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Flushing

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Flushing is one of the primary signs of rosacea and has become so important to most rosaceans to the point of confusing flushing with rosacea. However, flushing is one of the signs of rosacea, just as erythma (redness), pustules and pimples are signs of rosacea. To confuse flushing as rosacea is like confusing pustules and pimples as rosacea. While flushing is indeed one of the distinguishing signs differentiating rosacea from acne or other rosacea mimics, not all rosacea sufferers flush or blush any more than the general public or complain of flushing. Another important point to consider is that a rosacea sufferer may experience a flush or blush that subsides and does not result in a rosacea flare up.

Many rosacea sufferers do indeed complain of frequent and prolonged flushing which aggravates rosacea. One clinical paper says that "rosacea sufferers thought that that they blushed more intensely and were more embarrassed than controls during most of the tasks." [10] This has led to some theories that rosacea is a vascular disorder which assumes that flushing is at the heart of this disorder. However, this has never been proven.

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] [12] 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]

Another paper put this controversy into perspective:

"Flushing due to rosacea may be mistaken for sensitive skin, which can manifest as abnormal sensations during fairly acute reactions to a variety of triggers, many of which are shared by rosacea and sensitive skin. Nevertheless, the two conditions are clearly different. Rosacea is a vascular disease, worsens gradually over time, manifests as flares triggered chiefly by systemic factors, is largely confined to the facial and/or ocular regions, and responds to specific treatments. Sensitive skin, in contrast, is an epidermal cosmetic problem that runs a variable course, with diffuse skin involvement and flares triggered mainly by contact factors. The flares respond to specific cosmetics and are usually worsened by treatments for rosacea." [8]

So with the above paragraph in mind, it is possible you are suffering from flushing and sensitive skin, but the treatment for each of these are quite different and shouldn't be confused with each other. Flushing is totally different from sensitive skin. 

When rosaceans complain of frequent flushing, especially accompanied by burning, flushing avoidance is one of the chief means of controlling it usually with anti-flushing drugs.

Rosacea triggers can be divided into two categories:

(1) Anything that produces a rosacea flare up

(2) Anything that causes a flush or blush

To reiterate, it is important to remember that not every flush produces a rosacea flare up. It is possible to flush and later your skin returns to normal. Another important point is to differentiate between rosacea flushing and other conditions that produces flushing.

According to Izikson et al, "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-term facial application of topical steroids." [6] You may not be suffering from rosacea, instead, your condition may be something else. 

However, most rosaceans are more concerned with flushing/blushing and avoiding anything that could cause a flush/blush. Balance is the key and to not become obsessed with flushing avoidance. The following study underscores why a rosacean should be careful not to become overly obsessed with flushing avoidance:

"Blushing propensity scores are elevated in people with severe rosacea. Fear of blushing may contribute to social anxiety and avoidance in such cases. Cognitive-behavioural therapy for fear of blushing may help to reduce social anxiety in people with severe rosacea." [7]

It is important to differentiate flushing disorders from rosacea. As one report puts it, "The differential diagnosis of cutaneous flushing is extensive and encompasses a variety of benign and malignant entities." [11]

"However, trigger causation mechanisms are currently unclear.....These data indicate that rosacea affects SSNA and that hyperresponsiveness to trigger events appears to have a sympathetic component." [13]

An excellent article on flushing by Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, is worth the time reading. [14]

Treatment

Prescription and Non Prescription Drugs

ETS

Micro ETS at R2

Stellate Ganglion Nerve Block

More Help

More info on triggers

More info on Flushing

More info on Flushing Avoidance

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

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

[6] The flushing patient: differential diagnosis, workup, and treatment.
Izikson L, English JC 3rd, Zirwas MJ.
Department of Dermatology, University of Pittsburgh Medical Center, Pennsylvania, USA.
J Am Acad Dermatol. 2006 Aug;55(2):193-208.

[7] Blushing Propensity and Psychological Distress in People with Rosacea.
Su D, Drummond PD.
Clin Psychol Psychother. 2011 Jun 23. doi: 10.1002/cpp.763.

[8] Sensitive skin and rosacea: nosologic framework.
Misery L.
Laboratoire de Neurobiologie cutanée, Université de Brest, France; Service de Dermatologie, CHU de Brest, 29609 Brest, France.

Ann Dermatol Venereol. 2011 Nov;138 Suppl 3:S207-10.

[10] Blushing in rosacea sufferers.
Drummond PD, Su D.
J Psychosom Res. 2012 Feb;72(2):153-8. Epub 2011 Oct 1

[11] J AM ACAD DERMATOL, AUGUST 2006, p. 193 - 208
The flushing patient: Differential diagnosis, workup, and treatment
Leonid Izikson, MD, Joseph C. English, III, MD, and Matthew J. Zirwas, MD

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

[13] J Neurophysiol. 2015 Sep;114(3):1530-7. doi: 10.1152/jn.00458.2015. Epub 2015 Jul 1.
Augmented supraorbital skin sympathetic nerve activity responses to symptom trigger events in rosacea patients.
Metzler-Wilson K, Toma K, Sammons DL, Mann S, Jurovcik AJ, Demidova, Wilson TE.

[14] Flushing, Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, DermNet NZ

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