Red Face: when flushing isn’t Rosacea

flushing patient

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

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125 Reader Comments

  1. Bek says:

    Diana I’m much like you ! I have been on (in the last 6 months) many acne treatments (all of which have the dreaded side effect “may cause light/photosensitivity” . I stopped Accutane due to intense flushing. After my last tablet it took 17 days for flushing to stop completely. I started a topical (also retinoid based) to try & maintain the results I had obtained from the Accutane and the day after my first application of the topical the flushing returned. 2 weeks after this I went and saw my local GP and we both came to the conclusion that the retinoids were the culprit (alergic reaction/sensitivity) as I have had no other flushing at all since I last applied the topical. He prescribed me Duac (an antibiotic with benz.peroxide that also has a light/photosensitivity warning) and guess what … I’m 10 days in to using the cream and the flushing has returned. What a nightmare but honestly I’m stopping all medication for a while as the flushing is worse than the acne and really I feel while the flushing is happening it actually is causing more inflammation and brings up new spots. Just my 2 cents but I’m almost 100% sure this is the reason for my flushing,

  2. Jason says:

    Hi could I get a copy of the article sent to me? I have very recently been diagnosed with rosacea. But I also had stomach issues before that which included shortness of breath and acid reflux. Those issues have passed but I’m worried it’s all tied together somehow seeing as all of the symptoms are new to me and happened within 3 months of each other.

  3. Pete says:

    Hello David,
    If too much time has not passed I would love to get a copy of the article.
    Thanks so much

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