Red Face: when flushing isn’t Rosacea

Written by on August 2, 2006 in fact sheets, flushing, Red Face of Rosacea with 113 Comments

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 flushing

Common Causes

Benign cutaneous flushing

Emotion
Temperature
Food or beverage

Rosacea
Climacteric flushing
Fever
Alcohol

Uncommon, serious causes

Carcinoid
Pheochromocytoma
Mastocytosis
Anaphylaxis

Other causes

Medullary thyroid carcinoma
Pancreatic cell tumor (VIP tumor)
Renal cell carcinoma
Fish ingestion
Histamine
Ciguatera

Psychiatric or anxiety disorders
Idiopathic flushing
Neurologic

Parkinson’s
Migraine
Multiple sclerosis
Trigeminal nerve damage
Horner syndrome
Frey syndrome
Autonomic epilepsy
Autonomic hyperreflexia
Orthostatic hypotension
Streeten syndrome

Medications

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 syndrome

Summary: 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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About the Author

About the Author: David Pascoe started the Rosacea Support Group in October 1998. .

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113 Reader Comments

  1. Daniel says:

    Could I get the full article?

  2. Sandra says:

    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

  3. David Pascoe says:

    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.

  4. David says:

    Thanks David. The article helped with a question I had. Merry Xmas.

  5. Lindsey says:

    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?

  6. Portia says:

    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.

  7. Phil says:

    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.

  8. Chris says:

    Please send me a copy. Thanks

  9. Stefanie says:

    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.

  10. Maureen says:

    David, please send the full article. I am very interested in this topic. Thank you.

  11. justme says:

    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.

  12. Andy D says:

    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.

  13. Christy says:

    Hi, could you please email me a copy of this article. This is exactly what I face almost everyday. it’s very embarrassing. Thank you ahead of time!

  14. Louise says:

    Hi,
    Please could you send me a copy too. I have mild Rosacea, had it years but since last June Ive had a red chest and neck. This happened after what may have been an allergic reaction to Omeprazole or fake tan and was made much worse by the sun. All tests have come back negative apart from Ige of 1100 which may be my dust mite allergy that Ive had for years. Im at a loss, waited ages to see a dermatologist who just said it wasnt typical of an allergy, isnt Lupus as no scarring?? and that its Rosacea and flushing and gave me 3 months ABs for acne??? Lat doc said ay be stress urticaria, allergy or fungal infection. I dont know what to do next and am getting worried now.
    Thank you for any help.

  15. chris says:

    pleas send me a copy,my breakout of redness in social situations crushes my confidence and makes me feel terrible,and it goes through the roof when people start to comment on it

  16. Mike says:

    It’s actually a bit refreshing to hear that I am not alone. I find myself looking at other people’s faces and wondering why everyone else seems to have perfect skin except for me. I would like a copy if it is still available. Thanks

  17. Anne says:

    David, I have just started having these neon red faced flare up at the age of 49. Oh joy. It’s not hormonal because all that is long gone. I was glad to see all those comments ahead of me… at least I’m not alone, though I would not wish this on my worst enemy. It does make you want to hide from social activities, for sure. I would love to get a copy of the paper. Thank you so much. I’m sorry some have not bothered to thank you. anne

  18. Dan says:

    Like others, i have been dealing with this since i can remember, i am 29. I am fair complected however my cheeks feel hot, and get red often, especially when embarrassed, complemented, etc. Trying to figure out what to do. Dermatologist said some people are just genetically inclined to do this. I’d like to control it.

    Could you send it to me, please?

  19. Brandon says:

    Rosacea (assuming that’s what this is) is a killer. Sometimes you deal with it and you can almost forget about it, but when you have a bad day, it’d the worst day of your life. You put yourself under a microscope far worse than others and (especially) the way you perceive others. I would very much like a copy. Thank you very much.

  20. Lora says:

    I know exactly how everyone feels. I have been dealing with constant flushing since October. I was very stressed at the time, and it has only happened more with my higher stress levels. I’m very sensitive to heat and this happens later in the day or sometimes after lunch-but never in the morning. Please help and send me this article. I don’t know what to do.

  21. Fred says:

    Could you please e-mail me this full article. Thank you.

  22. Elizabeth says:

    I have had flushing for over 15-20 years. I never addressed the issue because I am alleergic to preservatives used in foods. I get really red in the chest up, I sneeze, and I have diarrhea after eating. Even when I watched what I eat, I still have the red chest, red face, and red scalp. Finally I decided that the pain in my left side below the ribs was not going away. The doctor thinks that I have carcinoid tumor. The next round of test are coming up. I pray to God that they find a noncancerous tumor.

