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Flushing Explained


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Facial flushing in a 22-year-old. Image courtesy of Wikimedia Commons

Phenotype 1 Flushing

"For a person to flush is to become markedly red in the face and often other areas of the skin, from various physiological conditions. Flushing is generally distinguished, despite a close physiological relation between them, from blushing, which is milder. Generally restricted to the face, cheeks or ears, but also presents in the vagina, specifically in the Vulva and generally assumed to reflect emotional stimulus such as embarrassment, or lovestruck|romantic stimulation. Flushing is also a cardinal symptom of carcinoid syndrome—the syndrome that results from hormones (often serotonin or histamine) being secreted into systemic circulation." Wikipedia

Gerd Plewig, MD, says, "there is no direct evidence that rosacea is primarily a vascular disorder. The response of the facial vessels to adrenaline, histamine and acetylcholine is normal, and the vessels do not seem abnormally fragile so the main abnormality is probably in the dermis surrounding blood vessels rather than in vessel walls. In addition, the distribution of rosacea is not identical with the flush area." [1] The controversy about flushing is best described by a noted authority on rosacea, Albert Kligman who wrote, "I, and others, regard rosacea as fundamentally a vascular disorder which ineluctably begins with episodes of flushing, eventuating in the 'red' face." [2] However, another noted authority on rosacea, Dr. Frank Powell "insists that episodes of flushing are not a prerequisite for making a diagnosis of rosacea, and that some patients can develop the full-blown disease without a prior history of frequent flushing. Rebora too, another investigator, says that flushing is not a necessary stage in the sequence leading up to the full-blown 'red face'." [4]  Powell in his book wrote a chapter on Flushing and Blushing and confirms what other clinicians have found that while both are seen 'sufficiently often enough' in rosacea patients and both flushing and/or blushing are the 'first features of rosacea to appear in some patients," nevertheless, "flushing and blushing are not necessarily a component of the clinical picture in all patients with rosacea." [5]

Flushing is a sign/symptom of rosacea just as telangiectasia, erythema, pustules/papules, ocular manifestations, or rhinophyma, which are the six phenotypes of rosacea. In the old subtype classification flushing was not separated into a subtype. 
Read this notice about the subtype classification

Flushing is now considered a phenotype of rosacea. However, not all rosacea cases include all six phenotypes. Not all cases of rosacea include the Flushing phenotype. [6] Generally speaking more rosacea sufferers experience flushing than those who report they do not flush. 

Flushing is associated as a sign/symptom with many conditions. As one report concludes, "flushing [is] associated with fever, hyperthermia, emotions, menopause, medications, alcohol, food, hypersensitivity reactions, rosacea, hyperthyroidism, dumping syndrome, superior vena cava syndrome, and neurologic etiologies. [7] It is important that the physician differentiates rosacea from these other conditions. 

Treatment for Phenotype 1

Blushing & Flushing Triggers

Prescription and Non Prescription Flushing Avoidance

List of Anecdotal Reports of Rosaceans Who Report No Flushing

End Notes 

[1] Rosacea: classification and treatment.
T Jansen and G Plewig
J R Soc Med. 1997 March; 90(3): 144–150.

[2] A Personal Critique on the State of Knowledge of Rosacea
Albert M. Kligman, M.D., Ph.D.
The William J. Cunliffe Lectureship 2003 –Manuscript

[4] Am J Clin Dermatol 2002; 3: 489-496.
The management of rosacea
Rebora A

[5] Rosacea Diagnosis and Management by Frank Powell
with a Contribution by Jonathan Wilkin

[6] Anecdotal reports of patients who received a diagnosis of rosacea who report no flushing:
Rhea, 4th August 2012 01:58 PM

More Info on Flushing

[7] J Am Acad Dermatol. 2017 Sep;77(3):391-402. doi: 10.1016/j.jaad.2016.12.031.
Etiologies and management of cutaneous flushing: Nonmalignant causes.
Sadeghian A, Rouhana H, Oswald-Stumpf B, Boh E.

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