia and the overall degree of poikiloderma. However, since these 3 conditions are all common, they may coexist in many patients. Also, since erythematotelangiectatic rosacea and benign cutaneous flushing may have common triggers for flushing, it may be reasonable to consider these 2 entities as different points on a single continuum, making distinction of academic value only.
…
Table II
Differential diagnosis of flushingCommon Causes
Benign cutaneous flushing
Emotion
Temperature
Food or beverageRosacea
Climacteric flushing
Fever
AlcoholUncommon, serious causes
Carcinoid
Pheochromocytoma
Mastocytosis
AnaphylaxisOther causes
Medullary thyroid carcinoma
Pancreatic cell tumor (VIP tumor)
Renal cell carcinoma
Fish ingestion
Histamine
CiguateraPsychiatric or anxiety disorders
Idiopathic flushing
NeurologicParkinson’s
Migraine
Multiple sclerosis
Trigeminal nerve damage
Horner syndrome
Frey syndrome
Autonomic epilepsy
Autonomic hyperreflexia
Orthostatic hypotension
Streeten syndromeMedications
Very rare causes
Sarcoid, mitral stenosis, dumping syndrome, male androgen deficiency, arsenic intoxication,
POEMS syndrome, basophilic granulocytic leukemia, bronchogenic carcinoma, malignant histiocytoma, malignant neuroblastoma, malignant, ganglioneuroma, peri-aortic surgery,
Leigh syndrome, Rovsing syndromeSummary: The differential diagnosis of cutaneous flushing is extensive and encompasses a variety of benign and malignant entities. Most flushing reactions result from benign causes. However, since flushing may be the presenting sign or symptom of several life-threatening conditions, it should prompt a thorough investigation to exclude such possibilities as anaphylaxis, systemic mastocytosis, carcinoid syndrome and other malignant tumors, pheochromocytoma, and autonomic epilepsy after more common benign causes have been ruled out and if there is no response to treatment. In the absence of an identifiable benign organic cause of flushing, psychiatric illness must be suspected and the patient should undergo appropriate evaluation. History and physical examination are critical in the evaluation of the cause of flushing and should be supplemented with laboratory and other investigations based on the clinical suspicion of an underlying cause. The most common causes of flushing – fever, emotional flushing, climacterium, and rosacea are obvious to most physicians and thus are likely to be promptly recognized and treated appropriately. Dermatologists have a unique role in the management of patients with flushing, as referred patients may be unresponsive to conventional therapy and are more likely to have a serious or life-threatening underlying cause. Accordingly, proper workup, recognition, and management of conditions that cause cutaneous flushing may have a significant impact on the patients’ morbidity and mortality.
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92 Comments over 2 pages ↓
One day after breast surgery, to remove a benign lesion, my face turned beet red, felt hot. upper cheekbones were sore to t he touch. It lasted three days. I’m on metoprolo for high BP, ontwo weeks now)
I have flushing on my face and neck for about 4 yrs. now. I could be sitting, relaxing, working and I get this flushing at any time it feels like it wants to show up. I have been to the Dr. quite a few times about this problem. (nothing seems to help) I turn a beat red for no reason it seems. I don’t feel any different when I start to turn red… (except) the heat from my cheeks. I am being treated for Rosacea. I can tell this is not the cure!!!!! I never had this problem in my life til now. I also put foundation on to cover the redness up, and it works in the beginning. But, as the day rolls on, It doesn’t help. This is very, very embarressing. I’m in good health otherwise. Blood Pressure, Pulse were good also. I’m not at all over weight, I have not changed my diet. I would really love to totally stop this flushing for good.
Mr. Pascoe, May I have a copy of the full article? I’ve had beet-red cheek flushing for over 6 months. Each episode lasts about 24 hours. I’m interested in reading about the “rare causes”. I have been through tests and scans with no real reason for the flushing becoming evident. Thanks for writing and sharing this information.
i’ve suffered from facial flushing for years. I recall as a child constantly getting what doctors referred to as “heat rash” everytime I got overheated. However, I noticed that the rash would also appear whenever I would get embarassed or anxious. These symptoms seemed to go away into my twenties and early thirties except for minor episodes after taking a hot shower or sitting in dry Sauna. However, as of late, Im 38 now, I’ve devloped recurring red cheeks that appear “ruddy” along with what seems to be acne on my forehead and cheeks. My dermatologist had the gaul to ask if I was taking oral steroids. Anywa,y everything I’ve read about Rosacea seems to indicate that i may be on to something. Can I also get a copy of this article for reference and sharing with my Dermatologist. Thanks!
please send me a copy of the article…..thank you
Can you please send me a copy of the article as well. Thanks!
please send me the full article I have been getting flushed in the face and feeling tired and hav eto rest when this happens.
