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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59 comments ↓
How prevalent is face flushing in multiple sclerosis? If there are no other symptoms.
What is the prevalence of flushing in homocysteinuria?
can ipl work for redness non rosacea??
please answer
Hi Felipe,
Yes, if your redness is vascular in origin then IPL could work well. Hopefully you can find a doctor who can tell you the exact reason for the redness – that would be a good start.
davidp.
my cheeks can be touched slightly by pure water and turn red, why is that, it haas been like that since my mid 16th birthday, is it possible that all my skin barrrier has been damaged by skin creams perscribed for acne?
if so is there a medicine/cream that can not help but actually rebiuld the skin barrier to be strong again?
thank you 4 ur time
Hello Davo, Can you send me a copy of this article? please.
I can’t find it in the web. Thanks a lot
Hi Ricardo,
I have sent it to you.
davidp.
Davo, I also would love to get a copy of the above mentioned article. Thanks.
and sent to Logan too.
Hi Davo,
Thank you for putting up this informative article. I would be grateful if you could send me a full copy of the paper.
John
aaaaand sent to John.
i don’t have a doctor and wouldn’t know where to find one.My face has a red appearanceand my forehead looks red and blottchy.idon’t use and sunblocks and anything on my face and its been this way for a year.im 37 and fair completed . what is wrong with me?oh i smoke
Please send me a full copy of the paper, too. Thanks
sent to Maryann.
Feel free to offer your own comments after reading the paper guys – would be nice to not just be a document server here….
Hi Davo,
I have been to dermatologist and nobody can tell me whats wrong. My face flushes so bad that my face will start hurting and my lips burn as well, almost like they are chapped. At night its calms and by morning I’m fine, but then as the day goes on it starts all over. I do ussually have diarrea and don’t know if this has anything to do with it. Any info would be great thank you.
Hi Jim,
Of course it is hard to say via the net. Facial flushing can cause pain. Finding a doctor to work with you will be key for you. The sorts of treatments you might like to explore with a doctor might be IPL or Red Light Therapy or things like clonidine.
One place to start might be the Facial Burning & Pain or Blushing & Flushing community forums.
davidp.
Hi. I am a 47 years old female. My entire face and eyes are always red. I do not have any breaking out just very red. I do not smoke or drink. I was told when I was 17 that I had Raynaud’s syndrome. I do take Thyroid medication. Can this still be rosacea?
Could you send me a full copy of this paper. Thanks.
Hi, I just suffer from Facial flushing. Face just turns red. Sometimes worse than other times. Is there a cure? I don’t have rosacea.
I have been to 4 docs trying to find out why my 12 yr old daughter flushes, runs a temp, feels extremely tired and sick. She has been doing this since Nov. of ‘08 and is still doing it 3-26-09. Some days are not that bad some days are really bad. She feels the flush coming on then she will feel sick, then she will flush sometimes moderate in which she can still function well. Then there are times that she will flush horribly and needs to pass out basically from feeling so tired. I don’t know how to get the docs to take concern in this …..there is something wrong. I don’t believe that you run a fever like she does with this unless something is wrong. She has had hormones tested, and anything else you can think of . If any one has an idea I’d really appreciate hearing from you. Thank you.
Sherri
Hi
I get major red flushes – not from rosacea. Any time im embarrassed, wrong, stressed, nervous. Its horrible and so embarrassing (which makes my face go redder) Is there any treatment for this?
Thanks!
have intense redness on neck and chest, wrists, sides of inner elbow. Was diagnosed with rosacea about 10 years ago. Could redness on body be associated with rosacea. Feels hot and itchy.
could be seborrheic dermatitis
Hello,
How can I get a full copy of this article?
I was diagnosed with Rosacea by one doctor, and another telling me it isn’t, yet every day I get worse and worse. The red flushing gets worse, I am having chest tightness and always short of breath and I am excessively tired all the time.
I was recently hospitalized after going into anaphylactic shock from an iodine injection (for an abdominal/pelvic scan), but I had the red face / flushing for years prior to this.
I am desperate.