  23. Cathy w says:

    I began having occasional flushing several years ago. Went to a dermatologist and she said I had “blushing capillaries”-still unsure what this means. In the last 2 years I am neon red from chest up and rarely my face feels like it is on fire. I have had rosacea ruled out. My blood pressure is under control and doesn’t spike. I have had left side facial tingling 2 weeks ago. My md said it was a mystery and couldn’t be serious since I had ran a 5 mile race 3 days prior. I am very concerned and would appreciate a recommendation. This is not normal- I mean I am a nuclear red female.

  24. Nancy says:

    Cathy:

    I would suggest that you make an appointment with a Romatologist who is trained to spot more specific symptoms of disease and can run some detailed tests that your internist won’t understand. Also, going to a Dermatologist at a teaching hospital where doctors are trained in diagnosing and treating inflammatory skin diseases. I happen to have severe rosacea but with the wonderful Dermatology staff at UCSF in n. CA, you would never know it if you met me because my doctor is also a Phd. who is trained to treat inflammatory rosacea and other skin diseases. I know how upsetting and frustrating these conditions can be, but don’t give up! Keep searching for a medical doctor who can give you an answer and diagnoses. It could be something simple or another issue that a specialist can treat.

    Best wishes,

    Nancy

  25. jo says:

    ive recently been diagnosed with rosecea and also when at the the gym last week after a strenuous work out i was like a strawberry for 2 hours after, it was very scary because i thought what if this isnt the rosecea? eventually the next day i was left with a rash of some sort which were a combination of pustules and flat blemishes under the skin
    ive been precribed rozex but its not made much difference but im giving it a chance and going to continue with it, most of the time my face is just red like other have mentioned on here,

  26. Courtney says:

    I would love to get a copy of this the full article. I also have had flushing that has gotten much worse over the last 3-4 years. It now occurs 80% of the day for no reason at all and it is painful most of the time. It occurs from my chest up and I would love to get some answers!

  27. tauseeq says:

    ti have had rosacea from 2 years with significant flushing triggers but last year , i went on for v beam (pulsed dye laser) after 6 treatments my redness has gone away but still flushing is there but quite manageable, i dnt think that flushing has any cure….

  28. John says:

    Can you please send me a copy as well. I have been told I have rosacea however none of the medicines I’ve received have helped and now I have bright red blotches on my neck, under my jaw, both cheeks, and forehead

  29. Patty says:

    i also have flusing. Mine is caused by systemic mastocytosis. I gave up sales because I was very slef concious of it. I didn’t want my customers to think that I was lieing to them. I would explain my disorder. Have your doctor look into this disorder. It is also a very painful disordorder that affects the whole body.Good luck.

  30. Linda says:

    Hi David – Could I pls have a copy of the “Red Face: When flushing isn’t Rosacea” pls? I have a mild Rosacea condition; but trying not to over-rely on topical gels over time. I am interested in seeking treatments with naturopathic doctors. Thanks.

  31. Kristina says:

    Can I have a copy please David? It would be greatly appreciated. I’ve been trying since I was 21 to get this under control and at 29 it’s so much worse, permanent damage. I’m devastated.

  32. Phillip says:

    I;m 40 years old and have been dealing with this since early teen years. I get bright red when speaking, especially in an “all eyes on me” setting (oral reports, meetings, etc, etc) … One side of my face is more flushed than the other, which could be because I have crossbite and misaligned jaw. I’m sure that pressure on the left side of my face does not help the condition. I get red on my ears, face, neck, chest, etc when I run or play with my children, especially after a shower or shave. People constantly ask me if I need water, because I look red all the time. Hot or cold! Earlier in my childhood years, I remember my family doc saying something about my cooling system not working right … I’d like to have the full article as well. If there is any homeopathic remedies that have worked, that would be helpful. Thank you!

  33. Dave says:

    This has worked for me. I had the same issue for years even as a child. Right now I have very little to no flushing.
    1. I’m now using Toleriane Creme Moussante Purifying Foaming Cream for Combination to Oily intolerant skin by La Roche-Posay.
    2. Exercise rigorously 1.5 hours three times a week until you are sweating. This is key to flushing out all the toxins out of your body and skin and it will raise your confidence and spirit.
    3. Take vitamins for your skin e.g. skin akin, oregano oil, vitamin e and buy a juicer. I drink about two oranges, two apples, blueberries and freshly squeezed grapefruit.
    4. Lastly try to relax. Stress and worry will flare you up.
    The above has worked for me.

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