07 April, 2016

Other conditions that cause facial flushing, and mimic rosacea symptoms

Facial flushing and redness are usually quickly associated with rosacea, but they can in fact be symptoms of a different medical condition. Often when you visit a dermatologist with rosacea symptoms, the diagnosis 'rosacea' is made based on an evaluation of your clinical symptoms, which can be assessed through a visual examination by your doctor or through an account of the symptoms you describe. There is currently no clinical 'test' to determine if you have rosacea. When you have redness of the face (especially the cheeks) and not the rest of your body, plus transient flushing issues and for many also burning sensations of the skin, the diagnosis is often easily made. Facial flushing is however not always a symptom of rosacea. Brady Barrows wrote about this in a Rosacea Forum post: "Some physicians, notably Dr. Kligman says that rosacea is a vascular disorder and flushing is one of the distinguishing characteristics for a diagnosis. While even Dr. Powell acknowledges that flushing is probably one of the most distinguishing characteristics in a diagnosis, he says he has seen patients with rosacea who do not flush any more than the general population and these patients do not report flushing. However, the inflammation or erythema associated with rosacea can cause the burning sensation that most rosaceans complain about." 



Unfortunately long term facial flushing episodes -years for instance- can worsen your rosacea, both in terms of increases baselines redness and increased flushing attacks and lowered flushing threshold. That meams the burning often worsens too over time. hence why trying to avoid flares and flushing helps to stabilize the condition. For many it's progressive by nature.
One flushing episode can subside and leave your rosacea unchanged and a year of this might as well, but years on end, usually not :/
I also found several official medical sites claiming that ongoing facial flushing (for instance from menopause hot flashes, from carcinoids, or anything else basically) can and has caused rosacea in the long run. Flushing can become a serious thing if you don't tackle it at some point..


*Clevelandclinic states: "Repeated flushing over a prolonged period can lead to telangiectasia and occasionally to classic rosacea of the face. [..] Patients with severe flushing caused by mastocytosis can develop rosacea in less than 1 year after the onset of flushing episodes." (Freedberg IM, Eisen AZ, Wolff K, et al (eds): Fitzpatrick’s Dermatology in General Medicine, 5th ed., vol. 1. New York: McGraw Hill, 1993, pp 142-1659.)

*Wiki states regarding hot flashes: "Excessive flushing can lead to rosacea."

*Dr. Mehmet Oz (love his show) wrote: "Hot flashes and the flushing they cause may trigger rosacea flare-ups."

*Dr. Richard Wagner wrote: "Actually, carcinoid syndrome can cause rosacea because of the chronic flushing"




And an interesting article on flushing from the Cleveland Clinic states:
"Flushing can be an exaggeration of a physiologic process or a manifestation of a serious condition that needs to be identified and treated. Flushing described episodic attacks of redness of the skin together with a sensation of warmth or burning of the face, neck and, less frequently, the upper trunk and abdomen. It is the transient nature of the attacks that distinguishes flushing from the persistent erythema of photosensitivity or acute contact reactions. Repeated flushing over a prolonged period can lead to telangiectasia and occasionally to classic rosacea of the face."






It goes on to give a (very thorough) definition of flushing;
"Redness of the skin may be caused by an increased amount of saturated hemoglobin, an increase in the diameter or actual number of skin capillaries, or a combination of these factors.2 Flushing is caused by increased blood flow through the skin, causing warmth and, because of engorgement of the subpapillary venous plexus, redness. The vasodilation of flushing may be caused by a direct action of a circulatory vasodilator substance—for example, histamine—or it may be caused by changes in the neurologic control of the cutaneous vasculature in the affected areas. In the face, neck, and upper trunk, where flushing is most frequent, the neurologic control of vascular tone is predominantly exerted by autonomic vasodilator nerve fibers. These fibers are found in somatic nerves supplying the affected skin, including the trigeminal nerve. Because autonomic nerve fibers also supply eccrine sweat glands, neurally activated flushing is frequently associated with sweating (wet flushing) as opposed to flushing caused by circulating vasodilator mediators, which frequently does not involve sweating (dry flushing). The presence or absence of sweating has therefore been proposed as a clinical guide to the mechanisms of flushing, although in practice this is not always reliable. Examples of wet flushing are physiologic flushing and menopausal flushing. An example of dry flushing is niacin-provoked flushing."




It also explains why flushing predominantly happens in the facial area: "The diameter of the blood vessels of the cheeks is wider than elsewhere, the vessels are nearer to the surface, and there is less tissue thickness obscuring them. This may explain why flushing occurs in that limited distribution.3 Polycythemia produces the characteristic ruddy complexion, but it may also cause a peculiar coloration termed erythremia, which is a combination of redness and cyanosis. The tongue, lips, nose, earlobes, conjunctivae, and fingertips especially demonstrate this coloration. Erythremia results when there is a combination of increased amounts of saturated and desaturated hemoglobin."





Clock Rosacea or Systemic Flushing
Flushing or facial skin redness is more likely to occur when the body temperature is elevated. You could say that the body operates on a clock. Hospital physicians have known for years that the lowest body temperature of the 24 hour day is usually around 3:00 to 4:00 A.M. while the highest temperature of the day is generally 7:00 to 8:00 P.M. The average rosacea sufferer does not have hospital waking and sleeping hours, therefore their temperature lows and highs may vary 3 to 5 hours each way. A high temperature for some may be as early as 3:00 P.M. The symptoms of flushing usually occur when the body becomes fatigued and/or stressed which stimulates the sympathetic nervous system. Any activation of these nerves causes vasoconstriction of 'blood vessels' -- except in the 'facial blush/flush areas' where it induces potent vasodilatation of the facial skin or flushing with the resulting 'rosacea redness'.
Stress stimulates the sympathetic nervous system.
Lack of sleep stimulates the sympathetic nervous system with a minimum of 8 to 9 hours being needed nightly.
Anxiety (fight or flight) stimulates the sympathetic nervous system.
Increase in internal body temperature stimulates the sympathetic nervous system, whereas obviously a decrease in body temperature decreases the sympathetic system due to the parasympathetic system calming the system (source).
Heavy meals and sugar/carbohydrates can also cause flushing (see the subtopic Allergies/ Food allergies/intolerance/ coeliac disease below here for more on that).
Steroids can cause flushing (see the subtopic Drug related flushing below here for more on that).


Exercise Flushing
Exercise flushing is caused by the cardiovascular system pumping harder and faster due to exercise with the result being vascular dilation. The key is to minimize vascular dilation while exercising to reduce the symptoms of facial skin redness. Exercise should be done moderately in a cool area keeping the body well hydrated with water to minimize the facial skin redness. It's best to adapt slowly over time to the exercise so that the body is aerobic (with oxygen) instead of anaerobic (without oxygen causing redness.) Therefore, you can handle more vigorous exercise as your exercise training increases. Better cardiovascular shape and exercise means more oxygen in the blood which constricts blood vessels (source).


Cold Weather Flushing
These flushing flare ups result from coming in from the cold into a warm room. While the rosacea sufferer is outside in the cold weather the cardiovascular system is pumping hard, however, the extremities such as the feet, hands, ears, and nose get less blood supply than the rest of the body. It's partially due to direct contact, but it is more a result of conservation of heat by internal thermostat -- causing constriction of vessels by decreasing sympathetic activity to vessels (similar to taking a 'cool' shower.) When the rosacea sufferer enters the warm office or home, the warmer temperatures quickly warm the facial skin areas and extremities while the cardiovascular system is still in a moderately high exercise mode. The rosacea sufferer should try to minimize the extreme cold exposure by warming up the car prior to use or wearing a facial mask/hat/scarf depending on length of exposure and severity of cold temperatures. After being exposed to the cold for a long period, try to enter the building slowly so the cardiovascular system will not be as stimulated, and then proceed slowly into the warmer office/home to minimize facial redness/flushing. This is a very insightful and important pdf article about the warm room flush. It comes down to advising people with rosacea to avoid extreme temperature changes. So to not make your house ice cold with an aircondition for instance, because it will mean that your blood vessels will disproportionally expand once you go a place with normal temperatures. You create rebound flushing and the advise is to keep your skin adjusted to average temperatures. There is a lotmore to read there however, so please check it out if you haven't heard from it yet. 



Even 'normal' and healthy people can flush. This is an explanation from the cleveland clinic on normal (physiological) flushing response: Embarrassment or anger may cause flushing in some individuals in whom the threshold for this response may be low or the reaction itself unusually intense; this is also known as blushing. If necessary, propranolol or nadolol may be used to alleviate the symptom. Heat causes flushing in many patients, and overheating can lower the threshold to flushing from other causes, such as menopause. Overheating, such as after exercise or sauna, can cause physiologic flushing because of the effect of the rise in blood temperature on the thermoregulatory center in the anterior hypothalamus. A similar mechanism is responsible for facial flushing caused by hot drinks, which produce a rise in temperature of blood in the oral cavity, in turn leading to an increase in temperature of blood perfusing the hypothalamus. The temperature of hot coffee, rather than its caffeine, causes flushing. A useful maneuver for patients faced with a brief thermal exposure is to suck on ice chips carried in an insulated cup. This attenuates flushing for the first 20 to 30 minutes.

Alcohol has been left out, but can obviously also cause flushing: "Asians with certain genotypes show extensive flushing in response to low doses of alcohol. They have been found to have higher plasma levels of acetaldehyde. This abnormality is probably related to a deficiency of an isoenzyme of liver aldehyde dehydrogenase. This population can be detected by using an ethanol patch test, which produces localized erythema. A special type of alcohol flush is also associated with chlorpropamide, the oral antihyperglycemic agent. Even small amounts of alcohol provoke intense flushing within a few minutes of ingestion. This flushing is not associated with sweating but, in some cases, tachycardia, tachypnea, and hypotension may be seen. The flush is mediated by elevated acetaldehyde plasma levels and possibly by the release of prostaglandins. Alcohol ingestion can also trigger flushing in those with carcinoid tumors, mastocytosis, medullary thyroid carcinoma, and certain lymphoid tumors. Trichloroethylene, a chemical that has been abandoned in recent years because of its carcinogenic potential, can cause flushing. When inhaled following ingestion of alcoholic beverages, a striking cutaneous reaction results, consisting in the sudden appearance of erythema of the face, neck, and shoulders, a reaction that has been termed degreaser’s flush. Nausea and vomiting can also occur." Plus; alcohol is a blood vessel widener and can cause even normal skin to blush or flush. The same goes for coffee and caffeine.  

Also, a night of drinking alcohol will cause your blood to have a measurable increased level of inflammation the next day. This is partly responsible for the 'hang over' feeling; it's like having the flu, scientists say. For rosaceans, having inflammatory substances in the blood is obviously not going to be good for our skin either. 




There are a lot of possible underlying causes and medical conditions for facial flushing

Not many people are submitted to (blood) tests or skin scraping biopts by their dermatologist though, and for rosacea these are usually non confirmative anyway. Skin biopts can exclude an infection however, and some doctors are able to test for demodex mites that way (but it's still not a widely used method). Demodex mites seem to mostly be at play (and this is still debated) with the papular subtype of rosacea; those with persistant redness and p&p's. When your skin is 'clean' and mainly deals with redness (erythema) and flushing, my dermatologists told me demodex is not at play. I hope they are right :)

David Pascoe wrote about this topic: "Cutaneous flushing—a common presenting complaint to dermatologists, allergists, internists, and family practitioners—results from changes in cutaneous blood flow triggered by multiple conditions. Most cases are caused by very common, benign diseases, such as rosacea or climacterum, that are readily apparent after a thorough taking of history and physical examination. However, in some cases, accurate diagnosis requires further laboratory, radiologic, or histopathologic studies to differentiate several important clinicopathologic entities. In particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma, mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid, pancreatic cell tumor, renal carcinoma, and others, should be considered."


PLUS: A lot of people with rosacea suffer from other health problems, which are often overlooked by doctors. For instance, many report and complaint about bowel disturbances, different types of inflammation in the body (of the joints for instance), other auto-immune diseases, allergies, thyroid or hormone issues. Even when people manage to get these coexisting health issues diagnosed, it is often very daunting to find a doctor (usually a dermatologist) who is capable and willing to look at the bigger scheme of things and to treat you appropriately. I have for instance seen an immunologist, internist, rheumatologist and a dermatologist and none of them were up to communicating with one another to come to a more coherent, overlapping treatment plan. Despite me asking for it :(  I was first diagnosed with rosacea back in 2002, after 3 years of rosacea symptoms. Then I was diagnosed with having Raynaud's syndrome (causing distorbed vascularity in hands and feet, giving often red swollen fingers and feet). Then an internist detected elevated ANA levels (went from very mildly elevated, 0:40, to slightly more elevated, 0:80 over the past 4 years), but they don't deem this serious enough to start treatment. Besides, from what I was told this elevated ANA marker is mainly an indication that there is some sort of auto-immune activity going on in the body, possible resulting in elevated inflammatory markers and levels inside. But these markers on their own don't say a whole lot and doctors often also look for clinical symptoms. Since I do not have the clinical symptoms of lupus for instance, they leave the markers for what they are and retest every few years. I have some sort of arthritis in me knees (since puberty) and have been diagnosed in 2005 and retested and diagnosed in 2009 (through coloscopy surgery) with colitis. More specific, with miscroscopic lymphocitaire colitis. Plus irritable bowel syndrome. Then a professor immunologist did very extensive immune blood tests in 2011 I think it was, which showed increased inflammation markers in the blood and elevated cells which indicated an auto-immune disease. But again, these markers weren't going through the roof, so doctors left it at that.
So, there are a couple of underlying issues going on, but none are really treated and I am left with anti flushing medication, diet, exercise and eliminating triggers to keep my rosacea and bowel issues calm. I can look pregnant at times from the bloating, but it's not painful or anything and I try to avoid wearing tight clothes around the waist and gas producing foods.


This research shows that many rosacea patients have positive ANA levels, which are the indicator for auto immune activity. Mine is positive too. Negative is zero or 1:20. 
"Fifty four of 101 rosacea patients (53.46%) had an ANA titer of 1 : 160 or higher. Twenty-four patients (23.76%) had the borderline ANA titer of 1 : 160. Titers of 1 : 320 and 1 : 640 were present in 14 (13.86%) and 9 (8.91%) patients, respectively. ANA titers of 1 : 1,280 to 1 : 2,560 were present in 7 patients (6.93%). In the control group, ANA titers of 1 : 160 and 1 : 320 were observed in 1 person each, out of 26 (7.68%) patients."


Below I will discuss some other medical conditions which can cause rosacea-like symptoms, such as facial flushing, burning and redness. There are some standard tests that your doctor can order, to eliminate some of these other potential causes. There is also a little summary of the experience rosacea patients have with diagnosing their rosacea and at times underlying coexisting health problems.



Please note that I am not a doctor. I'm an art historian, but no physician of any sort. All I do is research online and in books what rosacea might be like, look like etc. The information here is gathered by me and put in a (hopefully) comprehensive way, including symptom description, images of diseases and comparisons with rosacea symptoms, to make it easier for rosacea patients -or those suffering from facial flushing- to inform themselves about other illnesses that can cause their symptoms. Hope I didn't make mistakes, if so feel free to say so/comment/write about it. I try to link to all the sources I used and I want to stress that I do not (and can not) give any medical advice, nor want to be responsible for people diagnosing themselves. This should be done by a qualified doctor at all times. However, as many doctors seem unsure themselves often about the causes of facial flushing, this information here might help you to get some ideas of what to test for. I tried to make it easier to oversee all this information, as so far it takes for ever to find all this information yourself, being scattered all over the internet. I also share my personal experiences and thoughts on rosacea on this blog. Thanks.

Pictures are mostly taken from a series of around 2,500 'special photographs' taken by the New South Wales Police Department photographers. They depict mug shots from convicted criminals in Australia, shot between 1910-1930. I chose them to illustrate how these flushing causing diseases discussed here also are 'usual suspects' in their own right. And those at the end are a joke obviously ;) 







Diseases and medical conditions which can cause facial flushing, burning and redness

Seborrheic dermatitis/eczema

Lupus erythematosus

Systemic mastocytosis (and other histamine intolerances)

Hormone imbalances/Menopause 

Drug related flushing  

Allergies/ Food allergies/intolerance/ coeliac disease

Erythromelgia (EM) is also a very rare cause of facial flushing

Keratosis Pilaris Rubra faceii

Carcinoid Syndrome/pheochromocytoma

Polycythemia vera

Mixed connective tissue disease

Thyroid problems

Heliobacter infection/ SIBO 

Photosensitivity 

Harlequin Syndrome

Auriculotemporal Nerve Syndrome (Frey’s Syndrome)

Flushing with Pseudocarcinoid Syndrome in Secondary Male Hypogonadism

Erysipelas

Other Diseases Causing Episodic Flushing (including  asthma, epilepsy, Lyme disease and ROSACEA)

Steps to take for Evaluation Of The Patient With A Flushing Disorder


Coexisting health problems which people with rosacea often mention

A little summary of the experience rosacea patients have with diagnosing their rosacea and at times underlying coexisting health problems


Seborrheic dermatitis/eczema


Seborrheic dermatitis, or seb derm, is very often misdiagnosed as rosacea, or patients have both conditions and one worsens the other. Seb derm is a common skin disorder that mainly manifests itself on the scalp and facial T-zone (forehead, eyebrows very often, sides of nose and mouth), causing scaly, itchy, red skin and stubborn dandruff. Seborrheic dermatitis can also affect the upper chest, back and other areas of your body that have many oil (sebaceous) glands. On the scalp, seborrhoeic dermatitis usually causes roughly defined, dry pink or skin colored patches with yellowish or white bran-like scales. In winter the seb derm causes my (rosacea) skin to turn scaly and rough and red. This makes the skin around my mouth and on the inner cheeks and in the eyebrows stand out in a red color. The cause isn´t fully understood yet, as far as I can tell from the information that´s out there online and from the dermatologists I´ve seen. What I understand, is that seb derm might have an underlying autoimmune component to it. The skin responds badly to a common yeast that lives on it. This normal skin inhabitant is called Malassezia (formerly known as Pityrosporum ovale). Patients with seborrhoeic dermatitis appear to have a reduced resistance to the yeast and the toxic substances that it produces. Unlike in healthy people, it creates inflammation and skin irritation in us seb derm patients. An overproduction of sebum is also mentioned as a cause and there is an increased turnover of shedded skin (hence the flaking). In some cases, the seb derm is actually precursor of psoriasis...


Differentiating rosacea from seb derm

Seb derm flare; see the red rough areas on inner cheeks
Differentiating rosacea from seb derm can be tough. Both deal with red skin and rough skin texture.  One of the real differentiating aspects of rosacea I think, is the on and off redness. Rosacea tends to flare easily and when you feel flushed and hot from specific triggers (alcohol for instance, certain foods or hot rooms) then it is likely that rosacea is at play. A rosacea flare can erupt very quickly and then die out very soon again as well. Within hours for some. Seb derm is more of an eczema like rash, that tends to take a lot longer to form and to disappear again. Rosacea tends to flare in the sun, whereas seb derm might benefit from it. So scaling, flaking and more persistant, 'rough' redness (of which the redness can't be cooled down and 'paled out' with cold temperatures withing hours) might indicate seb derm. When you have a fatty like substance (dead skin, sebum) that you can rub off your skin with a cotton pad, then that's another symptom of seb derm (I posted some grossss pictures of this on my own skin in a Seb derm blog post). Some doctors are quick to rule out rosacea in favor of seb derm, because of young age of a patient. It's a misconception however that rosacea doesn't affect youngsters. Mine started age 19 and I know lots of youngsters, teenagers, with rosacea.

One way to find out if you have active or underlying seb derm, is to apply ketconazole cream to a small area of the affected skin for some time, and to see if it clears up. Seb derm can aggrevate rosacea (causing more skin irritation, dryness, flushing, burning and redness) when you have to deal with both of these charmers, so it might be a real catch 22 to sort the one out from the other. But rule of thumb is that rosacea has a tendency to flush and flare for shorter periods of time and seb derm is more persistant redness, roughness, scaliness and seb derm also has a preferance for the T-zone; forehead, eyebrows, nose, mouth and inner cheeks. Whereas rosacea usually manifests itself on the cheeks, sometimes nose and chin. It also takes quite a lot of years usually for rosacea to cause the skin to become more permanently rough, red, raised and swollen, whereas seb derm can cause that very soon onwards. Seb derm can also make you feel flushed though, to make matters more complex. And Seb derm can cause burning in the skin, but it's not common for that to happen, whereas rosacea almost definitely makes the skin feel sore and painful and hot and burning when it flares (but again, no 100% certainties here either, as some with ruddy red cheeks don't feel them burning, arggh...). Seb derm might itch (but not necessarily) and will feel and look irritated. For me, the seb derm also brings on some paps and little acne like bumps often. See the picure of a bad seb derm flare of my forehead here. For me, this makes it stand out from the rosacea (only see them in the flaky seb derm areas when that one is flaring) but for those with subtype 2 rosacea (papular), this might make matters even more difficult to distinguish one from the other.