Hi, I’m on corticosteroids (P.O. prednisone) for 4 years now . Also 4 years ago I had a therapy with UV light so I had to take photo sensitizing pills(3months), and no more than 6 months after I’ve got photodetmatitis (sun allergy) – which I have now for 3 years… And one year ago I discovered that my face is becoming red with emotions, first it was occasionally, but I started to be more nervous becouse of that and it got worse…(I’m23 y.old)
Can the corticosteroid therapy or the UV light therapy be the reason of flushing?
And also please send me the full article.
Thank you.
I would appreciate a copy of the article!!
many thanks!!
similar symptoms when in stuffy environment. a copy of article would be appreciated. Thanks
10 yrs ago I was told my red face was not rosacea, but about 5 yrs ago a different doctor told me it is. I also have ocular rosacea. I have found that it helps to avoid gluten and dairy. Dairy seems to be especially bad for me, just a 1/2 cup of yogurt will make my face red and blotchy for a couple of days. Also, I take 500 mg of L Lysine twice a day as I read that people with Rosacea have low levels.
If you could please send me a copy of the article. Thanks
What could cause a person’s face to only turn red when they come to work? It also includes burning. The doctor has given them the diagnosis of Roscea but again, it only happens at work. Other symptoms are headache.
I have redness and burning in the cheeks and my neck gets really red. This mostly happens when i get stressed out, drink hot beverages or with temperature changes. I was told i have rosacea but now starting to wonder if it’s this flushing your talking about! I was diagnosed with Rosacea summer of 2010 and i’m currently taking a chinese herbal pill..what else can i do?
If I could also get a copy I’d appreciate it. I am also going through very similar things now and am trying to read as much as I can!
Everybody always will ask me why my face is so red. I dont know if it is anxiety anymore of if there is something else going on. I have seen doctors, pyschologists, and pyschiatrists and after years of trying to find someone with an answer, i can not.
I wish i knew what the answer was. No one can apparently tell me. It is fine in the morning and only seems to worsen through the day. I have been taking trileptal, diazepam, bystolic for several years now. Could there be a link to this?
Please can I have a copy of the full article? Ive had severe flushing for years but was told over and over its all in my head. Now I have a lot of neurological symptoms and im wondering if the two are connected. Many thanks!
Please can i have a copy of the full article,
Thanks again for the paper David, its most informative and very well written. Iv’e scoured the net for a long time looking for info, this paper is the best i’ve seen by a long shot. I think you are doing a great job
Thanks for the information. Please send me the full article.
I am 32 and have red face almost everyday. I can not recall if I have had it since I was a child or not. But I know I have had it since I was a teen. It seems as thought it is getting worse with age. I seem to get it the worst when ever I get too involved in something. Like if I am concentrating on the computer for too long or am too focused I guess. If I take ibuprofen it helps some, but not much. If I cool it down it helps a bit too. If I’m rushing around at work or if I get stressed it really goes nuts. If I work out my face will turn so red it is almost purple! Can you please send me a copy of the artical too. I think we have ruled out rosasea and the lupus test say not lupus but close to those levels. I’m so tired of this hot face embaressing me.
Can I please have a copy of the full article? Thanks!
I share the same problem with everyone here. I get red especially after lunch to the point it appears purple too. I’ve tried dieting and avoiding beer and hot beverages. The only thing that has helped me in the past two years was living in a dry climate area. Now that I am back on the east coast, the redness has reappeared. I’m also tired of the looks and I can feel the warmth on my skin when it begins. Once it does, it almost impossible to control. I’m using a mild facial soap. I tried Zenmed lotion, but I feel it has made my condition worst. I think emotions and diet play a big part, but most times it just happens. If you take lotion steroids, stop it immediately!!! I was on it for four years and I developed an addiction to it. It took 6 months of intense redness to recover from it. It appears to help, but in the long run it will make your redness worst.
I would also like a copy of the article.
The symptoms I have, is exactly what every person above has described, unless you suffer from this, you can’t imagine the affect it has only your life. I would appreciate it if you could send me a copy.
I also suffer from the same symptoms as everyone has been describing, it is hard to live with. Can you please send me a copy.
