What could be causing my warm, red cheeks given my history of Sjögren's syndrome and use of Plaquenil (hydroxychloroquine)?

Warm, Red Cheeks in Sjögren's Syndrome

Your warm, red cheeks are most likely a cutaneous manifestation of your Sjögren's syndrome rather than a side effect of Plaquenil (hydroxychloroquine), and you should have this evaluated by your rheumatologist to rule out vasculitis or other serious systemic complications.

Understanding Skin Manifestations in Sjögren's Syndrome

Cutaneous involvement occurs in nearly half of patients with Sjögren's syndrome and includes various manifestations beyond the classic dry skin 1. Facial erythema and warmth can represent several distinct dermatologic patterns in Sjögren's syndrome 2:

Common Benign Manifestations

• Annular erythema presents as ring-shaped red patches that may feel warm and can affect the face 2
• Eyelid dermatitis can extend to involve the cheeks with redness and warmth 2
• Xeroderma (dry skin) may appear red and inflamed, particularly on the face 1, 2

Potentially Serious Manifestations Requiring Urgent Evaluation

Cutaneous vasculitis is a critical concern that can manifest as facial redness and warmth 1, 2. This finding is of paramount clinical importance because:

• It confers increased risk for life-threatening multisystem vasculitis 1
• It may indicate increased risk for non-Hodgkin lymphoma development 1
• Vasculitis can present as palpable or non-palpable purpura, but may also appear as simple erythema initially 1, 2

Hydroxychloroquine (Plaquenil) Considerations

While you're taking Plaquenil, it's important to understand its dermatologic profile:

Plaquenil is Unlikely the Cause

• The JOQUER trial demonstrated that hydroxychloroquine had no efficacy in improving Sjögren's symptoms including systemic manifestations 3
• Hydroxychloroquine can cause serious skin reactions, but these typically present as Stevens-Johnson syndrome, toxic epidermal necrolysis, DRESS syndrome, or acute generalized exanthematous pustulosis—not simple facial flushing 4

Plaquenil Can Worsen Certain Conditions

• Hydroxychloroquine may precipitate severe flares in patients with psoriasis 4
• It should be avoided in patients with porphyria as it can exacerbate the condition 4

Red Flag Symptoms Requiring Immediate Attention

You must seek urgent evaluation if you develop any of the following 5:

• Unexplained weight loss, fevers, or night sweats (suggesting lymphoma)
• New lymphadenopathy, particularly in the head and neck region
• Progressive skin lesions or purpura (suggesting vasculitis)
• Parotid swelling or enlargement

Recommended Evaluation Pathway

Contact your rheumatologist promptly for the following assessment 6, 7:

1. Physical examination focusing on:

   • Pattern and distribution of facial erythema
   • Presence of palpable purpura or other vasculitic lesions
   • Lymphadenopathy (head, neck, and systemic)
   • Parotid gland enlargement

2. Laboratory evaluation to assess disease activity:

   • Complete blood count (monitoring for cytopenias)
   • Inflammatory markers (ESR, CRP)
   • Complement levels (C3, C4)—low C4 indicates increased lymphoma risk 5, 8
   • Cryoglobulins (if vasculitis suspected)

3. Skin biopsy if vasculitis or other serious manifestation is suspected 2

Management Approach

Strict collaboration between your dermatologist and rheumatologist is essential for adequate management of Sjögren's syndrome skin manifestations 2:

• Avoid alcohol and tobacco smoking 2
• Maintain excellent skin hydration with emollients for xeroderma 2
• Systemic immunosuppression may be required if vasculitis or other serious manifestations are confirmed 5

Critical Pitfall to Avoid

Do not dismiss facial redness as a cosmetic concern or simple rosacea without rheumatologic evaluation, as cutaneous manifestations in Sjögren's syndrome can herald serious systemic complications including vasculitis and lymphoproliferative disease 1. The 5% lifetime risk of lymphoma in Sjögren's syndrome makes vigilant monitoring essential 5, 8.