Seb derm treatment options
  • ketoconazole cream or shampoo (1 or 2%)
  • Nizoral cream or shampoo
  • Zinc pyrithione shampoo 
  • 5% sulfur / 10% sulfacetamide lotion and or wash
  • Lamisil cream
  • salicylic acid
  • ciclopirox cream / ciclopiroxolamine
  • Elidel or Protopic cream (pimecrolimus cream or tacrolimus ointment). (Note: both made my rosacea flare, even when applied very locally on the areas around the mouth) 
  • Hydrocortisone or steroid creams (would absolutely warn against this in case you also have rosacea! Steroids can very quickly stir up or worsen the rosacea).
  • Tar cream can be applied to scaling areas and removed several hours later by shampooing.
  • Severe cases may receive a course of tetracycline antibiotics, oral antifungal medication, or sometimes, ultraviolet radiation



There are also more natural treatment options

including raw honey and virgin coconut oil. Some people use apple cider vinegar or tea tree oil on their seb derm and find it helpful. Watching your diet and avoiding foods with a lot of yeast (certain breads), high levels of simple sugars and certain fermented foods also helps some patients. Dairy products might also add to the problem for some. On the other hand, some other foods have been mentioned to help combat the seb derm, including garlic (anti fungal and anti inflammatory actions), coconut oil (idem) and probiotics.

For me the ketoconazol cream does the job very well. I use ketoconazole 2% and find it very effective in controlling (and in winter limiting) my seb derm rashes nowadays. Because of my very delicate and sensitive, flushing prone rosacea skin, I normally can´t even tolerate a neutral base cream (use nothing on my skin). However, my cheeks are the most sensitive and affected and the seb derm usually shows up around my nose and mouth folds, where my skin can handle the ketoconazole 2% cream. The alcohol in it irritates it though and for the past 4 years my (big hospital related) pharmacy makes a special cream for me. It contains 2% ketoconazolum (the active ingredient) and they make a neutral base for it (cetomacrogol), with no alcohols and no preservatives. In my case it contains the following (30 gram tube):
-Ketoconazolum 0,600 gram
-cera cetomagrogolis emulsion 4,500 g.
-decylis oleas (cetiol V) 6,000 ML
-aqua purificata bag in box 17,700 ML
-Sorbitolum 70% crist 1,200 ML

They removed the preservative from the cetomacrogol (bit of a waxy like cream, very neutral). The following pictures were taken in a bad seb derm year, was winter of 2010 when I didn't use the ketoconazole cream yet. The white dots are metronidazole cream and zinc cream; I was silly enough by then to think the metrocream would work for.


You can read more about seb derm in this older blog post from me on the matter. 








Lupus erythematosus

Lupus erythematosus (LE/SLE) is an auto-immune disease. It can be mistaken for rosacea (or vice versa) because lupus can also produce a red rash on the face, the so called Butterfly rash. However, it is an entirely different, systemic autoimmune disease (or autoimmune connective tissue disease) that can affect any part of the body. As with most autoimmune diseases, the immune system of a lupus patient attacks the own body, in this case its cells and tissue, resulting in inflammation and tissue damage. It is both a type II and a type III hypersensitivity reaction in which bound antibody-antigen pairs (immune complexes) precipitate and cause a further immune response. Wiki says about it: "SLE most often harms the heart, joints, skin, lungs, blood vessels, liver, kidneys, and nervous system. The course of the disease is unpredictable, with periods of illness (called flares) alternating with remissions. The disease occurs nine times more often in women than in men, especially in women in child-bearing years ages 15 to 35, and is also more common in those of non-European descent. There is no cure for SLE. It is treated with immunosuppression, mainly with cyclophosphamide, corticosteroids and other immunosuppressants. SLE can be fatal. The leading cause of death is from cardiovascular disease due to accelerated atherosclerosis. Survival for people with SLE in the United States, Canada, and Europe has risen to approximately 95% at five years, 90% at 10 years, and 78% at 20 years, and now approaches that of matched controls without lupus.
Lupus is Latin for wolf. In the 18th century, when lupus was just starting to be recognized as a disease, it was thought that it was caused by the bite of a wolf. This may have been because of the distinctive rash characteristic of lupus. (Once full-blown, the round, disk-shaped rashes heal from the inside out, leaving a bite-like imprint.)"


Signs and symptoms

SLE is one of several diseases referred to as "the great imitators" because it often mimics or is mistaken for other illnesses. SLE symptoms vary widely and come and go unpredictably. They range from limited skin disease at one end of the spectrum to a life threatening disease that invades other organs in your body at the other. Diagnosis can thus be elusive, with some people suffering unexplained symptoms of untreated SLE for years. Common initial and chronic complaints include fever, malaise, joint pains, myalgias, fatigue, and temporary loss of cognitive abilities. Because they are so often seen with other diseases, these signs and symptoms are not part of the diagnostic criteria for SLE. When occurring in conjunction with other signs and symptoms (see below), however, they are considered suggestive.


Dermatological Micrograph can show vacuolar interface dermatitis, as may be seen in SLE. H&E stain. As many as 30% of sufferers have some dermatological symptoms (and 65% apparently suffer such symptoms at some point), with 30% to 50% suffering from the  classic malar rash (or butterfly rash) associated with the disease. Some may exhibit thick, red scaly patches on the skin (referred to as discoid lupus). Alopecia (hair loss), mouth, nasal, urinary tract, and vaginal ulcers, and lesions on the skin are other possible manifestations. Tiny tears in the delicate tissue around the eyes can occur after even minimal rubbing. Focusing in on the skin problems you could experience with lupus erythematosus:



Discoid lesions
These are scarring, coin-shaped lesions commonly seen in areas of skin that are exposed to light, such as the scalp and ears, and the central portion of the face and nose. More rarely, your lips, mouth, and tongue might be involved. These lesions can produce a scarring baldness, and because they often affect your face, you may consider getting cosmetic treatment. Only 1 in 10 to 1 in 20 of patients who are initially diagnosed with this type of skin involvement will eventually develop the severe form of the disease that involves other organs in your body.


Subacute cutaneous lesions
These are non-scarring, red and scaly lesions that are very photosensitive, that is they get worse when they are exposed to ultraviolet light. They tend to occur on the face in a butterfly shaped distribution or can be more widespread on the body. Even though these lesions do not result in scarring, their extent and color change can cause you major cosmetic concerns. About half of the patients who are diagnosed with this type of skin involvement will, in time, develop other organ involvement (also called systemic involvement or systemic disease), such as arthritis conditions with their blood. Kidney disease is unusual in patients with this type of skin disease. It is seen in up to 2/3 of patients with systemic disease and may be the presenting feature in up to 40%. It may vary in degree from a mild redness or “rosy cheeks”, to multiple swollen red areas or plaques.

Lupus profundus
This is a rare type of skin lupus erythematosus in which the subcutaneous fat is involved giving rise at first to tender nodules that can leave, in time, saucer like depressions in the skin surface. This type most commonly affects the upper arms and trunk. Patients with this type of skin involvement may have either systemic disease or disease limited to the skin.



Lupus discoid lesions in pictures







 Pictures of subacute cutaneous lesions






 Pictures of Lupus profundus:





Other Lupus symptoms

Hair loss
Up to 1/3 of patients with systemic lupus erythematosus get reversible form of hair loss associated with flares of their systemic disease. They may also note, that their hair is more brittle than previously and breaks easily giving rise to shortened hair (“lupus hair”). Another form of reversible hair loss that leaves distinct bald spots, alopecia areata, may also be more common in patients with lupus erythematosus.

Vasculitis
Patients with systemic lupus erythematosus may develop inflammation of their blood vessels. This can result in varied manifestations running a spectrum from multiple scattered red bumps, that may crust and ulcerate to painful nodules.



What causes lupus erythematosus?

The skin manifestations of lupus erythematosus are the result of inflammation in the skin that is primarily mediated by inflammatory cells called T lymphocytes. How and why these T cells are activated to cause disease is still unclear. Contributing factors include a genetic predisposition and environmental factors. Genetic factors - These genes encode proteins that are important in controlling the immune system and in fighting infection. Ultraviolet light is an environmental factor that can have an adverse effect both on skin lupus and systemic lupus erythematosus. It is thought that ultraviolet light can increase cell death in the skin and thereby boost the immune response to self. Ultraviolet light can also alter the responses of the immune system itself to antigens.


I had extensive blood work test done by an immunologist prof in Germany, and my lab results also showed elevated Regulatory T cell levels.  Regulatory T cells were higher than normal (19,52 % where they should be in the range of 4,98 - 9,52). I have been tested for lupus on different occasions, and with an ANA level of only 0:80 currently (starting value of being positive), and no clinical signs apart from the red cheeks, doctors don't think I have lupus. However, the increased T cells do indicate that there is inflammation going on and the ANA indicated that there is some auto immune element involved. I still think that rosacea can also cause all this. When you scroll down on this link, below in the post are all my immune test results mentioned and explained (or tried to at least).





How is lupus diagnosed?

The specific skin forms of lupus erythematosus have a characteristic appearance. To confirm the diagnosis, your doctor can perform a skin biopt of the affected skin. Examination of a small sample of this skin under the microscope can allow a more definite diagnosis as the microscopic tissue changes are characteristic. In addition, a small sample may be obtained for an immunofluorescence test. Also, Lupus erythematosus is a condition in which there is antibody production to self-tissues, and these may be detected in the skin with this test. 97 percent of those with lupus will have a positive antinuclear antibody test (ANA). It’s very common to get somewhat different results at different labs. However, if a person has active lupus, the ANA will likely be positive at most laboratories most of the time. Other autoantibodies will also be present. Usually, your doctor will first request a complete blood count (CBC). Your blood is made up of red blood cells (RBCs), white blood cells (WBCs), platelets and serum. The complete blood count measures the levels of each. In cases of lupus, these blood tests may reveal low numbers. (Source). Other blood tests can be order for Antibodies to double-stranded DNA (anti-dsDNA), Antibodies to histone, Antibodies to phospholipids (aPLs), Antibodies to Ro/SS-A and La/SS-B (Ro and La are the names of proteins in the cell nucleus), Antibodies to Sm and RNP. Here all these tests and their function are further and more detailed explained.



More about this ANA test

Antibody Blood Tests: The body uses antibodies to attack and neutralize foreign substances, such as bacteria and viruses. The antibodies your body makes against its own normal cells and tissues play a large role in lupus. Many of these antibodies are found in a panel or group of tests that are ordered at the same time. The test you will hear about most is called the antinuclear antibodies test, referred to as the ANA test.
Antinuclear antibodies connect or bind to the nucleus or command center of the cell. This process damages and can destroy the cells. While the antinuclear antibody is not a specific test for lupus, it is sensitive and does detect the antibodies that are present in 97 percent of people with the disease.
The ANA can be positive in people with other illnesses or positive in people with no illness. Test results can also fluctuate in the same person. However, lupus is usually the diagnosis when these antinuclear antibodies are found in your blood. Fuly healthy people should have an ANA level of zero. However, between 0:20 and 0:40 can still be considered a normal value by many immunologists. 0:40 is the starting value of a mild positive outcome and 0:80 is generally accepted as a positive test value. The figures double, so the next value is 0:160, then 0:320 and so on. Some people with severe auto-immune diseases can have NA levels that cross the 1000 mark.



The difference between rosacea and lupus

Discoid lupus erythematosus can mimic many other skin diseases including psoriasis, fungal infection of the skin, and other rare inflammatory skin disorders. Or a common form of light sensitivity called polymorphous light eruption. In this condition, itchy bumps or welts may appear within minutes to hours after sun exposure. The malar rash of acute cutaneous lupus erythematosus can mimic rosacea, a common condition also causing redness of the cheeks. As skin lupus erythematosus can mimic many common skin conditions, a skin sample or biopsy is often required to confirm the diagnosis. A rule of thumb might be that lupus lesions can appear all over the body, whereas rosacea is usually limited to the face (and sometimes nech or upper chest for a small percentage of people). Rosacea is also associated with facial flushing, and lupus less so. Rosacea can also manifest itself in the eyes (occular rosacea) and lupus won't. The same goes for p&p's, which do occur in rosacea and not in lupus. Corticosteroids work well for lupus usually, but often worsen rosacea, especially after discontinuation.



Wisegeek writes about the difference between rosacea and lupus: "Rosacea and lupus are not linked in their etiology, but many lupus patients are initially misdiagnosed with rosacea. The primary reason for this is that lupus patients often exhibit a noticeable skin rash that has many of the characteristics of a breakout caused by rosacea. Since rosacea primarily effects the face, patients who do not have many of the other most common lupus symptoms may begin rosacea treatments until additional symptoms appear.
The similarities between rosacea and lupus tend to stop with the facial rash or swelling. Rosacea is a skin condition which causes flushing, swelling, itching, and redness — most commonly occurring on the face. Other symptoms can include prominent veins, redness on the nose accompanied by a bulbous or round shape, and a tendency to blush more often than most. These symptoms often come in cycles, with certain activities or situations causing them to flare up.
Lupus is an autoimmune disorder which can cause a wide range of symptoms. They can include a butterfly-shaped rash on the face, fatigue, chronic pain, organ malfunction, and stiffness in the joints. It is a form or arthritis, and causes many of the same symptoms as the more common variations of the condition. Medication may help to slow down progression of symptoms, and some patients go into remission and remain symptom free for many years."



The National Rosacea Society writes about the diagnosis between rosacea and lupus 

and makes an interesting observation about ANA levels in the blood of both lupus and rosacea patients (one of the diagnostic tools for lupus..): Link "Lupus erythematosus -- long known as an autoimmune disorder -- and rosacea share several signs and symptoms: facial redness, sensitivity to sunlight, and a tendency to affect women more than men. In fact, physicians have sometimes turned to blood tests to tell them apart. Now, researchers have discovered that those tests may not be as indicative as once thought.

The blood tests look for elevated levels of antinuclear antibodies (ANAs), proteins produced by the immune system that target the nuclei of normal cells. Patients with lupus usually have high concentrations of ANAs in their blood, and this was thought by some to differentiate the disease from rosacea.
However, a new study of 101 rosacea patients and 26 people with healthy skin, conducted by researchers in the Department of Dermatology at the Medical University of Lodz, Poland, found that 53.5 percent of the rosacea patients showed significantly increased levels of ANA in their blood, while only two of the control group with healthy skin had high levels of ANA. Patients with subtype 2 (papulopustular) rosacea were more likely to have significant ANA levels (32.7 percent of patients) than those with subtype 1 (erythematotalengiectatic) rosacea (16.8 percent of patients). After two years of follow-up, none of the patients with an elevated ANA developed an apparent autoimmune disorder.
The researchers concluded that ANA blood tests should not be relied upon alone for differential diagnosis of lupus versus rosacea. However, ANA-positive patients may need additional studies as indicated by other findings, and should be followed over time.



Posts on forums about this topic

Burnt1970 wrote on May 28th 2007: "This is what I'm dealing with right now. When my first derm diagnosed me with Rosacea 4 years ago, it was at first sight with no testing. My grandmother had Lupus pretty severe, and though I was tested for that 2 1/2 years ago (which came back negative), something else could be very much at work. The derm I saw a couple of weeks ago questions if I do have Rosacea since he was concerned about how sharply my redness cuts off. There are very defined borders on my neck. Also, my level of photosensitivity to fluoro lights concerned him, (he watched me turn 20 shades of red right in front of hi Ignore warning s eyes). Another thing that's been happening over the past few months is red, blotchy rashes under my eyes. They have a bit of a sting and scaliness to them. IN FACT, just yesterday I laughed so hard about something that I cried. The result of the tears were nasty rashes appearing immediately under each eye, which is still somewhat there today. If this is auto immune, or allergy related, I've been eating asprin like candy and taking antihistamines daily. I'm noticing some relief in color and other issues because of it."


Shantelle wrote on the Rosacea Forum about lupus: "Hi all In regards to the above posts...Yes, Lupus is not as common in males as it is in females (Ratio Females 9:1 Males). Lupus can present itself in may different forms, and symptoms (all inflammatory) often masquerade as other diseases or health issues. The butterfly rash is not seen in every Lupus patient, but if it does appear it can certainly masquerade itself as Rosacea (Type 1). Inflammatory hand and and feet symptoms are common symptoms of lupus, particular if the person has systemic lupus, or Raynards (Raynards is often seen in patients with autoimmune disease) or chronic cutenous lupus affecting the hands or feet (lupus chillblains/ lupus pernio). If anyone thinks that they might have lupus they should see their GP for a referall to a Rheumatologist (multiple inflammatory symptoms) or Dermatologist (symptoms all skin related). Lupus symptoms information:
http://www.dermnet.org.nz/immune/cutaneous-lupus.html
http://www.lupus.org/webmodules/weba...268&zoneid=526
http://www.hopkinslupus.org/lupus-info/"


Armabella wrote on July 18th 2013: "Hypothyroid and Rosacea or Lupus Hi, My my wife has a hypothyroid condition which supposedly is caused by an auto-immune disorder. She started taking Levothyroxine when she was 23 but stopped for a while in her early thirties because she wanted to try something natural. After a year of taking the natural substitue, tests didn't look to good so she went back on the levothyroxine drug and this is when her Rosacea started. 3 years have gone by and in this time she saw two dermatologists who told her that her flare was Rosacea. Recently however, she went to a doctor who did some blood tests and are saying that her rosacea could be Lupus butterfly rash. We don't really trust this doctor because my wife doesn't have any other symptoms of lupus and her skin rash does look like rosacea but we wanted to get opinions of other people in other parts of the world who might have experienced something similair. Is there anyone out there who has these two conditions (Rosacea/Hypothyroid) and does anyone know if there is a link between these two disorders or even between rosace and lupus? since they are both thought to be auto-immune diseases could rosacea be lupus or a kind of lupus?

Hugobb replied: "Hello armabella, I think that lupus rashes may vary from the classic 'butterfly shape' and sometimes it can be very similar to rosacea. In addition, it is known that some drugs can induce lupus-like symptoms. If you have any doubt, you should seek a second opinion, or maybe she wants to do a biopsy. Remember that having a lupus rash doesen't necessarly mean having systemic lupus. You should take a look at this article:
http://www.medicaljournals.se/acta/c...55-1414&html=1


Jrlhamcat2 wrote on October 18th 2012: "I thought there might be some interest in this short report about four ANA-positive patients with a rosacea-like condition who were successfully treated with plaquenil. The full text is available here: http://www.medicaljournals.se/acta/c...55-1414&html=1 Interestingly, the patients did not report having any flushing. I think this study probably reinforces the point that a red face is a fairly non-specific symptom with a variety of causes and treatments.[..] They're saying an anti-malarial cleared up a rosacea-like rash in a small group of patients who were originally diagnosed with rosacea but after further testing actually (or additionally?) had a form of lupus."


Kimberly replied on Octobr 31st 2012: ""Anti-Ro/SSA antibodies were also found in all 4 patients." I've been tested for those, and I didn't have them. Just the ANA and anti-histone. Anti-Ro antibodies are linked to sjogrens and photosensitivity."



Most important information from this link:


"The 4 patients with rosacea-like cutaneous LE were 3 women and 1 man (F/M ratio 3:1), with a mean age at disease onset of 54 years (range 41–69). The mean duration of disease was 13 months (range 6–24). On admission to our hospital, all 4 patients presented with erythema that was localized to the central face and was associated with a few raised, smooth round erythematous or erythematous-violaceous papules ranging from 2 to 3 mm in diameter over the malar areas and forehead (Fig. 1a); the skin lesions were accompanied by intense burning and, occasionally, by slight to moderate pruritus. In all 4 cases the onset of the above cutaneous picture had been sudden, and the patients had noticed aggravation of the rash after sun exposure. Before our observation, all 4 patients had been given treatments for rosacea in other institutions, including tetracyclines, azithro­mycin or metronidazole orally, in combination with topical metronidazole, with no benefit. The patients were not treated for other concomitant diseases. After LE was diagnosed, we evaluated the patients for systemic symptoms and signs associated with LE, which were lacking in all 4 cases; moreover, none of them fulfilled the American College of Rheumatology criteria for the diagnosis of systemic LE (SLE) (13). The possible association with Sjögren’s syndrome or other autoimmune disorders was excluded. The 4 patients were treated with oral hydroxychloroquine 400 mg/daily, which induced a complete clearing of the skin lesions (Fig. 1b) with a mean resolution time of 7 weeks (range 5–8 weeks). Hydroxychloroquine was discontinued 1 month following complete resolution. The patients were warned against exposure to sunlight and they were advised to apply total-block sunscreens in bright sunlight. Currently, all patients are alive and free of disease, with a mean time of follow-up of 4 years (range 2–7 years), with neither relapses nor evolution into SLE.