My cheeks are red and hot everyday since I had neck traction. I had a lupus test and my level was 1:80 which was the cut off point before it is marked out of range. Nothing has worked so far and my doctor won’t send me to a dermatologist. He says live with it. It doesn’t hurt or infected…but I know this isn’t my normal face complextion.
I dealt with this very embarrassing and sometimes dibilitating (depending on the circumstance) condition from the time I was 25 till I had a panic attack at age 48. I would seem very embarrassed when there was absolutely no reason. It doesn’t sound bad, but if you’re dealing with it, it is. It keeps you from social situations. Decreases your love for fun and interaction!
After having been prescribed paxil for the attack, I did research and changed things for my life. For me, these helped. God’sgreen earth provides food and herbs for everything and todays busy life styles cause us to deprive our bodies of these things.
FRESH fruits for seratonin levels (among other things). Sage for anxiety. Do your own research. Chocolate for stress. If I slack off on my diet, I feel the difference.
In a nutshell, I never would have thought the seratonin and diet would decrease my facial flushing… but it was found (to my delight) to be a fringe benefit when all I was after was finding a cure against any more panic attacks ( which was an awfully frightening experience!!!!)
I think that everyone here needs to look into candida overgrowth, and possibly bacterial overgrowth, better known as SIBO. Which is diagnosed with a hydrogen breath test. My daughter has flushing with a host of other symptoms so she is on a special anti candida diet that is supposed to starve the overgrowth in her system. So far she is seeing slow but good results.
I also suffer constant redness, Dermatoligy has not helped, I feel like an outcast.
Please send me a copy as well.
Thanks
Will you please send me the full article? Thanks!
Could I get the full article?
Read my blog just above about 4 or 5 blogs…. I don’t know if they’ll see your asking for the article. Try those things and a lot of water seems to help me feel energized, empowered, full of life. fresh…which helps with confidence and flushing
I do see each request for the article and email it freely.
Interestingly I have emailed dozens of copies of it, but only 2 or 3 have ever bothered to say thanks. Seems that something for free is not even worth a response from most.
dp.
Thanks David. The article helped with a question I had. Merry Xmas.
Im dealing w the same situation as most of you described. Its been going on for about a year now and it makes me feel so embarrassed. For me it happens when im eating dinner or lunch on break at work. After my red face settles down I get this awful headache. I think its an anxiety issue but I cant seem to find anything to help calm me down. Will u please send me the full article too?
Thank you for the efforts you put forth to help people like me who experience this syndrome. I have dealt with this for years. It is not hormonal – that has been ruled out. I have lupus, but was told that was not related. Much as others have noted, this appears out of nowhere, burns like the dickens, and yes, is embarrassing. The embarrassing I can deal with, the burning is extremely distracting, not to mention painful. Often I think I could fry an egg on my cheeks! I would appreciate receiving a copy of your article in order for me to further investigate this phenomenon.
Thank you in advance for your assistance.
Im 31. Been dealing with this crap since I was probably 12. Cheeks get red (sometimes upper chest but not very often) usually when stressed or getting too much attention and when I’m too hot or closed in. Extrememy socially dehabilitating. Would greatly appreciate your list to further my research and perhaps discover the way to a new me.
Please send me a copy. Thanks
Hello..please send me the full article..thank you!. I have been getting red and very blotchy on my face, neck and chest. the redness burns on my face and when people say something about it, it tends to get even worse. It happens a lot at work!. Im having a really hard time dealing with this and dont know where to turn. I tend to get red and blotchy when stressed,hot, emotional, or there is a lot of attention on me. I get relief if I go out in the cold. Its good to know reading this that I am not the only one dealing with this.
David, please send the full article. I am very interested in this topic. Thank you.
Hi David,
Please could you send me a copy of the article. I’ve been suffering from debilitating constant redness for over a month now. The doctor said it would go away, but it hasn’t. It began around a year ago as general flushing but now it’s constantly, bright ruddy red. My complexion is olive tone so this is NOT natural. Nothing I’ve been doing for a year seems to make any different; not omega 3, not zinc, not reducing gluten soy alcohol or dairy, not flax seed, not dairy-free probiotics, not manuka honey nor aloe vera nor oatmeal. I am at a loss. Thanks.
Hello David, along with everyone else on here I would really appreciate a copy of your report. I have suffered for years with a red, burning face – with no help or understanding from doctors. Thanks.