What causes flushing of the face?

Causes of Facial Flushing

Rosacea is the most common cause of facial flushing, characterized by persistent centrofacial erythema with periodic intensification by trigger factors. 1

Primary Causes of Facial Flushing

Rosacea

• Characterized by erythema, telangiectasia, papules, pustules, prominent sebaceous glands, and rhinophyma 2, 1
• More common in fair-skinned individuals but can occur in all skin types 2
• More prevalent in women but can be more severe in men 2, 1
• Often presents with history of easy facial flushing and telangiectasia 2
• Diagnosis may be challenging in darker skin tones due to difficulty visualizing erythema 1
• Demodex mites may play a role in pathogenesis with increased mite load in affected individuals 2

Medication-Induced Flushing

• Isotretinoin (used for severe cystic acne) can cause facial flushing and blepharitis 2
• Selective serotonin reuptake inhibitors (SSRIs) like escitalopram can cause flushing through serotonergic effects leading to peripheral vasodilation 3
• Metronidazole can cause flushing as an adverse reaction, especially when combined with alcohol 4
• Other medications known to cause flushing include prostacyclins, niacin, calcium channel blockers, and nitrates 3, 5

Alcohol Consumption

• Can trigger flushing, especially in combination with certain medications like metronidazole 4
• Causes abdominal cramps, nausea, vomiting, headaches, and flushing when consumed during or following metronidazole therapy 4

Menopausal Hot Flushes

• Common cause of episodic flushing in perimenopausal and menopausal women 6, 5
• Characterized by sudden sensation of warmth with visible cutaneous erythema 7

Less Common Causes

Carcinoid Syndrome

• Causes episodic dry flushing (without sweating) due to release of vasoactive substances 6, 7
• Often accompanied by gastrointestinal symptoms 7

Mastocytosis

• Characterized by mast cell proliferation and release of histamine causing flushing 6, 7
• May be triggered by physical stimuli, certain foods, or medications 7

Pheochromocytoma

• Causes episodic flushing along with hypertension, headache, and palpitations 6, 8
• Results from catecholamine release 7

Neurologic Causes

• Harlequin syndrome - unilateral facial flushing due to autonomic dysfunction 9
• Autonomic disorders affecting sympathetic pathways 9

Other Causes

• Hyperthyroidism can cause flushing along with other symptoms of thyrotoxicosis 5, 7
• Dumping syndrome after gastric surgery 7
• Food-induced flushing (spicy foods, MSG, sulfites) 5
• Hypersensitivity reactions 5

Diagnostic Approach

• Evaluate pattern of flushing (wet vs. dry, distribution, triggers, associated symptoms) 7
• Assess for accompanying symptoms:
  • Gastrointestinal symptoms may suggest carcinoid syndrome or other neuroendocrine tumors 7
  • Ocular manifestations like blepharitis, conjunctivitis, and keratitis suggest rosacea 2, 1
  • Hypertension and tachycardia may indicate pheochromocytoma 6
• Review medication history for potential causative agents 3, 5
• Consider underlying dermatologic conditions like seborrheic dermatitis, which is present in 95% of patients with seborrheic blepharitis 2

Clinical Pearls

• Rosacea is often overlooked in children who may present with ocular findings before cutaneous manifestations 2
• Children with a history of styes have an increased risk of developing adult rosacea 2
• Flushing episodes can sometimes mimic anaphylactic events and should be distinguished from more serious reactions 3
• If symptoms are not progressive and no serious underlying cause is found, patients can be reassured about the benign nature of their condition 6