Fig. 1. (a) Redness with small erythematous papules involving the central face in patient 1. (b) Complete resolution after hydroxychloroquine therapy. (c) Histology showing a pattern of lichenoid interface dermatitis (haematoxylin and eosin (H&E) stain; original magnification, × 100). (d) Medium-power view demonstrating the hydropic degeneration of the epidermal basal cell layer; in the dermis, a mixed inflammatory infiltrate associated with mucin deposition is evident (H&E stain; original magnification, × 200).

The erythrocyte sedimentation rate was moderately elevated in only one patient (case 3) at disease onset (53 mm in the first hour; normal < 20), and reverted to normal after resolution. Antinuclear antibodies (ANA) were present, up to 1/640 with a fine speckled pattern, in all 4 cases. Anti-Ro/SSA antibodies were also found in all 4 patients. All the other immunological parameters evaluated, notably anti-double stranded-DNA antibodies, were normal or negative. Anti-Ro/SSA antibodies, re-evaluated in clinical remission at the time of writing this paper, remained positive in all 4 patients.
The 4 patients demonstrated similar histological changes in biopsy specimens taken from facial papular lesions surrounded by erythema. These changes include epidermal atrophy, hydropic degeneration of the epidermal basal cell layer, and a superficial perivascular and periappendageal lymphohistiocytic infiltrate (Fig. 1c). Abundant dermal deposition of mucin was seen (Fig. 1d).
In all 4 patients, direct immunofluorescence performed on biopsy specimens taken from lesional skin revealed granular deposits of immunoglobulin (Ig)M and IgG (case 3) or IgM alone (remaining cases) at the dermoepidermal junction; dermoepidermal granular deposition of C3 component of complement was also demonstrated in 2 patients (cases 1 and 4).


DISCUSSION
Although an erythematous eruption involving the face with sun exposure as triggering event is a classical cutaneous finding within the spectrum of LE, the presentation in our 4 cases is unique in that it resembled acne rosacea (12). However, the absence of pustules, telangiectasia, flushes and ocular signs, in addition to the lack of response to classical therapies for rosacea led us to test the patients for ANA and other autoantibodies, allowing us to diagnose LE. The 4 patients responded dramatically to hydroxychloroquine and there were neither relapses nor evolution into SLE after a mean follow-up of 4 years. The very rapid response to antimalarials may be explained by the fact that more superficial LE skin lesions, including erythema and papules, as in our patients, usually respond more rapidly than scaly, atrophic and scarring lesions. The absence of recurrence after treatment withdrawal may be due to the less aggressive nature of this atypical presentation of cutaneous LE. Anti-Ro/SSA antibodies, which are closely related to photosensitivity, are possibly the laboratory hallmark for this presentation, as for SCLE (7). However, our patients were unlikely to have SCLE due to the absence of typical annular or psoriasiform lesions. While classic discoid lupus was easily ruled on the basis of clinicopathological criteria, the tumidus variant should also be considered. However, the typical skin lesions in LE tumidus are erythematous, urticaria-like, non-scarring plaques, and its histology lacks changes of interface dermatitis as seen in our cases and typically shows a dermal infiltrate (3, 14). The strong mucin deposits found in our cases might suggest reticular erythematous mucinosis (REM) (15). Based on its possible association with autoimmune diseases, notably LE, the commonly observed photosensitivity, the deposition of IgM at the dermoepidermal junction found in some patients with REM and the good response to antimalarials, it has been classified among the specific cutaneous lesions of LE (14). However, similarly to lupus tumidus, REM is regarded as an example of dermal cutaneous LE and anti-Ro/SSA antibodies are usually lacking in this subset (15).


The authors declare no conflicts of interest.








Systemic mastocytosis

Part of this information is based on my mastocytosis blog post. Mastocytosis is a rare disease characterized by an increase in mast cell number and activity in a variety of tissues. Mast cells normally produce substances that serve protective, inflammatory, and regulatory functions in the body. In mastocytosis, these substances are abnormally abundant, causing various skin and systemic symptoms. Many of the substances produced by mast cells are potent dilators that can cause skin flushing. All the classic symptoms of rosacea such as facial redness, telangiectasia, flushing and papules can be mimicked by certain forms of mastocytosis. Physicians emphasize that it is common for bouts of flushing due to mastocytosis to cause true rosacea in patients not genetically predisposed to the disorder.





Symptoms of Mastocytosis
Symptoms include cutaneous flushing, itching, nausea, diarrhea, vomiting, headache, heart racing and breathing difficulties. Any physician such as your primary care physician or general practitioner can test for this disorder. You may want to ask your physician about being tested for a underlying condition that may be mimicking rosacea. Because mast cells play a role in allergic reactions, the symptoms of mastocytosis often are similar to the symptoms of an allergic reaction. Other possible symptoms are:



Diagnosing mastocytosis
Doctors can diagnose urticaria pigmentosa (cutaneous mastocytosis, see above) by seeing the characteristic lesions that are dark-brown and fixed. A small skin sample (biopsy) may help confirm the diagnosis. By taking a biopsy from a different organ, such as the bone marrow, the doctor can diagnose systemic mastocytosis. Using special techniques on a bone marrow sample, the doctor looks for an increase in mast cells. Another sign of this disorder is high levels of certain mast-cell chemicals and proteins in a person's blood and sometimes in the urine, called Tryptase

  
How can Mastocytosis cause facial flushing?
This article explains that mast cells are cells of the immune system that are found around blood vessels in the skin, gastrointestinal tract, respiratory tract, and genitourinary tract. They contain several substances, of which histamine is the most common. They are released upon contact with certain foreign substances. In the most common form of mastocytosis, there are a greater number of mast cells in the tissues. And therefore there is also too much histamine release. These mast cells cause a typical skin response called urticaria pigmentosa in which hives immediately develop after stroking the skin with a blunt object. People with mastocytosis also experience symptoms throughout the body caused by the release of large amounts of histamine and other chemicals. The flushing occurs suddenly on the face and upper trunk. Many patients cannot identify a trigger that causes the flushing, but some identify exercise, heat, or emotional anxiety as a possible trigger. The red, hot face is often accompanied by palpitations, low blood pressure, dizziness, chest pain, explosive diarrhea, nausea, or fatigue. Medications such as opioid narcotics like morphine and codeine, and aspirin or other non-steroidal anti-inflammatory drugs like ibuprofen or naproxen can also start a flushing attack.



Pictures of Mastocytosis induced red skin
(Source of the first picture. This woman writes a blog about her life with mastocytosis actually)





The girl of the pictures on the right said about them: "The pictured episode was triggered by activity and allergens. It lasted about six or seven hours. MCAD (Mast Cell Activation Disease) flushing feels rather like a combination of sunburn and windburn, a sort of stinging sensation. I can feel a flushing episode before it becomes visible and also for a little while after it visibly fades. An episode can last a half hour or so for a very mild one to several days for a major one. During badepisodes, the reddened area is slightly swollen/raised."  Here are more pictures of mastocytosis.




Treatment of mastocytosis
The treatment of mastocytosis is mainly symptomatic. Patients should avoid known histamine-degranulating agents. Patients can take antihistamine medication. Usually doctors chose a combination treatment with an H1 antihistamine (hydroxyzine 10-20 mg for instance) and H2 antihistamine (cimetidine 200-500 mg for instance). Oral administration of the mast cell stabilizing agent disodium cromoglycate has proved effective in some patients. Photochemotherapy has been reported to cause symptomatic relief as well as objective reduction in the population of mast cells and the urinary excretion of MIAA.




Differences between mastocytosis and rosacea
People with mastocytosis often not only flush in their faces, but also on their chest and neck. They experince general hot flash symptoms and feelings. Whereas many rosacea parients just feel their face burn and the rest of their bodies can feel cold at the same time. People with mastocytosis also often have addition symptoms, like sneezing and allergie-related symptoms, unlike most people with rosacea. For people with mastocytosis, episodic bright red flushing can occur spontaneously, after rubbing the skin or after exposure to alcohol or mast cell degranulating agents. Flushing attacks may be accompanied by headache, dyspnea and wheezing, palpitations, abdominal pain, diarrhea, and syncope and may closely resemble the flushing episodes of the carcinoid syndrome, especially the foregut variety, which are also mediated by histamine. Rosacea may develop rarely. The flushing of cutaneous mastocytosis typically lasts more than 30 minutes, unlike the typical carcinoid flush, which lasts less than 10 minutes. In urticaria pigmentosa, the diagnosis is established by demonstrating that gentle rubbing of the lesional skin causes local itching, redness, and whealing (Darier’s sign). This reaction is caused by local histamine  release. Darier’s sign may also be demonstrated in skin without lesions.



This is a very interesting article about the differentiation between rosacea flushing and Mastocytosis flushing, characterized by either sweating flushes or dry flushes. 
In it, the author states about flushers who also sweat during a flushing attack, that their flushing tends to be a cholinergic nerve discharge and more typical of mast cell disease. "Why does it matter whether or not you sweat when you flush? Why is that so important in trying to distinguish between mast cell-related flushing and other causes of flushing?"
There are many different substances, the author continues, that can cause flushing, and which ones are at work is related to the specific cause of the flushing. In Table 1 (see below), the specific mediators of flushing due to various causes are listed. It should be noted that “With the exception of carcinoids, flushing due to tumors is rare and tends to occur in advanced stages.” So, while there are very benign causes of flushing, such as changes in temperature, emotional state, or exertion, as well as eating spicy food, flushing can also be a symptom of a serious physical condition.



The sympathetic nervous system’s neurons release acetylcholine,

which causes both sweat gland activity and dilation of blood vessels. So, when you see someone both sweating and “turning red,” you are probably witnessing flushing that is due the cholinergic effects of the sympathetic nervous system. In contrast, when histamine is released by mast cells in the skin, it has the effect of dilating blood vessels, but the histamine does not have an effect on the sweat glands. So when we see flushing without sweating, it’s more likely to be caused by histamine release in the skin, whereas when we see flushing and sweating together, it’s more likely to be caused by the release of acetylcholine by the sympathetic nervous system. There’s only one caveat to this explanation: When a person is going into shock, they will often begin sweating profusely, and as we know, anaphylaxis can send someone into shock.  So, sweating in the later stages of a mast cell crisis is to be expected — it’s only in the early stages that we expect flushing without sweating." One of the recurrent topics on the rosacea forum is how a lot of rosaceans there don't seem to sweat much. Me included. It's interesting to finally read about the sweat factor in flushing. It could indicate that in my specific type of vascular rosacea symptoms, the biggest trigger is not the sympathetic nervous system, as I always assumed, but histamine release.


Table 1. The mediators of flushing

Condition Specific mediators
Foods, beverages, alcohol Tyramine (present in ergot, mistletoe, ripe cheese, beer, red wine, and putrefied animal matter), histamine, sulfites, nitrites, alcohol, aldehyde, higher chain alcohols, monosodium glutamate (MSG), capsaicin (which is what makes chili peppers hot), and cigua toxin (fish)
Menopause Estrogen fluctuations
Mastocytosis, anaphylaxis, and mast cell-related disorders Histamine, prostaglandin D2, leukotrienes, tumor necrosis factor α (alpha), vascular endothelial growth factor, interleukins, heparin, and acid hydrolases
Carcinoid syndrome (symptoms and lesions produced by the release of serotonin from carcinoid tumors of the GI tract that have metastasized to the liver) 5-hydroxytryptamine (5-HT; no flushing but diarrhea), substance P, histamine, catecholamines, prostaglandins, kallikrein, kinins, tachykinins, neurotensin, neuropeptide K, vasoactive intestinal polypeptide (VIP), gastrin-related peptide, and motilin
Pheochromocytoma (a usually benign neoplasm in the adrenal gland’s medullary tissue) Catecholamines (epinephrine, norepinephrine, dopamine), vasoactive intestinal polypeptide (VIP), calcitonin-gene-related peptide, and adrenomedullin
Medullary carcinoma of the thyroid Calcitonin, prostaglandins, histamine, substance P, levodopa, ketacalcin, adrenocorticotropic hormone, and corticotropin-releasing hormone
Pancreatic cell carcinoma Vasoactive intestinal polypeptide (VIP), prostaglandin, and gastric inhibitory polypeptide
Renal cell carcinoma Prostaglandins and pituitary down-regulation
Neurologic Substance P and catecholamines





Forum posts from rosacea patients about mastocytosis 

Queta wrote on October 30th 2009: "It was Histamine Intolerance All along.. Just want to update people on my progress because it may help someone else. I have struggled with rosacea for years and years, since I was at least 12 years old. I have flushing, bloodshot eyes, swelling of my eyelids, nose, chin, and forehead. Then someone on this site talked about something called Histamine Intolerance. I looked it up and thought I would try a new supplement (and very expensive, unfortunately) called Histame which is supposed to help those who have trouble eating histamine rich foods. Well, guess what? My skin is not only clear but much, much less puffy. My eyes are not bloodshot but white. I look so much healthier. For me, it was Histamine Intolerance all along. That is probably why my skin and my diet were so interrelated, and why taking a mast cell inhibitor like quercetin helped me. Anyway, I am now one happy camper. I still stick to a low histamine diet, which most docs who treat Histamine Intolerance seem to recommend, but my face looks great. My whole appearance has improved. If you seem to react to high histamine foods (tomatoes, smoked fish, aged cheese, etc.) you might want to give it a whirl. Histame is very expensive, though, but I don't have much choice for myself. My body really seems to be lacking in DAO, one of the enzymes that helps the body deal with histamine. Regards Queta "

And: "I flush sometimes. My symptoms are more swelling in the cheeks, nose, chin, forehead, and eyelids. Bloodshot eyes. Veiny, splotchy complexion. My derm, incidentally, did mention that some of my symptoms may be related to histamine. I have also had other docs mention that I look like I'm allergic to something because of the dark circles under my eyes. I have used lots of anti-histamines (Singulair, Zyrtec, NasalCrom, NasalCort, Benadryl, Walgreen's brand Wal-finate) but this Histame works at a different level, and doesn't make me sleepy. I'm psyched! Now I'm trying to see how I can come up with the $100/month so I can take 3 per day. I took one in the morning yesterday with breakfast and two last night with dinner and my skin looked so good this morning! My eyes were white and the circles under them were gone. My skin was pale, non-blotchy, and non-puffy. My forehead did not have its usual early morning bumpiness (a state which is causing pre-mature wrinkling, BTW.) Regards Queta "

Queta had earlier written on May 16th 2009: "Hi, Just want to put in a plug for quercetin/bromelain supplementation. I kid you not, my rosacea is 95% gone now. I have been on this combo for a few months now. Quercetin is known to inhibit mast cells, which appear to play a role in rosacea. I take 2 capsules of quercetin/bromelain before each meal and my snack (so 4 times per day) and my rosacea is definitely getting better all the time. The day before yesterday I did the dreaded smile test where I smile in the car vanity mirror. Normally my face looks weird when I smile-my cheeks puff out too far and it looks like I have too much fluid in my face or something. The other day I did it and guess what? I looked almost completely normal. I have also been noticing people of the opposite sex checking me out more often which for me is a fairly good objective measure. Just wanted to share...if anyone out there thinks that supplements don't work I have to say I was in your camp but tried this out of frustration and fear of getting worse and worse. The visible veins on the end of my nose are almost gone now, too. It's been really amazing. I do still have to watch my diet, but this combo has taken my rosacea to a whole new level. Feel free to respond with any comments or questions. Cheers and all good things, Queta "


Lilyian wrote on January 21st 2008: "J, You are right on target with mastocytosis. However, I have IA, although my doc (one of the most renowned mast cell researchers) really thought I systemic masto (skin plus body symptoms). The only way to diagnose systemic masto is through a bone marrow biopsy, which I eventually had done. I tested negative, so I get labeled as having IA. It is tricky for me to know if my flushing was rosacea or my IA. I think it was 90% my IA and 10% rosacea perhaps. My histamine blocker meds were like magic. I never thought they would work, so you can imagine my surprise when I took them and saw that all my flushing disappeared! Not I only flush if my symptoms start to trigger; it is a warning sign to me if my face flushes and gets hot. I take 180 mg Allegra in the morning and 10 mg zyrtec in the early evening (among other histamine blocker meds) every day. Flushing can certainly point to IA or masto. The problem is that most docs don't know how to identify the diseases or diagnose it. Even if they think that they can diagnose it, they are usually wrong. There are only a handful of masto researchers in the country, and they are scattered at the main facilities, such as Univ Of Michigan, Mayo, and NIH. I absolutely cannot recall if you can diagnose UP by a skin biopsy; you cannot diagnose systemic masto that way. Does this help you figure out anything? P;ease feel free to as me more questions is it will help. I can give you a website to learn all about masto, but I am not sure if this forum allowes posts from this website's address here or not. Let me know, and I can post it if you like."
skin one is called urticaria pigmentosa. That consists of brown/reddish spots that appear on the skin always in the same places. Now, some people with that will have systemic symptoms, such as diarrhea, itching everywhere, burning feelings everywhere, flush, hives, throat tightening, difficulty breathing, anaphylactic shock, and more. All masto patients have symptoms unique to themselves. So, one might just have red brown spots while another might have no spots, just itchy bumps on face and yet have the severe GI distress.There is another disease exactly like masto, called Idiopathic Anaphylaxis (IA) (some docs call is Mast Cell Activation Disorder - MCAD). The symptoms triggers of the symptoms, and medications for both diseases are exactly the same. The difference is in the cause. Masto is caused by having too many mast cells or having mutated ones. IA is when the mast cells are completely normal, but way too sensitive. When triggered, the mast cells degranulate (release histamines -- like when the person who is deathly allergic to bees gets stung by a bee). So, the patient starts experiencing allergy type symptoms, even though he might test negative to all allergies.


Hoselio wrote on December 7th 2013: "I went to my family doctor for my usual flushing problems (contact flushing, flushing from exertion, heat, ect.) and told him some of my other symptoms (clogged runny nose when I eat, bright red itchy feet when I get out of the shower or stand up sometimes, heart palpitations, can't breathe properly through my nose, can only breathe properly by taking short quick breaths, and mild dermographia) and he told me that he thinks that I might have mastocytosis. I asked him if he could put me on Remeron since I also have severe depression & anxiety due a lot of bad things piling up on me lately, and he said that he wants to try a less potentially harmful antidepressant along with a mast cell inhibitor and antihistamine. So I ended up getting a prescription for Prozac, Cromolyn Sodium (oral), and Allegra."


Jrlhamcat2 replied: "I don't have experience with ketotifen or other mast cell inhibitors but would suggest making sure you've given the cromolyn sodium and Allegra a good long trial at a high dosage first, if you haven't already. I'm currently taking them and seeing a huge improvement, even though it's the worst time of the year for my skin. It does take up to a couple months and a rather large dosage, though. I'm currently on:Nalcrom (trade name for cromolyn sodium/sodium cromoglicate): 200mg 4x/day. Fexofenadine (generic Allegra): 120mg 2x/day. Both of these have had absolutely no adverse effects for me as far as I can tell over the two months I've been taking them, unlikely everything else I've tried. Ketotifen and Montelukast can help but can have some unpleasant effects so it's worth ensuring that something safer won't work first. It might be worth talking more with someone who specialises in allergy & immunology and mast cell disorders specifically since ruling out systemic disorders with these symptoms seems to require a long list of tests, and even smart and helpful GPs can't be familiar with all of it in my experience. Did your GP test serum tryptase levels since he suspects mastocytosis? As you probably know, some of what you described sounds like POTS, which is linked to various autoimmune, mast cell, and connective tissue disorders. A good immunologist might be able to give you most of the tests you need and suggest the right kind of specialist if any further testing would be useful."











Menopausal flushing 
source link About 80% of postmenopausal women experience flushing associated with sweating. A similar syndrome may also occur in men with prostate cancer receiving treatment with gonadotropin-releasing hormone analogues, such as buserelin. About 65% of postmenopausal women have hot flushes for 1 to 5 years, 26% for 6 to 10 years, and 10% for more than 11 years.


Signs and symptoms
There is considerable variation in the frequency, intensity, and duration of hot flushes within and among individuals.
A typical hot flush begins with a sensation of warmth or heat in the head and face, followed by facial flushing that may radiate down the neck and to other parts of the body; it is associated with an increase in temperature and pulse rate and followed by a decline in temperature and profuse perspiration over the area of flush distribution. Visible changes occur in about 50% of women. Each hot flush may last for 1 to 30 minutes (but lasts 4 minutes on average, although the numbers differ per online source). Wiki states: "Hot flashes, a common symptom of menopause and perimenopause, are typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and may typically last from two to thirty minutes for each occurrence, ending just as rapidly as they began. The sensation of heat usually begins in the face or chest, although it may appear elsewhere such as the back of the neck, and it can spread throughout the whole body. Some women feel as if they are going to faint. In addition to being an internal sensation, the surface of the skin, especially on the face, becomes hot to the touch. This is the origin of the alternative term "hot flush", since the sensation of heat is often accompanied by visible reddening of the face. 

