Flushing
by Brady Barrows

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. [1] 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. 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." [2]

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.” [3] 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'." [3] [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]

When rosaceans complain of frequent flushing, especially accompanied by burning, flushing avoidance is one of the chief means of controlling it along with anti-flushing drugs. [6]

Rosacea triggers can be divided into two categories:

(1) Anything that produces a rosacea flare up

(2) Anything that causes a flush or blush

It is good 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-termfacial application of topical steroids." [7]

More info on triggers

More info on Flushing

More info on Flushing Avoidance

Sources
[1] For more data on the confusion of flushing is rosacea click here

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

[3] 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] Rosacea 101: Includes the Rosacea Diet
by Brady Barrows; Chapter 10, Flushing

[7] 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.