Thanks.
Lyssa
My husband has red cheeks – the doc told him once that it has something to do with blood vessels being close to the skin surface–is there something he could do–some cream he could use to lessen the severity of his problem?
I would also love a full copy of this report…Thank you
Hi if I could have a full copy of the article please that would be great. I have facial flushing that gives me a headache and makes my heart race and have had anaphylactic reactions. I have been told that it is not allergies but mast cells that may cause this and then sent away by the immunologist. Still happening and so would value any info.
Katie
is IPl contraindicated with Roaccutane????
please answer back
Hello Felipe,
The Accutane Prescribing Information is pretty direct on this question “Do not have cosmetic procedures to smooth your skin, including waxing, dermabrasion, or laser procedures, while your are using Accutane and for at least 6 months after you stop. Accutane can increase your chance of scarring from these procedures. Check with your doctor for advice about when you can have cosmetic procedures.”
all the best,
davidp.
I have a red face.I went to the doctor and he done lazer.It worked and got rid of some reddness.However after geting it done i could not go anywhere for a week because Marks appeared on my skin then disapppeared after a week.I heard that IPL is better than lazer as it leaves no marks that need to be healed and also does a larger surface area of your face.Is that true and do you think its better?
Hi Tommy,
IPL can have less downtime, as can other more gentle forms of laser like V-beam. As to whether IPL is generally considered better than laser, that is a difficult question to answer categorically. If you find a good IPL doctor then I think you can expect good results for your rosacea.
You might find the Laser & IPL Forum helpful.
davidp.
i always go red when people embaress me and when i run around alot i hate it i wanna kill the disease awwww!!!! my friends always say ur goin red and that makes me even redder!!
Hi Dave,
could u send me a copy, too.
Could you please send me a copy also! Thanks so much!
when I started high school I started to flush really bad. It became so out of control and that i quit school and became very depressed. i also started having bad panic atacks that made it worse. I just turn red for any reason I hate it and am glad to know that others understand what i’m dealing with. i’m now 32 and still flush and when people notice they love to draw attention to my red face, which makes me even more flushed. Please help i feel like if i didn’t have this I would be able to live the life I was meant to live
I would be very appreciative to have a copy of this article.
Thanks,
Martha
Copy to sent to all who asked.
Please send me a copy of this article, too. Thanks very much!!!!!!!!
I am 64yrs. old just recently diagnosed with rosacea.
I have always had flushing in the face please help stay tuned in to all the info.
thanks.
Yessir, please send me a copy of the paper. Red-headed, often-sunburned-as-teen, beer-drinker that has also been diagnosed with rosacea and rhynophymia…and a large handful of other internal conditions.
Thanks,
Big Red
Hello, I also would like a copy. I’m 32 and for the last 4-5 years my nose and the center of my face has been red, and getting worse it seems,when I go skiing, in a spa or have beer it gets worse. It Sucks !!! Thanks for the info and any advice would be killer!!!
Hi,
I have always had flawless olive toned skin that turns golden when tan, but lately I developed severe dry eye (at 20), started breaking out and my face is starting to get very red. Do you think this could be rosacea, a food allergy, or am i overwashing my face ?
If you could send me this article, I would REALLY appreciate it.
Thank you!
Hi,
I have a really red face, red hands and feet. Very embarressing! I put cover up on my face, doesn’t work! I’m sooooo frustrated with this disease! Help, I really want to know what the heck this is!
could you please send me a copy of this article? thank you.
please.. please… send a copy of this article to me too any help would be helpful ….. mr red face in massachusetts
Could you please send me a copy of this article? Thank you.
I would appreciate a copy of the article too, thank -you.
Would appreciate a copy aswell. Thank you
Hi, I have been experiencing some really bad burning in my face and flushing. I do have SLE and am familiar w/ the butterfly rash but this is different. My eyes are burning also. I would like to have a copy of this article also. My 14 yr. old son has experienced facial flushing for years. I have taken him to the Dr. and they are baffled. I think this article will be of great help for the Dr. Thanks for your time!!
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!!
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