Excessive flushing can lead to rosacea. Other symptoms are drenching perspiration, a sensation of overheating before the onset of flushing and sweating, and waking episodes at night with the typical symptoms. Alcohol can enhance a menopausal flush. It is not yet entirely clear what causes hot flashes." The hot-flash event may be repeated a few times each week or every few minutes throughout the day. Hot flashes may begin to appear several years before menopause starts and last for years afterwards. Some women undergoing menopause never have hot flashes. Others have mild or infrequent flashes. The worst sufferers experience dozens of hot flashes each day. In addition, hot flashes are often more frequent and more intense during hot weather or in an overheated room, the surrounding heat apparently making the hot flashes themselves both more likely to occur, and more severe.



Causes of menopausal flushing
There are indications that reduced levels of estrogen are to blame and are the primary cause of hot flashes. Rapid estrogen withdrawal is more likely to cause hot flashes than a low estrogen level by itself. Hot flashes may also be due to a change in the hypothalamus's control of temperature regulation. And another source blames very high levels of gonadotrophins as the ovaries fail.


Young women
If hot flashes occur in a young woman's menstrual cycle, it might be a symptom of a problem with her pituitary gland; seeing a doctor is highly recommended. In younger women who are surgically menopausal, hot flashes are generally more intense than in older women, and they may last until natural age at menopause.

Men
Hot flashes in men could have various causes. One is a possible sign of low testosterone. Another is andropause, or "male menopause". Men with prostate cancer or testicular cancer can also have hot flashes, especially those who are undergoing hormone therapy with antiandrogens, also known as androgen antagonists, which reduce testosterone to castrate levels.There are also other ailments and even dietary changes which can cause it. Men who are castrated can also get hot flashes.




Treatment options for menopausal hot flashes
Treatment options include hormone replacement therapy, selective estrogen receptor modulators, selective serotonin reuptake inhibitors (SSRI's), isoflavones, the use of natural phytoestrogens (like ginseng and flaxseed). Also used are progestogen, eg norethisterone or megestrol, and the anticonvulsant gabapentin.  Examples of useful SSRI's are paroxetine (20 mg daily), fluoxetine (20 mg daily), citalopram (20 mg daily). Veralipride, an antidopaminergic drug, can cause reductions in the frequency and intensity of menopausal flushing in premenopausal women pretreated with goserelin (a gonadotropin-releasing hormone agonist) for endometriosis. Neurotransmitters that may be involved in the pathogenesis of hot flushes include norepinephrine and other noradrenergic substances. The central noradrenergic system in the hypothalamus triggers the hot flushes via α2-adrenergic receptors on the noradrenergic neurons. Thus, clonidine, an α2-adrenergic agonist, effectively alleviates hot flushes through reduction of noradrenergic release.



The differences between menopausal hot flashes and rosacea
Hot flashes tend to last shorter than a typical rosacea flare (often only minutes whereas a rosacea flush can take a lot longer to build up and calm down again). Rosacea, unlike menopausal hot flashes, is usually not associated with sweating and a rapid pulse. Neither does it typically spread further than the face. The hot flashes sometimes associated with menopause may bring on a flare-up or even the initial onset of rosacea. A Swedish study also noted that postmenopausal women with rosacea may be more likely to experience migraine headaches.



Another type of hormone related flushing: Adrenaline Flushing
This kind of vascular dilation is caused by an adrenaline rush. Adrenaline facial skin flushing is the same as systemic flushing, but it is hormone released. Stress is the body's reaction to a perceived threat. Adrenaline and hormones are released, and the nervous system is activated, sharpening our senses, but simultaneously our pulse rises, our muscles tense and our immune system begins to shut down. Adrenaline activity can also cause acne in both men and women as a reaction to mental or physical stress. In women, half of their testosterone is produced by the ovaries with the other half being produced by the adrenal glands. Estrogen smoothes out the testosterone produced by the ovaries, but when the estrogen level drops several days before the menstrual periods, sometimes resulting acne occurs especially when the adrenal glands over produce due to stress or fatigue. The adrenal glands can be stressed continually in both men and women resulting in too much testosterone with the resulting over stimulation of the sebaceous glands. Similarly, in the male an over abundance of testicular testosterone especially with overly stimulated adrenal glands causes the overly stimulated sebaceous glands. Quite often more stress is placed on the adult after puberty resulting in the symptoms of over active sebaceous glands. While we can not produce more estrogen to level out the testosterone, we can drink much more water which will help relieve the symptoms of stress and assist both acne and rosacea. Getting enough sleep and finding ways to relax will help relieve stress and reduce the adrenaline reaction that follows. (Source)



Forum posts from rosacea patients about menopausal hot flushing

Irishgenes wrote on January 28th 2006: "This is my first post this year, as I have been cured of rosacea by finding the right amount of estrogen for my body. Although Climara is a bioidentical form of estrogen, the patch form was never enough for me, and I continued to suffer even wearing two patches at a time. The patch also does not last the length of time that they claim. These standard doses are just not good for most women, and that is why the majority of women discontinue hormone replacement therapy. I used compounded Tri-Est capsules for years, but lately I have discovered compounded estrogen skin gel. With the gel, I can modify the dose from time to time as needed. The gel is made up in gm doses, which is 1/4 tsp. I have bought a set of measuring spoons called "dash, pinch, and smidgen" which measures 1/8, 1/16, and 1/32 tsp. Thus, I can adjust the dose on days when I need a little extra or feel like I have too much (easily recognized by bloat and breast pain).



These are all the symptoms I have had which have been cured by the right dose of bioidentical estrogen: heart palpitations, flushing, fever of 2 degrees at times, chest pain, gastro-esophageal reflux, arm & leg cramps, severe migraine headaches, hunger pains & weight gain, high blood pressure, depression, irritability, urinary urgency, forgetfulness, dry eyes, diarrhea, and ROSACEA! Yes, there are estrogen receptors in every body system. As soon as my estrogen dips too low, I get (among other things) red, swollen, dry, scaley, & itchy eyes and lids. As soon as my dose is absorbed, it all goes away like magic. I have ceased all expensive supplements and all drugs, and I have had no rosacea for about a month now. I eat whatever I want, including former "trigger" foods (and SUGAR, Brady!) I can go in the sun without fear. I will report back in the summer to tell you if I have stayed rosacea-free.

It seems like I must have had every menopausal symptom there is, but other women have symptoms like fibromyalgia, carpal tunnel, and chronic fatigue which may be related to estrogen deficiency. I recommend the book "Screaming to be Heard: Hormonal Connections Women Suspect & Doctors Still Ignore" by Dr. Elizabeth Vliet to discover all the many symptoms that may be caused by estrogen deficiency. For those who are afraid of estrogen, thinking it causes cancer (it doesn't--all the studies have been done on the horse estrogen Premarin), I recommend the book "Sex, Lies, & Menopause: The Shocking Truth About Hormone Replacement Therapy" by T. S. Wiley. That book is half footnotes, so don't buy it unless you are scientifically inclined. But it will change your attitude forever about hormones when you see how often conventional medical wisdom is often not based on evidence, but on nothing more than a single misinterpreted study which 99.9% of doctors never read. They just parrot what they hear from others.
For those who are peri-menopausal, there is no need to suffer for 15 years or more until you reach menopause. Your estrogen levels start declining in your 30's, and just because your doctor tested your estradiol on one day does not mean it did not dip down too low the next day. For practical advice on how to use bioidentical estrogen for various symptoms from your 30's on up, I strongly recommend the wonderful book, "Natural Hormone Balance for Women" by Dr. Uzzi Reiss. He gets into the nitty-gritty of EXACTLY what to do and how to do it, so that you will become an expert at dosing yourself. Of course, you will still have to find a doctor who will prescribe it for you, but with the gel, you won't be stuck with a standardized dose. If you are peri-menopausal and have symptoms on just a few days a month, you can use just a little gel on those days.
Dr. Reiss doesn't discuss rosacea in the book, but then who knew that rosacea could be caused by estrogen deficiency? I started getting the eyelid symptoms in my late 30's (along with the migraines), but thought I had an allergy. As for the migraines, I hate to think of all the hours of pain and vomiting-- the codeine, Imitrex shots & then pills, and trips to the ER for Toradol shots. Now when I get the first inkling of a migraine, I rub on a smidgen of estrogen gel and it is gone. No more pain pills for me! The gel takes about an hour to absorb, but Dr. Reiss mentions sublingual estrogen drops for migraines that work even quicker, and I plan to get a prescription for those soon.

For those women who have rosacea in your 20's, I would suggest finding a different birth control pill if you are currently on the pill or maybe going off the pill to see if it helps. (See Dr. Vliet's book for a list of the best bc pills, which are those with a high estrogen to progestin ratio.) For those women who got rosacea in childhood, estrogen deficiency now may be making your rosacea worse, but you obviously won't be cured by estrogen. For guys (if you've read this far), don't try this at home! "



Ruthuk wrote on January 3rd 2012: "Hello, I was diagnosed with premature ovarian failure (early menopause) in May. I've been struggling badly with hot flushes, despite being on an increasingly high dose of HRT. More recently I've noticed that my face is almost permanently red. In real life I was the palest person you could imagine, although not troubled by blushing. Now my skin looks suspiciously healthy most of the time and if I get hot (by which I mean any temperature above really freezing), do any sort of light exercise, have a glass of wine, I go bright red on my nose, and pretty red on my cheeks, rest of face, neck and upper chest. It seems to get worse over the course of the day too. But it is not a "normal" hot flush in that it just doesn't go away ... I am therefore wondering about rosacea. I believe that menopause often triggers rosacea, or perhaps my versions of hot flushes are just not the normal ones? My main problem, because I can live with the redness (and its not the searing red I've seen in bad rosacea cases just very pink, like after you get out of a hot bath), is that I am UNBELIEVABLY HOT. Its making my life a misery. What do you think? Rosacea or just menopause? Its wierd that the hrt isn't taking the heat away, which is why I'm thinking I must have something else ...I'd be very grateful for any info. " 



Judworth replied: "Hello Ruthuk, Do you get any sensitivity or pain with the flushing? I am approaching menopause & find that the 'hot flushes' that I get with menopause is a very different feeling to a rosacea flush/heat. I am taking beta blockers for rosacea & it appears to be helping confine my hot flushes to my body! Judy " 


And Judworth wrote on May 2nd 2014: "Hello Wendy, I do hope that you don't mind me replying. I am 56 next month (sadly still peri-menopausal) but my rosacea HAS got better over the years. It started when I was 44 and I would get hourly flushing............now although I flush, get P & P's, the real attacks are maybe 2-5 times a month (I know as I keep a rosacea diary!). The longer the months between periods are, I find things are so much better, it's only the build up to yet another one that will cause me pain. I hope that gives you some hope for the future? Hugs Judy "










Drug related flushing

Some drugs and medications are known to have the potential to induce facial flushing. Some of them are: morphine, sodium monoglutamate, nitrates, calcium channel blockers, TRH injection, nicotinic acid and alcohol. Other potential suspects are corticotropin- releasing hormone and doxorubicin.

Corticosteroids of any form can cause flushing or worsen existing rosacea. 

Flushing is a side effect of sildenafil citrate in 12% of patients. Systemic administration of morphine can cause flushing of the face, neck, and upper shoulders, which is believed to be histamine-mediated. Patients can develop facial flushing, generalized erythema, or both after epidural or intra-articular administration of glucocorticoids.



Here is a list of the drugs that can cause facial flushing:
All vasodilators (e.g., nitroglycerin, prostaglandins)
All calcium channel blockers
Nicotinic acid (not nicotinamide)
Morphine and other opiates
Amyl nitrite and butyl nitrite
Cholinergic drugs (e.g., metrifonate, anthelmintic drug)
Bromocriptine used in Parkinson’s disease
Thyrotropin-releasing hormone (TRH)
Tamoxifen
Cyproterone acetate
Oral triamcinolone
Cyclosporine
Rifampin
Sildenafil citrate



Steroids and flusing
When a rosacea patient is erroneously treated for a prolonged time with topical steroids, the least severe consequence is that the rosacea may at first respond and clear up (especially the p&p subtype 2), but inevitably the signs of steroid atrophy will emerge with thinning of the skin and marked increase in telangiectasis. The complexion becomes dark red often. Soon the surface can become studded with round, follicular, deep papulopustules, firm nodules, and even secondary comedones. The appearance of the facial skin redness can soon become shocking with a flaming red, scaling, papule-covered face. At worst, those with no rosacea symptoms but a predispotion for the illness, will find that steroid use can trigger the rosascea to erupt. Or those with existing rosacea can find that even a simple steroid inhalor for asthma can sent their rosacea into a much worse state. Oral prednisone can do the same thing but most notorious are the topical hydrocortisone creams.
I had normal skin, but already blushed from alcohol or when I went out dancing for instance in a hot place. It never bothered me, nor did I ever have a hot flushed feeling. BUt 3 days of hydrocortisone cream on my face for an eczema flare sent me right into rosacea misery. My dermatologist told me stories of patients he had battled for years with to control the rosacea, and right when they had succeeded the patient used an asthma inhaler and they were "back at square one", as he put it. Morale of the story; he urges me and his other flushing patients to stay well clear of steroids, as they can have very inpredictable effects on rosacea.


Steroid rosacea is an 'avoidable condition', and not only results sometimes from topical steroid use, but also from the use of a vitamin A derivative called Roaccutane. In addition to disfigurement, steroid rosacea is accompanied by severe discomfort and pain. Withdrawal of the steroid is inevitably accompanied by exacerbation of the disease, a trying experience for a patient and physician. Most dermatologists know not to prescribe a steroid for rosacea. (Source)





Cigarette Flushing
Smoking, a vascular dilator which robs the skin of oxygen, is a potent initiator of telangiectasis and the symptoms of facial skin redness. The smoker may have a variety of medical problems such as high blood pressure and mineral deficiencies which can cause the appearance of telangiectasis. I discussed smoking, nicotine and rosacea also in another blog post.

Forum posts from rosacea patients about drug related flushing
There are really many, many forum posts on steroid induced rosacea. It is a very serious potential side effect of steroid use and made many victims along the way, some who never had flushing issues prior to taking steroids or roaccutane.


Brady collected a few anecdotal threads on steroid induced rosacea.

Metiner wrote on February 20th 2013: "Hi, I know that steroid induced rosacea is actually not rosacea, but mimics it. Therefore it might heal. I had rosacea in a tiny area on my face and I was given a steroid cream. I used it for about 10 days. A few months after I went off it, my rosacea exploded on my entire face and looks horrible. Now, do I have steroid induced rosacea? Even though I already had rosacea before using the creams? The horrible change before and after steroids are unbelievable. My rosacea was very mild and small for about 6 months, and then I applied steroid on it for 10 days. In about 4 months the rosacea got so bad that my face was unrecognizable. Therefore it makes me think I might have steroid induced rosacea.I appreciate your thoughts.. "

Bloem replied: "I used steroid creams before I knew I had rosacea. It was pretty strong. It got really bad for a month - 6 weeks. And it slowly got better, but it took like a year. It did get better, but it never went away completely. The only thing that helped was avoiding triggers, (creams etc that stung) and IPL. People can hardly tell now. Whatever the cause, if it is really bad now, it's probably due to the steroids and it will get a lot better. It takes a lot of time."

Steph623 wrote on April 9th 2012: (its a very long post, I shortened it a bit) ":( Unhappy Steroid Induced Rosacea? Hi. New to the forum, but not new to skin problems. I'm 47 years old and have had a history of hormone-related acne. When I was younger (in my late 20s) I was treated, successfully, with Accutane. That settled the worst of my acne, but I struggled with it on and off for years due to endometriosis and polycystic ovarian disease. [..] About 14 months ago or so, my formerly pretty oily skin was becoming very dry. It was uncomfortably so but any use of moisturizers would usually set off a round of pimples. This is just the nature of my skin. With all the dryness, is started developing scaly patches. Well, stupid me, I decided to treat the scaly patches with steriod cream. I'd done this in the past, but only for very brief periods.[..] Eventually, I was treating pretty much everything from the bottom of my eyes down to the middle of my neck with a thin film of the stuff, twice a day. [..] About 4 months ago, I started getting these weepy bumps that were tender or itchy. They looked like pimples to a degree, but had an entirely different nature about them than I was used to (and goodness knows I had years of experience with acne). They couldn't be
popped and they seemed to spread in clusters over my cheeks and chin. They also started getting a 'flushed' look to them. I started to suspect rosacea since I am of celtic heritage and I know my grandmother had rosacea, so I wasn't entirely unfamiliar. Well, last week, I'd about had it with all of this irritation and finally went to my long-time dermatologist - someone I hadn't needed to see in a number of years. He took one look at me and said, 'Looks like rosacea.' I told him what I had been using: desonide, tea tree and he said, 'Stop the steriod!' Although, he didn't explain why other than to say that it can worsen rosacea. In addition, he gave me an prescription for doxycycline 50 mg 1x/day and a topical gel called Aczone (dapsone). Well, that night I did not use the desonide nor the tea tree but only applied the Aczone and took my doxycycline. The next day my skin looked pretty good. It was 24
    I woke up feeling like my face was on fire and I looked in the mirror and nearly fainted. My face was bright red from the eyes down to my mid-neck and it had dozens of the painful, weepy pimple-things that made my entire face look like the skin of an orange! I was horrified. My first thought was that I was allergic to the new Aczone. My second thought was this was some sort of 'purge' as I had gone through that lovely phase a few times in my life. Well, I stuck it out for 4 days and each day it has gotten worse. The pain is now accompanied by severe itching and when I smile, my skin looks all atrophied and wrinkly.
    Trying to calm myself down and think rationally, Friday evening I began researching [..] which led me to the information on steroid-induced rosacea. I'm now starting to think that I have steroid-induced rosacea. [..] I would appreciate any comments, recommendations or feedback anyone could give me. I've read a number of posts by Ghost here and I'm very intrigued by his account of treating demodex. Thanks for reading."
hours after THAT that all hell broke loose.

Prem replied on May 5th 2012: "I think i may also have steroid induced rosacea. I'm not sure if i do have rosacae, but either way....my eyes also burn, and i have dry rough scaley skin that is spreading. It sounds just like yours. I used steroid cream for about 5 months, i stopped it now. So yeah...its become worse and worse over the past 5 months. Could you please look at my post and help tell me if it is rosacea :S? "

Here, here, here and here are more Forum Threads about steroid induced rosacea.










Allergies/ Food allergies/intolerance/ coeliac disease

Flushing Associated with Food
Please also read my Food blog post if interested in this topic :) Eating spicy or sour foods can cause facial flushing. This gustatory flushing is caused by a neural reflex involving autonomic neurons carried by the branches of the trigeminal nerve. The flushing may be unilateral. Flushing can happen in response to monosodium glutamate (MSG) -a food additive often found in Asian food for instance- or other dietary agents, such as red pepper, other spices, nitrites and sulfites (additives in many foods), thermally hot foods and beverages, and alcohol. Scombroid fish poisoning (tuna and mackerel) is caused by the ingestion of fish that was left in a warm temperature for hours. In addition to flushing, patients with scombroid fish poisoning experience sweating, vomiting, and diarrhea. These symptoms are caused by intoxication with histamine, which is believed to be generated by histidine decarboxylation by bacteria in spoiled fish.

Heavy Meal and Sugar/Carbohydrate Flushing
Facial skin flushing or vascular dilation can be caused by stress on the digestive system (eating heavier meals), resulting in a higher blood flow to the digestive system with the residual blood being heavier to the face (hence; more blood flow circulation to help digest all that food, and therefore also more blood that circulates to the face area, causing more flushing issues). The digestion process itself also produces some heat and increased temperature in the body, a bit more for women and children than it dores for men. You can limit this type of flushing, by eating smaller meals, spaced out over the day, with some healthy snacks to keep your blood sugar level stable and prevent the digestion system from being 'bombarded' all at once with a massive meal. This will also maintain the proper blood sugar content for energy to prevent fatigue or exhaustion. The type of food that you eat is also very important as various foods stimulate blood flow differently.
Simple carbohydrates such as donuts, sugars, alcohol, etc. enter the blood stream quickly causing hyperglycemia (high glucose spikes.) This rapid influx of sugar into the blood stream is a potent vasodilator. Carbohydrates are needed for energy and as a part of every meal; however, try to switch from simple to complex carbohydrates. For instance, sweet potatoe, apples or quinoa. However, in the next paragraph things will get more messed up and complicated, because complex carbs actually also heat the body up when they get digested.... Why is all this so complex for us rosaceans??
Fiber intake decreases the amount of food that the stomach has at one time and prolongs digestion; therefore, it prevents the sudden influx into the blood stream with the resultant facial skin flushing. (source).

Foods That Make You Hotter
Ice cream: It turns out the fat content in ice cream actually makes your body warmer. Foods that contain more fat, protein, and carbohydrates often heat the body up a little bit while digesting food. The sheer temperature difference gives a cooling sensation, but when your body starts to digest, you feel warm because your body has to provide energy to digest that food product. Fat is notorious for moving slowly through the digestive system so it takes more energy to digest that fat. Anytime you are putting more energy through the system, whether it be digestion or weight lifting, your body has a tendency to heat up.
Brown rice: Complex carbohydrates like rice and other whole grains are also harder to digest, making the body warmer during the process. Anything with a lot of complex carbohydrates and processed foods like rice and cereal products can be more warming than cooling.
Beer: Alcohol can dehydrate you and make your body flushed — a process called vasodilatation, which is caused by the widening of blood vessels. This can cause your skin to heat up. When the body starts to vasodilate, you can flush pretty heavily. It is going to be warming, especially in the surface capillaries in your face.This also depends on how much alcohol you consume in one sitting. The more alcohol someone drinks, the more flushing will occur. (source)




Foods That Make You Cooler

Watermelon: As a general rule, the higher the water content in a food, the more likely it will keep your temperature down. Watermelon is chock-full of water, which slows down digestion and takes less energy from the body. Note that melons are high in salicylate, another substance that can worsen some rosaceans flushing, for those sensitive to salicylates. If you flush from aspirin, you might also flush from high contents of salicylates in food.
Leafy greens: Most raw fruits and vegetables are 80-95% water, and anything that contains a lot of water is very easy to digest and goes through the digestive system very quickly, giving you a cooling sensation. Easy digestion means less energy and heat.
Peppers: Spicy foods can make you sweat, which provides a cooling sensation. Peppers are often consumed in countries close to the equator because they are perceived as cooling foods primarily because they influence the body when you perspire, and through evaporative cooling, you feel cooler. It doesn’t cool you to the core, but it cools the skin. Note, this is obviously not wise to eat for anyone with rosacea and flushing issues. This tip only applies to the general population with ormal skin I think.

Inflammatory foods
Internal inflammation can happen for a host of different reasons: high temperatures when cooking food, eating processed foods, sugar, trans fats, etc. A high level of inflammation within the body can cause many health problems and stir up both rosacea and facial flushing. Inflammatory foods include corn, sugar, pork, processed food, any food that went into the deep fry, alcohol. According to the Traditional Chinese doctors I visited, garlic, unions, ginger, spices, predator fish types, lamb, citrus fruits, tomatoes, strawberries, chocolate and dairy and wheat products also cause internal inflammation in the body.

TOP 10 ANTI-INFLAMMATORY FOODS
1. Wild Alaskan Salmon: Salmon contains anti-inflammatory omega-3s (wild is better than farmed) and has been known to help numerous ailments. Note, fish can be high in histamine and heavy chemicals like mercury and can actually worsen flushing for some. Its trial and error with what fish types your rosacea tolerates and which not.
2. Kelp: High in fiber, this brown algae extract helps control liver and lung cancer, douses inflammation, and is anti-tumor and anti-oxidative. Kombu, wakame and arame are good sources. 
3. Extra Virgin Olive Oil: The secret to longevity in Mediterranean culture, this oil provides a healthy dose of fats that fights inflammation, can help lower risks of asthma and arthritis, as well as protect the heart and blood vessels.
4. Cruciferous Vegetables: Broccoli, brussel sprouts, kale and cauliflower are all loaded with antioxidants. Naturally detoxifying, they can help rid the body of possible harmful compounds.
5. Blueberries: Blueberries not only reduce inflammation, but they can protect the brain from aging and prevent diseases, such as cancer and dementia. Aim for organic berries, as pesticides are hard to wash away due to their size. Note that blueberries are high in salicylate, another substance that can worsen some rosaceans flushing, for those sensitive to salicylates. If you flush from aspirin, you might also flush from high contents of salicylates in food.
6. Turmeric: This powerful Asian spice contains a natural anti-inflammatory compound, curcumin, which is often found in curry blends. It is said to have the same effect as over-the counter pain relievers (but without their side effects). Note that turmeric is a spice and while it helps some rosceans, it can worsen symptoms as well for some (for me it did when I tried it with bromelaine).
7. Ginger: Ginger contains a host of health benefits. Among them, it helps reduce inflammation and control blood sugar. Ginger tea is a great addition to any diet. Note that ginger is a spice and while it helps some rosceans, it can worsen symptoms as well for some. My traditional Chinese doctors warn against it, as it can heat the body up they say, for people with inflammatory skin diseases.
8. Garlic: Though a little more inconsistent (in terms of research), garlic can help reduce inflammation, regulate glucose and help your body fight infection. Note that garlic might help some rosceans, it can worsen symptoms for some. My traditional Chinese doctors warn against it, as it can heat the body up they say, for people with inflammatory skin diseases.
9. Green Tea: Like produce, this tea contains anti-inflammatory flavonoids that may even help reduce the risks of certain cancers. Note that some people react to the tannins and other chemicals in some types of green tea, and that a good alternative is to make tea from rosemary or thyme, both have anti inflammatory substances in them.
10. Sweet Potato: A great source of complex carbs, fiber, beta-carotene, manganese and vitamin B6 and C, these potatoes actually help heal inflammation in the body. Note, I love sweet potatoes! My rosacea handles them well, in moderation.

TOP 10 INFLAMMATORY FOODS
These foods have been linked to obesity, increased risks of numerous diseases and can elevate inflammation levels in the body and worsen auto-immune diseases
1. Sugar: Sugar is everywhere. Try and limit processed foods, desserts and snacks with excess sugar. Opt for fruit instead.
2. Common Cooking Oils: Safflower, soy, sunflower, corn, and cottonseed. These oils promote inflammation and are made with cheaper ingredients.
3. Trans Fats: Trans fats increase bad cholesterol, promote inflammation, obesity and resistance to insulin. They are in fried foods, fast foods, commercially baked goods, such as peanut butter and items prepared with partially hydrogenated oil, margarine and vegetable oil.
4. Dairy: While kefir and some yogurts are acceptable, dairy is hard on the body. Milk is a common allergen that can trigger inflammation, stomach problems, skin rashes, hives and even breathing difficulties.
5. Feedlot-Raised Meat: Animals who are fed with grains like soy and corn contain high inflammation. These animals also gain excess fat and are injected with hormones and antibiotics. Always opt for organic, free-range meats who have been fed natural diets.
6. Red and Processed Meat: Red meat contains a molecule that humans don't naturally produce called Neu5GC. Once you ingest this compound, your body develops antibodies which may trigger constant inflammatory responses. Reduce red meat consumption and replace with poultry, fish and learn cuts of red meat, once a week at most.
7. Alcohol: Regular consumption of alcohol causes irritation and inflammation to numerous organs, which can lead to cancer.
8. Refined Grains: "Refined" products have no fiber and have a high glycemic index. They are everywhere: white rice, white flour, white bread, pasta, pastries... Try and replace with minimally processed grains.
9. Artificial Food Additives: Aspartame and MSG are two common food additives that can trigger inflammation responses. Try and omit completely from the diet.
10. Fill in the Blank: Do you constantly have headaches or feel tired? Do you feel flushed every time you eat a certain food item? Sometimes, you may develop an allergy to a food and not even know it. Coffee, certain vegetables, cheese... there might be a trigger you aren't even aware of. Or you are not actually allergic to the food, but intolerant to it (sensitivity that will cause you symptoms, but that won't show up in a standard blood test for allergies). Try and take a few foods out to see how you feel and slowly incorporate them back in to see if there might be a hidden culprit lurking in your diet!

Alcohol Flushing

The best way to avoid this type of flushing is to not drink any alcohol! Alcohol is a vasodilator. All alcohol is fermented, but because beer and wines (red wine being the worst) are not further distilled, they can cause the symptoms of allergy facial skin redness for many rosacea sufferers. Red wine also contains tannins and sulphates which can make you even more flushed and red than from the alcohol itself. Alcohol is a diuretic which pushes water out of the body cells. In this state of dehydration, the body is prone to skin redness and flushing. Alcohol is a concentrated source of calories and is metabolized very quickly. This causes the blood vessels to dilate causing facial redness symptoms.
If you feel you need to drink alcohol at social functions or to relax, here are some recommendations to minimize the flushing effect:

Avoid beer as it is higher in carbohydrates. However, if you like beer, drink domestic beer from your own country as it is usually sold within six weeks of production. Foreign beers imported into your country usually have preservatives which make for more redness. Domestic 'light beer' usually does not have as many carbohydrates and less alcohol content making it the beer of choice.
Wine is heavy in carbohydrates and even higher in preservatives/sulfides and alcohol causing more flushing with the red wines usually being the worst for most of us. If you prefer wine, a white wine would be best.
It is better to drink small amounts of gin, vodka, or whiskey, diluted with water instead of sugared soft drinks or mixes which also can stimulate the cardiovascular system. A good choice would be a Long Island Ice Tea substituting the mix with water and diluting it. Small amounts of gin are frequently less stimulating than vodka or whiskey. You should "chase" any alcoholic drink with water.
Although these recommendations can help to minimize facial skin redness/flushing, the best advice is to not drink any type of alcohol at all.
In this Rosacea Forum post, patients rate their top alcohol triggers. 
(Source, this girl has a blog about gluten allergy, but described flushing from alcohol in this picture)






Food Allergy Flushing
Many patients with rosacea have other symptoms that suggest the diagnosis of food allergy. A red nose, cheeks, and red ears may act like warning lights that turn on when a food reaction starts. Rosacea patients should identify the reactive foods when this flushing or vascular dilation occurs. Often, it is the symptoms of food allergy that motivate people to start diet revision and an improvement in their rosacea condition is noted along with improvement in other symptoms such as gastrointentestinal disturbances, migraine headache, sinusitis, and fatigue.
As mentioned earlier, rosacea redness can be partially caused by high calorie carbohydrates (pastas, breads) and sugar spiking from all sweet foods. Quite different are the foods that are blood vessel dilators such as vinegars, hot spices, and various other spicy seasonings, hot sauces, peppers (including black pepper) and meat marinades. Tomatoes, citrus fruits, and related juices, bananas, and red plums, raisins, figs, pasta, cheese, and chocolates are some of the worst offenders to many. Other very common known flushing foods are liver, yogurt, sour cream, vanilla, soy sauce, yeast extract, eggplant, avocados, spinach, broad-leaf beans and pods, including lima, navy or peas. Allergies to malt and yeast beverages, and fermented alcohols would fall into the allergy induced redness category. Stimulants such as coffees, teas, soft drinks with caffeine, alcohol beverages, and chocolates stimulate the system resulting in more facial redness or dilation.

Thermally hot foods and drinks even cause vascular dilation or flushing in non-rosaceans. Avoid all hot foods and drinks until they have cooled to body temperature or better yet cooled well below body temperature. The best way to drink a small amount of coffee, tea, or soft drink is refrigerator cold as this will not cause as much vascular dilation.
Food allergies are common in causing nasal membrane mucous resulting in vascular dilation causing reddening or facial flushing for many. This condition gets the same response (but for very different reasons) as the common cold or influenza which often causes facial flushing due to a bacterial and virus infection.
Aspartame and NutraSweet in soft drinks, jellos, and other foods causes noticeable flushing in 30% of rosaceans. Try a 60 day non-aspartame period to watch your facial skin redness improve.
After all the foods that cause more vascular dilation or blushing, a bonus is that cherries, blackberries, and blueberries which are vascular constrictors actually assist in reducing the symptoms of facial skin redness.


Susybranch wrote on June 5th 2014 on The Rosacea Forum: "I had type 2 on my nose, with seb-derm, As many on this board know, some of us who have Rosacea have found a connection to our digestive systems. In my case, I turned out to have so many mild -- but across the board-- food allergies, that the doctor diagnosed me with Leaky Gut syndrome. My immune system was reacting to all these irritants by upsetting my stomach, and my skin. Rather that randomly cutting out food groups, my allergy test let me know exactly what to avoid. (The doctor says that in a few weeks my system should start to "re-set" and I will probably be able to eat most of those foods again.) Between the new diet and the Prosacea, occasional Histame, along with some digestive enzymes and probiotics, I am almost entirely clear.  I can even drink a little vodka -- not on my "verboten" list! I urge you all to get a full allergy workup, rather than shoot in the dark about what foods to avoid. I spent a bit of money but saved myself years of guessing."
and occasional papules. It could be tamed -- somewhat -- by Oracea and Metrogel, but these were a band-aid, and I was also having stomach issues and began to suspect food intolerance.



Pollen and Contact Flushing

Spring in most countries is the time for pollen and mold spores with the result that it affects many rosacea sufferers. However, some areas have enough warmth and proper vegetation for pollen and mold spores year around. You may even see mold spores growing in your bathtub or shower. Other allergies can also stir up rosacea flushing, for instance dust mite allergy or cat dander allergy.


Gluten allergy

Acne rosacea has been brought in connection with gluten allergy, also called Celiac disease, and with gluten intolerance. Celiac disease is an auto-immune disease. People respond badly here to a protein in certain grains, mostly wheat, barley and rye.The gluten itself is a protein made up of two protein parts, gliadin and glutenin. The gliadin part is responsible for the abnormal immune reaction that causes gluten sensitivity and celiac disease. Between 0.5 and 1% of the world’s population suffers from gluten-sensitivity. Gluten sensitivity is not the same as a gluten allergy. The gluten proteins of corn and rice lack the gliadin part and do therefore not cause any sensitivity. The immune system’s overreaction to wheat’s gluten causes celiac disease, in which the lining of the small intestine becomes chronically inflamed. Anecdotal evidence suggests that those following a gluten-free diet can sometimes reduce flare-ups of rosacea (source).
Many rosacea patients who are diagnosed with gluten intolerance or celiac disease have noticed that the gluten-free diet clears up much of the redness apparent with rosacea. While there is not much medical evidence yet to link the two conditions, it is possible that there is a connection. It is possible that the inflammation of the intestines contributes to an overall stronger inflammatory response in the facial skin of rosacea patients.
Symptoms of gluten sensitivity or celiac disease include chronic diarrhea, cramps, bloating, bowel disturbances, changes in stool, flatulance, weight loss, weakness, fatigue, joint pain, headaches, depression, abnormal menstrual cycles and malabsorption of essential nutrients, which could result in secondary symptoms such as psychological and neurological problems. The gluten sensitivity makes it difficult for the body to absorb vitamins, in particular vitamin D.
Read more on wikipedia-gluten sensitivity or wikipedia coeliac disease.


 This is an article about gluten sensitivity; it explains gluten intollerance and -allergy and the other grains that might cause problems for your system and why:
"(Quote) Two years ago, at the recommendation of a nutritionist, I stopped eating wheat and a few other grains. Within a matter of days the disabling headaches and fatigue that I had been suffering for months vanished. Initially my gastroenterologist interpreted this resolution of my symptoms as a sign that I perhaps suffered from celiac disease, a peculiar disorder in which the immune system attacks a bundle of proteins found in wheat, barley and rye that are collectively referred to as gluten. The misdirected assault ravages and inflames the small intestine, interfering with the absorption of vital nutrients and thereby causing bloating, diarrhea, headaches, tiredness and, in rare cases, death. Yet several tests for celiac disease had come back negative. Rather my doctors concluded that I had nonceliac “gluten sensitivity,” a relatively new diagnosis. The prevalence of gluten sensitivity is not yet clear, but some data suggest it may afflict as many as 6 percent of Americans, six times the number of people with celiac disease. (...) Lately, however, some researchers are wondering if they were too quick to pin all the blame for these problems on gluten. A handful of new studies suggest that in many cases gluten sensitivity might not be about gluten at all. Rather it may be a misnomer for a range of different illnesses triggered by distinct molecules in wheat and other grains.“You know the story of the blind man and the elephant? Well, that’s what gluten-sensitivity research is right now,” says Sheila Crowe, head of research at the gastroenterology division at the School of Medicine at the University of California, San Diego."


Lactose allergy

Lactose intolerance, also called lactase deficiency and hypolactasia, is the inability to digest lactose, a sugar found in milk and to a lesser extent dairy products. People who are lactose intolerant have lower levels of lactase -an enzyme that is needed to break lactose down into glucose and galactose in the digestive system-, which may be genetic or environmentally induced.  Lactose, a disaccharide molecule found in milk and dairy products, cannot be directly absorbed through the wall of the small intestine into the bloodstream so, in the absence of lactase, passes intact into the colon. Bacteria in the colon can metabolise lactose, and the resulting fermentation produces copious amounts of gas (a mixture of hydrogen, carbon dioxide and methane) that causes the various abdominal symptoms. The unabsorbed sugars and fermentation products also raise the osmotic pressure of the colon, causing an increased flow of water into the bowels (diarrhea). When people with this eficiency do consume enough amounts of lactose, this usually causes symptoms like abdominal bloating and cramps, flatulence, diarrhea, nausea, rumbling sounds coming from the stomach or vomiting. The severity of symptoms typically increases with the amount of lactose consumed; most lactose-intolerant people can tolerate a certain level of lactose in their diet without ill-effect. Some studies have produced evidence that milk consumption by lactose intolerant individuals may be a significant cause of inflammatory bowel disease.
Wiki states that most mammals normally stop to produce lactase, and will naturally become lactose intolerant after weaning, but some human populations have developed lactase persistence, in which lactase production continues into adulthood. (Perhaps this is because humans began to drink milk as part of their normal diet at some point in time, and evolution then made us produce lactase for a longer period of time?). It is estimated that 75% of adults worldwide show some decrease in lactase activity during adulthood. The frequency of lactose intolerance ranges from 5% in Northern European countries (England, Scotland, Ireland, Scandinavia, and Iceland) to 71% in Italy (Sicily) to more than 90% in most African and Asian countries. This distribution is now thought to have been caused by recent natural selection favoring lactase-persistent individuals in cultures in which dairy products are available as a food source. Small intestine problems that can cause lactose intolerance include bacterial overgrowth, celiac disease and Crohn's disease. 

Important note: 

also for those who do not suffer from an actual allergy, cutting down on dairy might be good for your health. In this article, a scientist with recurrent breast cancer did research why in China breast cancer hits 1 in every 100,000 women only, whereas in the UK this is 1 in 10 (and in The Netherlands even 1 in 7!!!). She concluded it is because of dairy products. Interesting read and a quote from the article here:
"Professor Plant believes while going dairy-free helped her breast cancer, it could prove beneficial for those patients diagnosed with colorectal, lymphoma and throat cancer. 'We have all been brought up with the idea that milk is good for you,' Prof Plant told the Telegraph. 'But there is evidence now that the growth factors and hormones it contains are not just risky for breast cancer, but also other hormone-related cancers, of the prostate, testicles and ovary. 'Cows’ milk is good for calves – but not for us.' Scientists understand cancer-causing genes may not become active until particular conditions arise in the body, to effectively switch them on. Equally, the science suggests those that can be switched on, can also be switched off. Therefore this means that what a person eats can have a genetic impact. Scientists believe cancer cells are hypersensitive to chemical messenger proteins called growth factors, as well as hormones, including oestrogen. Growth factors are produced by the body, and perform vital tasks such as making cells grow. The risk of cancer comes when we have abnormally high levels of growth factors in the blood, circulating the body. Professor Plant and her co-author, Professor Mustafa Djamgoz, state the same growth factors and hormones responsible for the growth of cancer cells, are found in food that comes from animals. They say certain foods provide the 'fertiliser' cancer cells need to grow, with the main protein in cows' milk being considered the most dangerous. A leading U.S. nutritional scientist, Professor Colin Campbell at Cornell University, has aruged that cows' milk should be regarded in the same category as oestrogen, as a leading carcinogen. Professor Plant told the Telegraph: 'Cow's milk has been shown to contain 35 different hormones and 11 growth factors.' For those patients already diagnosed with cancer or those shown to be at high risk of developing the disease, she advocates, among other things, cutting out all dairy – from cows, sheep and goats, and whether organic or not."


Testing for lactose intollerance

Your doctor may suspect lactose intolerance based on your symptoms and your response to reducing the amount of dairy foods in your diet. Your doctor can confirm the diagnosis by conducting one or more of the following tests:
*Lactose tolerance test. The lactose tolerance test gauges your body's reaction to a liquid that contains high levels of lactose. Two hours after drinking the liquid, you'll undergo blood tests to measure the amount of glucose in your bloodstream. If your glucose level doesn't rise, it means your body isn't properly digesting and absorbing the lactose-filled drink.
*Hydrogen breath test. This test also requires you to drink a liquid that contains high levels of lactose. Then your doctor measures the amount of hydrogen in your breath at regular intervals. Normally, very little hydrogen is detectable. However, if your body doesn't digest the lactose, it will ferment in the colon, releasing hydrogen and other gases, which are absorbed by your intestines and eventually exhaled. Larger than normal amounts of exhaled hydrogen measured during a breath test indicate that you aren't fully digesting and absorbing lactose.
*Stool acidity test. For infants and children who can't undergo other tests, a stool acidity test may be used. The fermenting of undigested lactose creates lactic acid and other acids that can be detected in a stool sample (source).


What foods to avoid when you want to avoid consuming lactose?
Lactose is present in two large food categories—conventional dairy products, and as a food additive (casein, caseinate, whey), which may contain traces of lactose. If you want to avoid eating lactose, the prime product to avoid is milk. Lactose is a water-soluble substance. Most lactose is found in the water-based portions of dairy. Milk for instance. Less lactose will be found in the fatty contents of dairy products, like butter. The butter-making process separates the majority of milk's water components from the fat components. Lactose, being a water soluble molecule, will largely be removed, but will still be present in small quantities in the butter unless it is also fermented to produce cultured butter. Clarified butter, however, contains very little lactose and is safe for most lactose-intolerant people. Dairy products that are "reduced-fat" or "fat-free" generally have slightly higher lactose content. People can be more tolerant of traditionally made yogurt than milk, because it contains lactase produced by the bacterial cultures used to make the yogurt. Frozen yogurt will contain similarly reduced lactose levels.
With cheese, fermentation and higher fat content contribute to lesser amounts of lactose. Traditionally made Emmental or Cheddar might contain 10% of the lactose found in whole milk. In addition, the ageing methods of traditional cheeses (sometimes over two years) reduce their lactose content to practically nothing. Commercial cheeses, however, are often manufactured by processes that do not have the same lactose-reducing properties.  You can read more on lactose intollerance on wikipedia.


Forum posts from rosacea patients about food allergies or intollerance

Scully555 wrote on September 19th 2009: "I had very similar rashes that I lived with for many years that were so severe I stopped going out with friends on the weekends and avoided social contact with anyone but my closest friends because I was tired of the "What's wrong with your face?" comments and having people say EEEEEEIIIIIIIIIWWWWW. After years of misdiagnosis from two or three "specialists" I finally did what a coworker suggested. I read all the labels on my bath soap packaging and on my hair care products. It turns out I was using a heavily medicated dandruff shampoo loaded with "tar" that was only supposed to be used a few times a week when dandruff appeared and once or twice a month when dandruff was not visible, as a preventative measure. I was using it daily and sometimes twice a day for years. When I stopped using the shampoo, my face cleared up 100% within a few weeks and never came back. So, either 3 or 4 years of expensive creams and prescription drugs with little to no affect all of a sudden kicked in on one particular two week period for no apparent reason, or, my shampoo was loaded with a chemical additive that introduced way too much heavey tar into my skin that the skin could not handle causing flush, swolen and very irritated blotchy areas on my face, neck and forehead. I highly recommend that if your only simptoms are a red face with a bulbous nose and big lumpy chunks of swolen skin mass on your face or neck that you pleeeeaaasssse, read all the labels and accompanying warning disclaimers on everything that comes in contact with your face and hands, including clothing labels, dishwashing soap, bath soap, hair care products laundry soap, everything that you use on a daily or
otherwise regular basis that comes in contact with your skin unless you have properly been diagnosed with anything at all through the proper and comprehensive testing from a very competent doctor. Without proper testing please do not assume that your doctor has made the correct diagnosis. My doctor looked at my skin from 4 feet away and asked me three questions. How long have you had this rash? Is the rash more severe in the sun? Does it get worse when you drink pop or alchohol? Yes, Yes and Yes. Boom, you have Rosacea. Please proceed to the pharmacist and pay the nice man there and we will see you in three months for some new and improved (and more expensive) treatment. Sorry if I sound bitter but I have no idea what I have (had) but it took several years out of my social life and yes, I am pissed that my so called specialist did not take the time to do any tests of any kind whatsoever."

There are countless forum posts on food, diet, gluten allergy, lactose intolerance and the likes, so I invite you to go the the Rosacea Forum and go to the search bar in the top right and look for the topics you are interested there (you can make a topic search there and find all the posts related to it).


Here are some post suggestions:

Rosacea and Gluten
A rosacea blog about gluten
Does rosacea always get worse? Forum thread
Acne forum; is eliminating dair the answer? 
Acne help, rosacea and SIBO
Is gluten free helping? Rosacea forum 
Gluten-wheat free diet, Rosacea Forum  
Gluten intolerance, the culprit, Rosacea Forum
Does a low carb, no sugar or dairy help with skin burning and irritation?   
Should I give up dairy?












Erythromelalgia (EM) is a rare neurovascular disorder that typically affects the skin of the feet or hands, or both, and causes visible redness, intense heat and quite severe burning pain. It makes the blood vessels of the extremities (mostly hand and feet but also at times the face) episodically blocked, then become overly dilated and inflamed, causing throbbing heat, redness and burning pain. The pain is caused by the small fiber sensory nerves. The attacks are periodic and are commonly triggered by heat, pressure, mild activity, exertion, insomnia or stress.
The term erythromelalgia describes the syndrome: erythros (redness), melos (extremity) and algia (pain). It can also affect the legs and arms or the face, nose and ears. Even in mild-to-moderate cases, normal functioning such as walking, standing, working, socializing, exercising, and sleeping may be impaired. Triggers for flare ups can be warm temperatures and even mild exercise. Cooling the hot body parts relieves the pain, as does elevating the affected areas. This is one of the hallmark characteristics of EM: cooling bringing relief. 
The cause of EM is unknown in the vast majority of cases. Only 5% of patients is said to have a genetically inherited cause. Peripheral neuropathies are often at the root of the problem and sometimes EM may be secondary to other disorders like the blood disease polycythemia.
Recent research in the U.S. found the incidence of EM (the number of people a year diagnosed with EM) to be 1.3 per 100,000. The rate for women was higher – 2.0 per 100,000 per year – than men, which was just 0.6. The median age at diagnosis was 61 (source).


Treatment

Like with rosacea, each case seems to react differently to treatment options. Traditional over-the-counter pain medications or stronger prescription drugs help some. NSAID's and blood vessel constricting medication might help. Anticonvulsant drugs like Neurontin and Lyrica help others. Certain antidepressants like Cymbalta might help.  Combinations of drugs also have been reported effective. For instance, Lyrica and Cymbalta, at the lowest possible dosage, have been reported  to be more effective than either drug by itself. It is recommended that people with EM find a doctor willing to help them pursue a trial-and-error course of treatment


EM or Raynaud's phenomenon?

Raynaud's syndrome also gives red and flushed extramities (hands and feet typically). It is characterized by excessively reduced blood flow in response to cold or emotional stress, causing discoloration of the fingers, toes, and occasionally other areas. They can also swell a bit and start to throb or itch even. It can cause the fingers and feet to become pale, white and cold (usually when you are exposed to cold temperatures and the blood flow doesn't read the hands and feet), or for them to become purple (when oxygen supply is depleted) or red and hot (when the blood supply is up to normal again).  Raynaud's and EM can go together sometimes.
EM seems to give much more pain than Raynaud's and the discolorations and blood vessel constriction of toes and hands from Raynaud's tend to last a lot longer at a time, compared to the short EM attacks. However, some EM patients report attacks lasting from one hour to a few weeks even. Both can be triggered by cold and heat but EM can flare without any obvious trigger at play. People with EM complaint about random attacks, very red and swollen extremities which can feel like skin burns, yet also itch at times (probably due to the skin swelling and the nerves getting stimulated or trapped I can imagine). It prevents some patients even from working and sleeping and one patient details how she sometimes has to try to sleep with her hands raised in the air, in search of some relief (source). Read more on Raynaud's here.


Tests that you can ask by your rheumatologist are

An ANA test - please ask him to specify that it be done by IFA methodology.
An ENA panel (includes SCL-70, and anti-RNP)
Anticentromere B test
nailfold capillaroscopy
(source).
EM lies within the field of 3 different medical specialisms, hematology, neurology and vascular diseases, which makes it even harder to treat, as very few specialist seems to master all fo those 3 fields. You can read more on EM here.And here.



What does erythromelalgia (EM)  look like



 






Forum posts from rosacea patients about erythromelalgia (EM)
 
KRC wrote on May 4th 2014: "I am beginning to suspect that I might have something of this nature(EM) as in addition to horrific facial burning I appear to also have burn on my lower legs! The only confusing thing is I also get some of the minor breakouts associated w. rosacea. I am under a little bit of stress as life tends to do and am wondering if a plain old tranquilizer might help me - So many avenues to pursue. I wish the medical community were a little better educated to all of this. As it is with so many symptoms I feel like they just think I am nuts. And any mention of demodex makes them really squirm lol. It is classic as so many on the board have elaborated."

Meg replied: "You are welcome. May I suggest you take a look the the EM site - www.erythromelalgia.org and if you want to discuss with others who have the same symptoms, join the following support group - https://groups.yahoo.com/neo/groups/EM/info. I think you will find that many people with EM have both rosacea and Face EM, depending on the severity. If your legs are burning, along with your face, you probably have EM. It is primary EM is there is no other cause, but if you have something causing these symptoms, then it's seen as secondary. For instance EM can be caused by peripheral neuropathy, diabetes, lupus, etc,... EM is really a set of symptoms which are essentially red, hot, burning skin that is often relieved with cooling, etc,... More details on the first site listed above. Also, feel free to email me directly if I can be of further help."

*Erythromelgia is also a very rare cause of facial flushing
 That may be Erythromelalgia (EM) - look at www.erythromelalgia.org. It's usually hands and feet, but faces can be involved too

Meg wrote on May 4th 2014: "You are welcome. May I suggest you take a look the the EM site - www.erythromelalgia.org and if you want to discuss with others who have the same symptoms, join the following support group - https://groups.yahoo.com/neo/groups/EM/info. I think you will find that many people with EM have both rosacea and Face EM, depending on the severity. If your legs are burning, along with your face, you probably have EM. It is primary EM is there is no other cause, but if you have something causing these symptoms, then it's seen as secondary. For instance EM can be caused by peripheral neuropathy, diabetes, lupus, etc,... EM is really a set of symptoms which are essentially red, hot, burning skin that is often relieved with cooling, etc,... More details on the first site listed above. Also, feel free to email me directly if I can be of further help."

GracieTiger wrote on December 19th 2008: "i need help understanding this - visit with derm NOT GOOD. hi all - i just visited a dermatologist for the first time since i started flushing. he is recognized as a "top doc" in this city and came recommended on the rosacea site. for those of you who don't remember me, i'd like to give a brief history of my symptoms. i lived in rural africa for a year, and about two weeks after returning, i started having a lot of unusual symptoms. the first of which was facial flushing. i had no history of flushing/blushing at all, ever. it started suddenly, and at first, it was pretty transient. more like blushing. then it progressed to the point that i felt like my face was red and hot all the time. that feeling eventually subsided a bit, however, when that winter began, i realized that i had quite a problem on my hands. when my body was cold, then became warm, i would flush really really intensely for about eight to ten hours. the burning was near unbearable. without a doubt, every single time that i felt cold, then took a hot shower, or entered a hot room, i would have a major flush. it was pretty unbelievable to me that in just a couple months i went from never flushing to major major flushing.along with the flushing, i also had a lot of other problems. heart arrythmias, panic attacks (no history at all), breathing problems, vision issues, joint swelling, etc etc. Eventually i was diagnosed with having a type of autonomic nervous system dysfunction - POTS.
Over the summer, the flushing wasn't nearly as bad. my skin got kind of red in the summer, but i wouldn't say i flushed. no burning. now that it is cold again, however, it is unbearable flushing. my body temp, during a flush, will go from like 96.5 pre-flush to 99 within ten minutes of flushing.
    i don't know if this is rosacea or not. but it doesn't really matter what it is. it is debilitating. i used to be a zookeeper and was working really really hard to be a wildlife veterinarian. that dream is shot out the door due to flushing. i can no longer work outside. i used to be an avid winter sportswoman, now i cannot do any outdoor activities. i used to love mountain camping, but now i can't do that, ever, because it gets too cold at night to camp and i flush when it warms up in the day.
    so, i finally went and saw a dermatologist. after educating myself about rosacea, flushing, blood vessel damage, etc. i felt like i would be a good candidate for some laser treatment. my dermatologist completely writ me off. he kept saying that it's clear i don't have rosacea because i have no inflammation and because i was not red at the time i saw him. he said it is clearly an autonomic nervous system dysfunction, and that he had no idea why i thought he could help me. he completely belittled me, repeatedly asking what i thought i would get out of him. when i tried to share my knowledge of blood vessel damage from prolonged flushing and the benefits of laser in curbing that damage, he told me i sound too educated to think he could do anything for me.
    again, this is the top-rated dermatologist in my area. that is fine if he feels there is nothing that can be done for me. i was not expecting a miracle cure. but to repeatedly ask me why i came to see him, that was crossing the asshole line. i tried to explain how much i have lost in my life due to this flushing and he kept telling me that my other issues (heart problems, etc) are the ones i should be concerned about. yes, i agree, and i do worry about those too, but the psychological impact that the flushing has had on my life is far greater than the other issues. what killed me the most was when my doctor said he would never want rosacea so i should be glad i don't have it. whatever the name of what i have is, flushing is flushing!! plus, if he would
never want rosacea, then how dare he question me as to why i am visiting him for assistance. obviously the flushing is pretty darn damaging to me too. i don't know how much longer i can go on with this flushing with no treatment at all. the propanolol helps a little, but not much. i can't even blow dry my hair and straighten it anymore. i look like a crazed mountain woman. haha, not really, but i would love to be able to straighten my hair once in a while without knowing that i will be red and burning for ten hours.
    so i am really venting my frustrations, because i am really really frustrated right now, but also hoping you all can help me. given that i flush, and have been intensely flushing for about two years for hours at a time, am i really not a candidate for laser? even if i don't have rosacea? let's say that the autonomic dysfunction is causing all my problems, can't flushing alone be reason for laser? wouldn't blocking the newly formed or damaged blood vessels help stop the burning, at least? the derm also pointed out that flushing can become rosacea eventually. so don't i want to treat it early to prevent it from crossing that point? and how does he know it hasn't already? just because i don't have bumps? i didn't think that was a criteria for rosacea. don't many of you just have flushing? and isn't it important to treat it early? wouldn't i want to start now in order to prevent it from ever becoming rosacea?    soooo frustrated. my doc's solution: move to southern california, hawaii or florida. great, huh? oh sure, let me just pack up my bags now!!! thanks for listening."
none of my docs knew however if the flushing could be explained by the POTS or if it was rosacea.


Meg replied: "Sounds a lot like you do in fact have an autonomic nervous system dysfunction. I have severe and painful flushing that was diagnosed at the Mayo Clinic as a form of autonomic dysfuntion. It turns out that I also stopped sweating, which is another autonomic problem. You might consider seeing the autonomic neurologists at Mayo for an acurate diagnosis. Also, I find my flushing to be more like erythromelalgia, rather than rosacea, due to the burning pain. If you have red hot burning pain when you flush, look at http://www.erythromelalgia.org/. Hope this helps. Best regards, Meg"


And also: "Erythromelalgia (EM) definitely includes the face. If you look at the EM (TEA) website, you will see they even post photos of people who have EM on their faces. Having a face only case is rare. Most people seem to have the face involved in addition to hands and feet, but some cases also involve the face or even the torso. Any part can be affected. EM is noted or defined as red, hot burning skin that is relieved by cooling. Generally, it is a form of autonomic nervous system dysfunction. GracieTiger, my flushing/EM is face only. I have no symptoms on my hands, feet or other body parts. Just my face and ears. Hope this clears things up. Meg
    ps - I have cut and pasted the info below from the EM (TEA) website (note the inclusion of the face under the "Location" paragraph -
    Symptoms
    If you have been diagnosed with EM, symptoms may include hands or feet that are very red to purple in color, are perhaps swollen, hot to the touch, and have burning pain.
    Location
    For some, EM symptoms may appear in the face, ears, knees or other parts of the body. The intensity of the symptoms varies from person to person. Some notice a continual burning pain while others are troubled with "flare-ups" or episodes lasting from minutes to days in length.
    Triggers
    Warm temperatures seem to be the most frequent trigger for EM episodes. Flare-ups are provoked by heat and exercise, and symptoms are relieved by cooling and elevating the affected extremities. Some TEA members have found that foods, spices like MSG, beverages (particularly alcohol) and some drugs can make EM symptoms worse.

 

 

Keratosis Pilaris Rubra faceii

Keratosis pilaris (KP, also follicular keratosis, lichen pilaris) is a common genetic follicular condition, that produces  rough, slightly red, bumps on the skin. It most often appears on the arms, but can also occur on the thighs, hands, and tops of legs, sides, buttocks, or on any body part except for the palms of the hands or the soles of the feet. Often the lesions will appear on the face, which may be mistaken for acne.
Keratosis pilaris results in small bumps on the skin that feel like rough sandpaper. They are skin-colored bumps the size of a grain of sand, many of which are surrounded by a slight pink color. They are seldom sore or itchy. They occur when
the human body produces excess keratin, a natural protein in the skin which is cream colored. It surrounds and entraps the hair follicles in the pore. This causes the formation of hard plugs. Doctors can often diagnose keratosis pilaris simply by examining the skin; tests are usually not needed.
According to wiki, KP affects worldwide an estimated 40-50% of the adult population and approximately 50-80% of all adolescents. It is more common in women than in men, and is often present in otherwise healthy individuals. The skin condition is prevalent in persons of all races. No particular race is at higher risk for contracting keratosis pilaris. Although keratosis pilaris may manifest in persons of any age, it usually appears within the first decade of life and is more common in young children. In most cases, the condition gradually improves before age 30, however it can persist longer.

There are several different types of keratosis pilaris, including keratosis pilaris rubra (red, inflamed bumps which can be on arms, head, legs), keratosis pilaris alba (rough, bumpy skin with no irritation), keratosis pilaris rubra faceii (reddish rash on the cheeks), and related disorders. Because of the resemblence with rosacea, I will focus on this last subtype. 


Treatment

Wiki states that keratosis pilaris is harmless and that medical treatment is not necessary. Many patients do however look for treatment because of the cosmetic apearance of KP. Topical creams and lotions are currently the most commonly used treatment for keratosis pilaris, specifically those consisting of moisturizing or keratolytic treatments, including: urea, lactic acid, glycolic acid, salicylic acid, tretinoin, Vitamin D, or topical retinoids. Steroid creams can also be used to reduce redness. However, the effectiveness of these treatments is limited and research to discover more effective treatments is ongoing. Improvement of the skin often takes months and the bumps are likely to return. Taking long, hot baths followed by exfoliating the affected areas with a coarse washcloth or stiff brush may help unplug pores and therefore can also be used as a treatment method. Some cases of keratosis pilaris have been successfully treated with laser therapy, which involves passing intense bursts of light into targeted areas of the skin. Depending on the body's response to the treatment, multiple sessions over the course of a few months may be necessary. Note that most of these treatments can be detrimental to underlying rosacea, in case you suffer from both conditions. Steroid creams are not recommended when you have rosacea and long hot baths neither. Some of the suggested creams here can worsen rosacea as well.

This blogger with KP suggests for treatment: "For the majority of cases of Keratosis Pilaris, one can use moisturizers along with basic lubes that can be bought which are non-prescription such as Cetaphil and also Lubriderm and lactic acid lotions for instance AmLactin and Lac-Hydrin. Your affected area ought to be washed that has a mild moisturising soap or even facial bathe twice a day. By no means use unpleasant ingredients that can dry up your skin layer since this is only able to worsen the problem. Your skin specialist may also prescribe creams using alpha hydroxy acids, vitamin A lotions and immunomodulators. Even though not that effective in completely smoothing out Keratosis Pilaris, you can also use gentle exfoliant soaps and also facial scrubs to improve the disorder of the skin."
 

KP or rosacea?
\
People with keratosis pilaris rubra faceii can have very red faces. The excess Keratin that KP patients have, here aggrevates the blood vessels in the cheeks and causes them to be more visible from the surface. People with fair skin are more likely to suffer with this as it would be harder to see the blood vessels with people with darker skin. It can be very difficult to distuinguish these red cheeks from rosacea. Especially when you read that KP is so common and widespread. I can hardly believe to be honest that about 60 to 80 % of youth are afflicted by the item, whereas just 40 per cent of grownups manifest some degree of the condition (source). Wiki estimates these percentage even higher as you could just read. I doubt these massive numbers of people have the keratosis pilaris rubra faceii, if so I hardly see them! I assume the majority of these people have the small red bumps on their arms and legs instead, at times.Update; KPRF is a lot more rare than regular KP. On this forum a member writes: "As keritin disorders affecting the face are rarer than rosacea it would be good to see a derm who is familiar with these to rule out KPRF or KPAF."

Keratosis pilaris rubra faceii (KPRF) is often misdiagnosed as rosacea (source), as it primarily affects the face and makes the cheeks also red and ruddy looking. However, KP can be accompanied by itching in the affected area, whereas rosacea rarely itches, and often burns instead. Also, KP not only gives a bright rosy color, but this color can be very clearly marked from normal looking skin (and rosacea rarely has such a clear cut division line), and KPRF can also look very smoothly red/rosy colored, whereas rosacea rarely is as evenly red or pink (but again, there are exceptions for all this).  KP can come with the typical KP bumps. However, to make matters more difficult: KPRF doesn't even have to have the chicken skin feel of normal KP. Also people who have Rubra Faceii usually also have a small bit of Keratosis Pilaris on other body parts, like the backs of their upper arms (however as 1/2 population has KP this is probably not that great a test).
Another difference is that rosacea usually also affects your nose, the sides of your nose, your chin and your forehead (this can come gradually. I started of with only redness in the cheek area but by now, 15 years later, my chin and nose are also getting a lot more red). Rubra Faceii affects the cheeks, the area just under the nose and just under the eyes. In addition, as written before, Rosacea usually is quite blotchy while Rubra Faceii gives a much more even red skin tone (source). People with KPRF do blush and flush easily, something they share with a lot of rosacea patients. Also KPRF does not  affect the eyes, unlike rosacea (causing occular rosacea; dry, gritty, painful eyes). KPRF can also hit at a young age, whereas rosacea usually starts after age 18. Some derms still say rosacea only affects people in their 30's, but this is most definitely incorrect. Mine started age 19 and I know a lot of people from forums who had rosacea from their 20's, but I only heard of people getting affected with it as early as puberty (seldomly) and onwards. KP seems to start in kids already, and also very often or even usually during puberty. Some other KPRF indications are a paler patch right in the middle of the cheek redness area, or roughness or pitted areas (small depressions) in the redness, around the hair follicules on the cheek. Also, both KP and rosacea can run in families, so if any of your family members have one or the other, this can be another indication of which of the 2 you might have when you are dealing with these symptoms that can be both KP or rosacea.

For more information on KP, see this forum.
Here and here a patient asks if he has KP or rosacea. 
See also this and this thread.




What does KPRF look like?














Helicobacter pylori infection

Infection with Heliobacter pylori (H. pylori) is the cause of most stomach and duodenal ulcers. It is a bacterium (germ) that can infect the lining of the stomach and duodenum. It is a common infection, although it is getting less common as time goes by. More than a quarter of people in the UK for instance become infected with H. pylori at some stage in their life. Once you are infected, unless treated, the infection usually stays for the rest of your life. 
Commonly there are no problems when you are infected. Most people who are infected with H. pylori have no symptoms or problems caused by the infection. These people do not know that they are infected. A number of H. pylori bacteria may just live harmlessly in the lining of the stomach and duodenum.
When it does cause symptoms, H. pylori also causes some cases of non-ulcer dyspepsia. You can read more about that here.
Infection with H. pylori can be confirmed by a test done on a sample of faeces (stools), or in a breath test, or from a blood test, or from a biopsy sample taken during an endoscopy. A one-week course of two antibiotics plus an acid-suppressing medicine will usually clear the H. pylori infection. This should prevent the return of a duodenal or stomach ulcer that had been caused by this infection.


Reasons for testing on H Pylori (not complete, a selection)
If you have recurring dyspepsia (recurring indigestion symptoms). When you have a duodenal or stomach ulcer. When you have a first-degree relative (mother, father, brother, sister or child) who has been diagnosed with stomach cancer. When you are taking long-term anti-inflammatory medication such as ibuprofen, diclofenac, aspirin, etc. The combination of these medicines and H. pylori increases the risk of developing a stomach ulcer. When you have atrophic gastritis (inflammation of the stomach lining).


   
Is there a relation between H. Pylori and rosacea

In this Pubmed article a group of rosacea patients was tested on H pylori presence in the stumach and oral cavity, as well as a test group without rosacea/skin conditions. Both had dyspeptic symptoms (soem burning in the stumach area I assume).
A stunning 88% of the rosacea patients group had H. Pylori, compared to 65% in the control group.
"A noticeable number of rosacea patients showed chronic active gastritis predominantly in antrum but also in the corpus while those with NUD showed only mild gastritis confined to the antrum only."
The rosacea patients received antibiotic treatment (omeprazole (2 x 30 mg), clarithromycin (2 x 500 mg) and metronidazole (2 x 500 mg), plus gargling and application of metronidazole paste in the case of Hp oral cavity infection. Afterwards, H. Pylori was eradicated from the stomach in 97% and from the oral cavity in 73% of treated patients. Within 2-4 weeks, the symptoms of rosacea disappeared or decreased markedly in 51 subjects.
The scientists concluded that rosacea is a disorder with various gastrointestinal symptoms closely related to gastritis. That eradication of H. Pylori leads to improvement of symptoms of rosacea and reduction in related gastrointestinal symptoms. And that if rosacea symptoms didn't clear after treatment, this could be because there was still H. Pylori bacteria lingering in the oral cavity. "Rosacea could be considered as one of the extragastric symptoms of Hp infection probably mediated by Hp-related cytotoxins and cytokines."


This is what my dermatologist, Dr. Chu wrote to a friend of mine with similar rosacea about the link between H. Pylori and rosacea:

"There is often an association with hyperacidity/stomach ulcers and rosacea and this led to the theory that Helicobacter was a cause of rosacea - treatment of helicobacter is with combination antibiotics and this obviously settles inflammatory rosacea but not flushing and it recurs when the antibiotics are withdrawn.
Possible the stress of the stomach problems is exacerbating the rosacea and absorption of the drugs could be a problem.
Would suggest trying omeproazole - need at least 20mg/day and possibly twice daily to settle the stomach .You can buy omeprazole at the chemist but quite expensive. Also possibly antibiotics to eradicate the helicobacter."










Carcinoid Syndrome/ pheochromocytoma


Carcinoid syndrome describes the flushing that comes from having carcinoid tumors. It is caused by secretion of mainly serotonin and kallikrein from within the tumor. It is not the serotonin that produces this blood vessel dilation (and therefore the flushing) -also called vasoactive substance-, but it is the secretion of kallikrein. (read here how serotonin might actually decrease flushing according some; also, I take mirtazapine which increases serotonin levels in the brain and I find it really lowers my flushing). Kallikrein is the enzyme that catalyzes the conversion of kininogen to lysyl-bradykinin. The latter is further converted to bradykinin, one of the most powerful vasodilators known. Other components of the carcinoid syndrome are diarrhea (probably caused by serotonin), a pellagra-like syndrome (probably caused by diversion of large amounts of tryptophan from synthesis of the vitamin B3, niacin, to the synthesis of 5-hydroxyindoles including serotonin), fibrotic lesions of the endocardium, particularly on the right side of the heart resulting in insufficiency of the tricuspid valve and, less frequently, the pulmonary valve and, uncommonly, bronchoconstriction. The carcinoid syndrome occurs in approximately 5% to 10% of carcinoid tumors and becomes manifest when vasoactive substances from the tumors enter the systemic circulation escaping hepatic degradation. Interestingly, if the primary tumor is from the GI tract (hence releasing serotonin into the hepatic portal circulation), carcinoid syndrome generally does not occur until the disease is so advanced that it overwhelms the liver's ability to metabolize the released serotonin. (source). By the time the symptoms of carcinoid syndrome appear, the tumor has usually spread. This makes it important to diagnose the tumors and carcinoid syndrome as early as possible.


The most common symptoms of carcinoid syndrome

Diarrhea, flushing of the skin or face, heart palpitations, stomach cramps, shortness of breath, wheezing. Note that having a carcinoid tumor can give a lot of different symptoms on top. Please read here for more info on that.



Facial flushing from carcinoid syndrome 

The facial (and sometimes flushing of the chest and neck) flushing of carcinoid syndrome is usually a dry flushing, and not associated with sweating like other kinds of flushing. The flushing is often a symptom that others notice before patients do. They may not feel it themselves. These symptoms may be worsened by stress, physical exertion, or drinking alcohol. Eating certain foods, such as aged cheese like cheddar or stilton cheese, salted or pickled meats, or other foods that contain tyramine may also trigger symptoms (source). (source)

The character of carcinoid syndrome flushing differs, depending on the site of origin of the tumor. Tumors of the foregut (stomach, lung, pancreas) are associated with a bright red geographic flush (this means little small red area's cluttering together, almost appearing like the different countries and continents on a geographical map). These flushes continue for quite a long time and are accompanied by wheezing, sweating, and a sensation of burning. The flushing seen with foregut carcinoids is caused by the release of histamine.
In ileal tumors, the flush is patchier and more going towards purple in color, intermingled with areas of paler skin, and does not last as long. Flushing seen with ileal carcinoids cannot be explained solely by the production of serotonin. Serotonin may or may not be released into the circulation during flushing, and IV infusion of serotonin does not cause flushing. Foregut carcinoids do not generally secrete serotonin but, instead, its precursor, 5-hydroxytryptamine. Screening should therefore seek this product if the other metabolites are not elevated. Other mediators that have been proposed include prostaglandins and tachykinins. Tachykinins are believed to be mediators of the flushing in tumors of the midgut. They exert vasodilation and contraction of various types of smooth muscle. These peptides include substance P, substance K, and neuropeptide K.
Both types of flushing can also cause swelling of the face, which may persist and lead to telangiectasia and even facial rosacea.
Table 1 Classification of Carcinoid Tumors According to Site of Primary Tumor
Site Biochemistry Clinical Picture
Foregut bronchi, stomach, first part duodenum 5-Hydroxytryptophan, adrenocorticotropin, growth hormone, gastrin, growth hormone releasing hormone Protracted, purplish or violaceous flush, manifestation of other ectopic hormone secretion
Midgut second part of duodenum, jejunum, ileum, ascending colon Serotonin, kinins, neuropeptides, prostaglandins Pink-red flush

Hindgut transverse, descending colon and rectum
None Only local symptoms




Diagnosis

The most useful initial test is the 24 hour urine levels of 5-HIAA (5-hydroxyindoleacetic acid), the end product of serotonin metabolism. Patients with carcinoid syndrome usually excrete more than 25 mg of 5-HIAA per day. For diagnosing tumors and tumor metastasis, you have to undergo a special scan, called a scintigraphy. Here they will inject you with a low radioactive substance and then make scans in the scintigraphy machine.
Clinical diagnosis of carcoid syndrome is not difficult in patients with flushing episodes associated with systemic symptoms (e.g., diarrhea, wheezing, weight loss) and hepatomegaly. It is more difficult in patients who have occasional flushing and no associated symptoms. When in doubt, a carcinoid flush can be provoked by alcohol ingestion (4 mL of 45% ethanol) or the infusion of 6 µg noradrenaline, an effect that can be blocked by phentolamine (5-15 mg IV). Calcium gluconate, 10 to 15 mg/kg, administered IV over 4 hours, may produce a flush mimicking a spontaneous attack. Epinephrine reverses flushing in patients with mastocytosis but provokes flushing in patients with the carcinoid syndrome. For more information, see this link.



Distinguishing rosacea from carcinoid syndrome

Both rosacea and carcinoid syndrome can cause facial flushing. Both types of flushing can appear very similar, affecting the same areas in the face and to make matters more complex, is that both types of flushing are triggered by similar factors: heat, stress, exercise and the same list of foods, including foods high in histamine like tomatoes, chocolate, cheese, as well as alcohol and spices. In this blog, a woman with carcinoid syndrome tells about her flushing.



What does carcinoid syndrome flushing look like?

 Flushing of carcinoid syndromeHistamine-evoked flushing of foregut carcinoid tumor



Forum posts from rosacea patients about carcinoid syndrome

LesleyC wrote on May 18th 2012: "Yes, I was tested about a year back for carcinoid syndrome. This was done by performing a 24 hour urine sample, it was an easy test to perform. My internist requested for the test because at the time, I had other symptoms besides flushing, and he wanted to rule out carcinoid tumors and adrenal gland tumors (pheochromocytoma) as well."

Anathema wrote on April 22nd 2014: "Rosacea vs Carcinoid syndrome what is the difference? Basically my question is how is rosacea flush different from a carcinoid syndrome flush, also should every flusher get tested for this disease? If anyone has done some research on this would be nice to hear. Thanks"

Wicksyx replied on April 22nd 2014: "I was tested for the carcinoid syndrome with a 24hr urine test because of my flushing, the main symptom of the tumour (some carcinoid tumors have no symptoms at all) is diarrhoea and abdominal pain which I also was dealing with at that time. My dermatologist told me that if you suffer from the tumour you can also develop Rosacea from flushing so much and the dilated blood vessels. Luckily my tests were all clear and I didn't have it, but now I am still left curious about what causes my flushing. [..] But yes every flusher should be tested for this disease,defiantly."

Anathema replied: "Thanks for all the information wicksy I am going to get that test done right away, since I am have bunch of symptoms, and do you know if the carcinoid flush is different than a rosacea flush?"

Wicksyx replied: "There is no difference! I suffer from very severe burning pain and my derm said that there was no difference between Rosacea flush and carcinoid one because all the triggers are the same. I'm glad your going for the test and hope you get good results!!"  

Graemeb wrote on March 9th 2014: "Hi my name is Graeme. I have been suffering from facial flushing for around 7 months. The redness is across my nose, around my eyes, and on my forehead. The redness is itchy and is usually worse after a shower. I can't even wash my face with soap anymore through fear of burning. Anyway I was tested for carcinoid syndrome which terrified me. Nothing came up with that so the drs believe i have rosacea. I have been putting cream called metronidazole on my face which has helped a little. I have now been given tetralysal to take on a daily basis, which i have been taking for a week. They don't seem to be helping." 

J-MIll wrote on March 28th 2008: "I think when people first flare with Rosacea they are stressed out. The stress tends to cause all sorts of weird symptomology that the disease process does not explain. Doctors start looking for zebras instead of treating horses to use medical lingo.
When I first flared I was stressed and I developed brutal GI distress, lost 25 pounds in 2 months, etc. They were checking for lupus, carcinoid (btw it is not 100% fatal, I actually know someone who has carcinoid and they live a very normal comfortable life but take beta blockers, it is only 100% fatal if it moves to your liver, but seldom happens), etc. When I managed to get my skin under some control and my stress levels decreased, the GI distress went away and the weight came back on, all of a sudden I just had Rosacea (w/Seb Derm just to be safe)." 

Mistica wrote on January 19th 2012: "I have been tested several times for increased levels of serotonin and catecholamines as part of the screening for carcinoid syndrome. This syndrome occurs when certain tumours (normally in the gut) release these hormones. They are vasodilative. I have always tested negative, and really don't think I have any type of cancer."







Polycythemia vera

Polycythemia vera (PV) is a type of blood cancer in which the bone marrow makes too many red blood cells. It may also result in the overproduction of white blood cells and platelets. It is a slow-growing type of blood cancer.
Polycythemia vera isn't common. It usually develops slowly, and you may have it for years without noticing signs or symptoms. Often, polycythemia vera is found during a blood test done for some other reason.Without treatment, polycythemia vera can be life-threatening. However, with proper medical care, many people experience few problems related to this disease. Over time, there's a risk of progressing to more-serious blood cancers, such as myelofibrosis or acute leukemia. PV is more common in the elderly and may be symptomatic or asymptomatic. Common signs and symptoms include itching (pruritus) especially after a warm bath or shower, and severe burning pain in the hands or feet that is usually accompanied by a reddish or bluish coloration of the skin. This stems from circulation problems in the small blood vessels, which can cause erythromelalgia and severe pains in hands, feet, toes or fingers. PV can also cause headaches, dizziness, vision problems, excessive sweating and shortness of breath. Patients with polycythemia vera are more likely to have arthritis. Treatment consists primarily of phlebotomy (source) and (source). Symptoms may also include a flushed, red face (facial plethora), high blood pressure (hypertension), and an enlargement of the spleen (splenomegaly) (source).

Diagnosis

Doctors most frequently use blood tests to diagnose polycythemia vera. If you have polycythemia vera, blood tests may reveal: An increase in the number of red blood cells and, in some cases, an increase in platelets or white blood cells. Elevated hematocrit measurement, the percentage of red blood cells that make up total blood volume.Elevated levels of hemoglobin, the iron-rich protein in red blood cells that carries oxygen. Very low levels of erythropoietin, a hormone that stimulates bone marrow to produce new red blood cells. If your doctor suspects you have polycythemia vera, he or she may recommend a bone marrow aspiration or biopsy to collect a sample of your bone marrow. Read more here.








Treatment of Polycythemia vera


The goal of treatment is to reduce the thickness of the blood and prevent bleeding and clotting. A method called phlebotomy is used to decrease blood thickness. One unit of blood (about 1 pint) is removed weekly until the hematocrit level is less than 45 (males) or 42 (females). Then therapy is continued as needed. Occasionally, chemotherapy (specifically hydroxyurea) may be given to reduce the number of red blood cells made by the bone marrow. Interferon may also be given to lower blood counts. A medicine called anagrelide may be given to lower platelet counts. Some patients are advised to take aspirin to reduce the risk of blood clots, though it increases the risk for stomach bleeding. Ultraviolet-B light therapy can reduce the severe itching some patients experience (source). Read more about treatments here. And on this forum also.




What does Polyccythemia vera look like?

Picture left is from Erythromelalgia in a patient with longstanding polycythemia vera






 

Mixed connective tissue disease

Mixed connective tissue disease features signs and symptoms of a combination of disorders — primarily of lupus, scleroderma and polymyositis. For this reason, mixed connective tissue disease is sometimes referred to as an overlap disease. In mixed connective tissue disease, the symptoms of the separate diseases usually don't appear all at once. Instead, they tend to occur in sequence over a number of years, which can make diagnosis more complicated. Early signs and symptoms often involve the hands. Fingers may swell up like sausages, and the fingertips might turn white and become numb. In later stages, some organs — such as the lungs, heart and kidneys — may be affected. Mixed connective tissue disease occurs most commonly in young women. Treatment often includes drugs such as prednisone (source).

The connective tissues are the structural portions of our body that essentially hold the cells of the body together. These tissues form a framework or matrix for the body. The connective tissues are composed of two major structural molecules, collagen and elastin. There are many different collagen proteins that vary in amount in each tissue of the body. Elastin is another protein that has the capability of stretching and returning to original length like a spring. Elastin is the major component of ligaments (tissues which attach bone to bone). Connective tissue diseases are disorders featuring abnormalities involving the collagen and elastin. Connective tissue diseases are often characterized by a variety of immune abnormalities that are common for each particular type of illness  (source).
Your doctor may suspect mixed connective tissue disease based on your signs and symptoms. A physical exam may reveal signs such as swollen hands and painful, swollen joints. A blood test can determine whether you have a certain antibody in your blood that indicates mixed connective tissue disease.Doctors will look for a positive, speckled anti-nuclear antibody and anti-U1-RNP antibody.


Symptoms


Early indications of mixed connective tissue disease may include:
*General feeling of being unwell. This malaise may be accompanied by increased fatigue and a mild fever.
*Cold and numb fingers. One of the most common early indicators is known as Raynaud's phenomenon — in which your fingers feel cold and numb, often in response to cold or stress. Fingers may turn white and then purplish blue when the blood vessels constrict. After warming, the blood vessels relax, blood flow resumes and the fingers turn red. Toes also can be affected.
*Swollen fingers. Many people who have mixed connective tissue disease experience swelling in their hands and fingers, sometimes to the point where the fingers resemble sausages.
*Muscle and joint pain. Mixed connective tissue disease also can result in muscle aches and joint swelling and pain. In some cases, the joints may become deformed, similar to what is seen in rheumatoid arthritis.
*Other symptoms, such as Sjögren's syndrome, muscle inflammation, and sclerodactyly (thickening of the skin of the pads of the fingers).

Causes

Doctors don't know what causes mixed connective tissue disease. The disease is part of a larger group of diseases known as autoimmune disorders. When you have an autoimmune disorder, your immune system — responsible for fighting off disease — mistakes normal, healthy cells for intruders. In connective tissue diseases, your immune system mistakenly attacks the fibers that provide the framework and support for your body. 





Coexisting other diseases

Mixed connective tissue disease often consists of the following classic immune-related connective tissue diseases: systemic lupus erythematosus, rheumatoid arthritis, scleroderma, polymyositis, and dermatomyositis. Each of these diseases has a characteristic presentation with typical clinical findings that doctors can recognize during an examination. Each also has characteristic blood test abnormalities and abnormal antibody patterns. However, each of these diseases can evolve slowly or rapidly from very subtle abnormalities before demonstrating the classic features that help in the diagnosis. When these conditions have not developed the classic features of a particular disease, doctors will often refer to the condition as "undifferentiated connective tissue disease." This implies that the characteristic features that are used to define the classic connective tissue disease are not present, but some symptoms or signs of connective disease exist. Individuals with undifferentiated connective tissue disease may never develop a fully definable condition or they may eventually develop a classic connective tissue disease
(source). The prognosis of mixed connective tissue disease is in most cases worse than that of systemic lupus erythematosus (SLE) in spite of prednisone treatment as this disease is progressive and may in many cases evolve into a progressive systemic sclerosis (PSS), also referred to as diffuse cutaneous systemic scleroderma (dcSSc) which has a poor outcome. In some cases though the disease is mild and may only need aspirin as a treatment and may go into remission where no Anti-U1-RNP antibodies are detected, but that is rare or within 30% of cases. Most deaths from MCTD are due to heart failure caused by Pulmonary Arterial Hypertension (PAH).


Flushing

I couldn't find much information about Mixed connective tissue disease and flushing, but I guess part of the flushing that is reported for this disease can stem from the flushing that lupus erythematosus can produce. I did find
this information however on the skin symptoms of MCTD: The clinical spectrum seen in patients with lupus, dermatomyositis and scleroderma can range from skin-limited disorders to multi-systemic diseases. The skin can often be the presenting sign of illness. 
 

What does Mixed connective tissue disease look like?








 

Thyroid problems
   
The thyroid gland is located on the front part of the neck below the Adam's apple. The gland produces thyroid hormones, which regulate metabolic rate (how fast calories are consumed to produce energy). Thyroid hormones are important in regulating body energy, body temperature, the body's use of other hormones and vitamins, and the growth and maturation of body tissues.
Diseases of the thyroid gland can result in either production of too much (overactive thyroid disease or
hyperthyroidism), too little (underactive thyroid disease or hypothyroidism)
thyroid hormone, thyroid nodules, and/or goiter. Hyperthyroidism is due to an overproduction of thyroid hormones. Hypothyroidism stems from an underproduction of thyroid hormones. Since your body's energy production requires certain amounts of thyroid hormones, a drop in hormone production leads to lower energy levels.Thyroid problems are much more common in women than in men. Read more about symptoms here.



This is a list of thyroid related diseases:

Hypofunction - Hypothyroidism
    Hashimoto's thyroiditis / thyroiditis
    Ord's thyroiditis
    Postoperative hypothyroidism
    Postpartum thyroiditis
    Silent thyroiditis
    Acute thyroiditis
    Iatrogenic hypothyroidism[clarification needed][citation needed]
    Thyroid hormone resistance
    Euthyroid sick syndrome

Hyperfunction - Hyperthyroidism
    Thyroid storm
    Graves' disease
    Toxic thyroid nodule
    Toxic nodular struma (Plummer's disease)
    Hashitoxicosis

Nodular abnormalities - Goitre
    Endemic goitre
    Diffuse goitre
    Multinodular goitre
    Lingual thyroid
    Thyroglossal duct cyst
 


How can thyroid diseases cause facial flushing

Both hyper- and hypothyroidism can cause facial (or body-)flushing, sweating and heat intolerance. Hyperthyroidism can by itself cause flushing and sweating. Patients also complaint about their thyroid medication making them flushed often, for instance the drug synthroid/Levoxyl (Levothyroxine) used to treat hypothyroidism. Flushing is also named by patients as a general symptoms from a hypothyroidism attack (sources here and here for instance). 'Subdiseases' like Hashimoto's disease, can also cause facial flushing, flushed cheeks and redness by itself. In this and this forum thread, patients write about their thyroid diseases and flushing problems.  





Forum posts from thyroid disease patients facial flushing

Juliva wrote on March 30th 2010: "My face but mostly neck and chest were super flushed/red when I had gone hypo! Probably the first sign for me that I have NEVER experienced before. A friend of mine commented on how "Red" I was and one week later I found out my levels were off. It's been months and I'm still red but not as red as I was.. still working on levels. It was like a bad sunburn."

And she also wrote: "I flushed horribly with this last hypo episode I was in. Face/Neck/Chest. Never had that happen before in the ten years of thyriod disease but I know now it can happen. Looking back I'd say it was the first symptom I had that I was going hypo."

Brucergoldberg replied on March 30th 2010: "I got this too at first. It is called "flushing". It came and went when I started the levo.  I also had what I thought was vertigo as well.  My Doctor called them "menopausel hot flashes" because they are very similiar.  Keep in mind im a 42 male."

And he also wrote: "Face flushing is definitely could be a sign of thyroid issue.  I had the same thing..  Then the ear ringing started."

Bugaboo52 replied: "Is this a hypo symptom or just a side effect of finding the right level of medication? I have experienced the flushing for 4 years and was told it was rosacea but I am not convinced that is what it is and neither is my dermatologist. I am trying a trial of thyroid medicine and I hope this is one symptom that gets better."

Juliva responded: "As for me this is what I think caused my redness.. My joints/muscles/tendons ached because of the inflammation caused by going hypo. I believe the inflammation also effected my skin. My entire body was inflamed including my nerves. I'm sure the stress and pain wasn't helping either. That's my personal take on it." 


Jenna96 wrote on December 14th 2008: "I have hypothyroidism and rosacea.  My doc started me on levoxyl about 3 years ago.  Within about 2 months, I was diagnosed with Rosacea.  I finally made the connection about 1 year ago that maybe it was the levoxyl making my face so red, so I stopped taking it.  And sure enough my face stopped being so red.  But, I really need the thyroid meds so my doc had me take synthroid, this made my face red again with little bumps this time.  Just wondering if anyone has this problem and if you have found a solution.  Maybe a thyroid treatment that does not cause a red face."

wxCathy2 wrote on July 6th 2005: "Hi All, The last month, I've been having almost permanent red hot face - almost burning - and I'm HOT all the time sweaty (with night sweats)....but my face feels like it's on fire (not like nerves burning/tingling - just hot) - is this a thyroid symptom? (still have cold feet though). Thanks! Kathy (diagnosed with thyroid disease and multinodular goiter 1.5 years ago)"

THX 1138 replied: "I'm a guy and I've had the same problem for six years. I was also told that it was roseacea by a dermatologist who later changed it to sebhorric(sp?) dermatitis. The skin on my face is reddish in color and I flush after washing my face with water or taking a shower. I always feel tingling sensations on my face and scalp...occasionally burning sensations. I was dx with hypothyroidism about 1.5 months ago and am on synthyroid. I'm currently trying to get on a t3 supplement because my symptoms have no lessened much. I'm hoping my flushing/red skin/burning/tingling face problem will go away once the thyroid is corrected."

 

 

Photosensitivity

Photosensitivity is an abnormally high sensitivity to sunlight. People who are photosensitive may develop a skin rash or severe burn even after limited exposure to the sun. Some chemicals contribute to sensitivity to the sun. These can cause two different types of photosensitive reactions: phototoxic and photoallergic.
Phototoxic reactions are usually caused when a new chemical in the body interacts with ultraviolet rays from the sun. Medications are the most common cause of this type of reaction. Doxycycline and tetracycline, for example, can cause this reaction. The result is a skin rash that looks like a severe sunburn. These usually develop within about 24 hours of exposure to the sun.
Photoallergic reactions can also develop as a side effect of some types of medication. They can also develop because of chemicals found in products like beauty products and sunscreen. Photoallergic reactions to the sun tend to be delayed. It will usually take a few days for a rash to develop after sun exposure (source).

The most common symptom is an exaggerated sunburn or a skin rash. The rash may or may not cause itching. In some cases, the sunburn can be so severe that blistering develops. Weeping of the skin and peeling can also occur in severe cases. The amount of sun exposure required for a reaction varies greatly. For some people, very little sun exposure can cause a rash or burn. Others may need prolonged exposure in order to have a reaction. Photosensitivity can also cause a worsening of rosacea. Most rosaceans find that sun exposure on their faces can worsen their symptoms. However, for people with no rosacea, photosensitivity by itself can give them a face that looks like it has rosacea. Photosensitivity may produce a rash, which is known by the general term, photodermatosis. Patients may not associate their skin complaint with exposure to light. It is not always the bright summer sun which is responsible; some people also react to sunlight in winter, and very sensitive subjects may even be affected by fluorescent lamps indoors (source).


Sometimes photosensitivity is caused by a pre-existing disease or skin. 

These include conditions such as:

*Lupus erythematosus (especially subacute and systemic forms)
*Dermatomyositis
*Darier's disease
*Rosacea
*Pemphigus
*Atopic dermatitis
*Psoriasis
You can read more detailed information here and here.



What does photosensitivity look like?







 


Harlequin Ichthyosis Syndrome

Harlequin syndrome is a condition characterized by asymmetric sweating and flushing on the upper thoracic region of the chest, the neck, and the face. Harlequin syndrome happens in only one side of the face. In the affected half, the face does not sweat or flush even with simulation. The arms and trunk can also be affected. In contrast to the patient's beliefs, the affected side is not the one that flushes and sweats, but the pale and anhidrotic side. This condition is induced by heat, exercise and emotional factors. It is caused by sustaining an injury to the sympathetic nervous system and it is a rare disease, affecting fewer than 200,000 people in the United States. It can also affect the eyes. Harlequin syndrome is clearly different from rosacea as it makes only half of the face flush and sweat, which is usually not the case with rosacea.
You can read more on Harlequin syndrome here and here.





In this youtube video a young patient explains her Harlequin syndrome:




What does Harlequin syndrome look like?





 








Auriculotemporal Nerve Syndrome (Frey’s Syndrome)

Frey's Syndrome is a syndrome that includes sweating while eating (gustatory sweating) and facial flushing. The sweating associated with Frey's syndrome can happen from eating any type of food (even ice cream) or from just thinking about food. Patients find it usually extremely embarrassing and uncomfortable. Many cases of gustatory sweating show up after surgery or trauma to a parotid gland. Most people have a pair of parotid glands, one located on each side of the face, below and in front of the external ear. The parotid glands are the body's largest salivary glands. Saliva is secreted by salivary glands to aid chewing, swallowing, and digestion of food. If a parotid gland is damaged or if surgery to a parotid is required (damage can occur due to inflammation, infection, and mumps, and tumors can require surgery), then the related nerves may become damaged or may regenerate from such damage in a way that causes them to become "mixed up" and/or "intertwined". The result is that when a person is supposed to salivate, he or she may also sweat and experience facial flushing. This combination of sweating and flushing related to parotid trauma is called Frey's syndrome. Usually Frey's syndrome affects just one side of the face.
It is caused by injury to a nerve, called the auriculotemporal nerve, typically after surgical trauma to the parotid gland. This nerve, when it heals, reattaches to sweat glands instead of the original salivary gland (which had been removed during surgery).
Gustatory sweating can also occur for no known reason (idiopathic) or related to another medical condition ("secondary hyperhidrosis" due to conditions such as diabetes, cluster headaches, Parkinson's, and facial herpes zoster or shingles). In these cases, the sweating is often experienced on both sides of the face and particularly on the temples, forehead, cheeks, neck, and/or chest, as well as around the lips. Redness and sweating may appear when an affected person eats, sees, thinks about, or talks about foods.

Medical treatments include:
    Topical anticholinergic ointments (scopolamine, glycopyrolate)
    Topical anti-perspirants (deodorant)
    Topical α agonist (clonidine)
    Botulinum toxin (botox) injections
Botulinum toxin appears to be the easiest and safest method. It provides the longest period of symptom relief with the lowest complications. However, none of these treatments allow a definitive cure; relief is only temporary. For permanent treatment, reconstructive surgery is the only option.
You can read more on Frey's syndrome here and here.


Pictures of what Frey's syndrome can look like 













Flushing in Secondary Male Hypogonadism (low testosterone)

Male hypogonadism is a condition in which the body doesn't produce enough testosterone — the hormone that plays a key role in masculine growth and development during puberty — or has an impaired ability to produce sperm or both. You may be born with male hypogonadism, or it can develop later in life from injury or infection. The effects — and what you can do about them — depend on the cause and at what point in your life male hypogonadism occurs. Some types of male hypogonadism can be treated with testosterone replacement therapy.

Hypogonadism, or low testosterone levels, by itself can cause males to flush. This article states: "It is likely that the patient’s flushing was caused by his low testosterone to estrogen ratio, a symptom commonly seen in men undergoing androgen deprivation therapy for prostate cancer."


On top, such males might need to be checked for underlying carcinoid tumors. This article states: "A series of three male patients with secondary hypogonadism has been described, in whom flushing was associated with elevated 24-hour urine 5-HIAA levels. Flushing disappeared, and 5-HIAA levels normalized after starting testosterone enanthate treatment. Male patients with flushing and increased urinary 5-HIAA levels should undergo assessment for hypogonadism after screening for carcinoid tumor."

Those mentioned urinary 5-HIAA levels and hypogonadism was also at play here: Tested were  three male patients who had flushing, secondary hypogonadism, and increased urinary 5-HIAA levels, but normal blood serotonin levels. Their clinical and laboratory features were described before and after treatment with testosterone. In addition, six male patients with hypogonadism (three with primary and three with secondary hypogonadism) without flushing were assessed.
"Urinary 5-HIAA levels became normal after treatment with testosterone. When testosterone therapy was discontinued in two patients, flushing and increased urinary 5-HIAA levels recurred. Furthermore, flushing and the elevated urinary 5-HIAA values resolved when testosterone treatment was reinitiated. The six patients with hypogonadism without flushing had normal urinary 5-HIAA levels. CONCLUSION: Male patients with flushing and increased urinary 5-HIAA levels should undergo assessment for hypogonadism after screening for carcinoid tumor. If hypogonadism is diagnosed, resolution of flushing and normalization of 5-HIAA may be achieved with testosterone treatment."

Treatments that lower the serum testosterone level, such as orchiectomy or luteinizing hormone-releasing hormone analogues, cause hot flushes in more than 50% of men. Lack of regulatory feedback in the hypothalamus from circulating serum testosterone is the presumed mechanism.

 








Erysipelas

Erysipelas (which can be translated as red skin, "holy fire", and "St. Anthony's fire") is an acute infection of the upper dermis and superficial lymphatics, usually caused by streptococcus bacteria. Erysipelas is more superficial than cellulitis, and is typically more raised and demarcated.
Patients typically develop symptoms including high fevers, shaking, chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. The erythematous skin lesion enlarges rapidly and has a sharply raised edge between the red skin and the normal looking skin. It appears as a red, swollen, warm, hardened and painful rash, similar in consistency to an orange peel. Lymph nodes may be swollen, and swelling may occur. Occasionally, a red streak extending to the lymph node can be seen.
The infection may occur on any part of the skin including the face, arms, fingers, legs and toes, but it tends to favor the extremities (arm, leg, face). Fat tissue is most susceptible to infection, and facial areas typically around the eyes, ears, and cheeks. Repeated infection of the extremities can lead to chronic swelling. This disease is most common among the elderly, infants, and children. People with immune deficiency, diabetes, alcoholism, skin ulceration, fungal infections and impaired lymphatic drainage (e.g., after mastectomy, pelvic surgery, bypass grafting) are also at increased risk. This disease is diagnosed mainly by the appearance of well-demarcated rash and inflammation. Depending on the severity, treatment involves either oral or intravenous antibiotics, using penicillins, clindamycin or erythromycin. While illness symptoms resolve in a day or two, the skin may take weeks to return to normal.












Other Diseases Causing Episodic Flushing


Monoamine oxidase deficiency can cause episodes of flushing affecting the face and chest precipitated by emotion or certain foods. It is also called Brunner syndrome, and caused by a monoamine oxidase A (MAOA) deficiency, which leads to an excess of monoamines in the brain, such as serotonin, dopamine, and norepinephrine (noradrenaline). Blood serotonin can become raised and the activity of monoamine oxidase is decreased. See for more information this and this link.
.
Flushing is rare in patients withpheochromocytoma, a rare, usually noncancerous (benign) tumor that develops in cells in the center of an adrenal gland (link). If flushing occurs at all, it is seen after an episode of hypertension, tachycardia, palpitations, chest pain, severe throbbing headaches, and excessive perspiration. Paleness is typically seen during the attack, and mild flushing may occur after the attack as a rebound vasodilation of the facial.


Asthma flushing

In an asthma attack, the breathing pathways constrict, making it difficult to exhale carbon dioxide. When you can't exhale an adequate amount of carbon dioxide, you can't inhale oxygen. The lack of oxygen causes the face to turn red. This is not a true rosacea flush, but it's not uncommon for rosacea suffers to also have asthma. Asthma flushing/redness can result from a food allergy, airborne pollutants or toxins. Using an allergen air filter and changing it every one to two weeks can help reduce indoor pollens, toxins, fungi, and/or molds in the home. Air purifiers can also be helpful. Controlling your environment as much as possible can help to relieve some of the symptoms of asthma.



POTS; Postural orthostatic tachycardia syndrome

I stumbled upon this blog, where a girl blogs about her dealing with this disease POTS. Postural orthostatic tachycardia syndrome (POTS) is defined as an abnormal increase in heart rate on becoming upright. There are many causes. Although blood pressure does not necessarily fall, symptoms are similar to low blood pressure and can consist of dizziness, fainting, headache, sweating, shakiness, nausea, poor concentration and memory, discoloured hands and feet, sense of anxiety, chest pains and many others - mostly worse when standing. Treatment can consist of high fluid intake, care with posture, careful fitness training and, in some patients, high salt intake and medication (source).

She also mentions being flushed in the face at times and shared a picture. She writes: 


"My flushing and hives have died down significantly since I got off the beta blocker (I also took myself off of all 3 antihistamines). I still get the episodes but not as bad and it’s been something I could ignore because they haven’t been nearly as bad. But today, after eating the same macaroni and cheese that I have eaten recently with no symptoms, my face flushed and i got the standard inflammation and itchiness in my eyes, lips and nose. My whole being is fatigued and I just to put my head down and close my eyes. I feel lethargic and worn down. Brain fog has definitely arrived. My face isn’t nearly as red as it can get and I don’t have the hives down my neck, chest and arms though I have that feeling like it’s slightly there (and I am definitely itchy). I am not sure what my blood pressure is but I know my heart rate is up and it’s pounding too. As you can see from my other post today, I am having a pretty symptomatic day and I know I probably need to lay down – though I can’t because I am at work.

I am just confused. I know I am in a downswing in regards to how I have been feeling physically but what in the world is triggering the flushing episode to return in a huge way? I have been considering looking into antihistamines again now that I am off the beta blocker (since I believe that was the culprit in making my flushing episodes significantly worse!). The only thing is that I want to know what’s triggering these episodes first before I go back on anything to treat them and also, I have found that since being on Zantac 150 for antihistamine purposes and going off of it, I actually have heartburn! The only time I have ever had heartburn in the past was when I was pregnant with my daughter and maybe a time or two after that due to the hormonal changes during “that” time of month. I don’t know if the Zantac triggered something or what but there is no other explanation for me having increased heartburn!This is so annoying and frustrating. I guess I will have to start using my blood pressure/heart rate monitor again and start keeping notes on everything for awhile. But to be perfectly honest, I feel ridiculous pulling out that monitor while I am out and about and especially at work. It’s not quiet and yes, I will admit that I am afraid that people will think I am just looking for attention… and that’s why I haven’t been doing it. Yeah, I know."





In this research, POTS is linked to facial flushing and mast cell issues:

Link to image Source

"Postural tachycardia syndrome (POTS) is a disabling condition that commonly affects otherwise normal young females. Because these patients can present with a flushing disorder, we hypothesized that mast cell activation (MCA) can contribute to its pathogenesis. Here we describe POTS patients with MCA (MCA+POTS), diagnosed by episodes of flushing and abnormal increases in urine methylhistamine, and compared them to POTS patients with episodic flushing but normal urine methylhistamine and to normal healthy age-matched female controls." Note, I placed the picture right above this (the girl with POTS, picture with the 4 little frames) in my mastocytosis blog post initially. It was a forum member called Jrlhamcat2 who notified me that when you read her blog carefully, she is not diagnosed with mastocytosis actually but with POTS.


Autonomic epilepsy and seizures
can als provoke facial flushing. (Link)


Lyme disease can also provoke facial flushing. Read more on Lyme disease  here and here. Please also watch this very insightful and important video on Lyme disease


 




Rosacea



Persistent flushing from any cause may eventually lead to rosacea. The lesions of rosacea that initially occur in the central convex areas of the face consist of papules and pustules against a background of erythema, telangiectasia, edema, and eventual permanent induration or thickening of affected skin.1 Patients with severe flushing caused by mastocytosis can develop rosacea in less than 1 year after the onset of flushing episodes.


This is a blog by a doctor who works for the German army and here he writes about a patient of his with rosacea and face swelling, and how he treated her. I have written a lot about rosacea on this blog and I will just give some common symptoms and characteristics of rosacea here, together with pictures of rosacea skin. It might serve to see differences with other medical conditions mentioned and envisioned here.

Rosacea consist of redness of the facial skin. Rosacea usually causes persistent redness in the central portion of your face, potentially including the cheeks, chin, nose and even ears and forehead.Some people find that the redness can spread to the neck and chest as well, but this is more rare. Apart from facial redness, which is usually not in one smooth, even looking color. Small blood vessels might also become visible over time on your skin, as well as wollen red bumps. Many people who have rosacea also develop bumps on their face that resemble acne, the so called subtype 2.  
These bumps sometimes contain pus. Subtype 1 patients are dealing more with general redness, skin burning and facial flushing (although those in subtype 2 can also encounter all these symptoms). Your skin may feel hot and tender. About half of the people who have rosacea also experience eye dryness, irritation and swollen, reddened eyelids, also called occular rosacea. In some people, rosacea's eye symptoms precede the skin symptoms. Rarely, rosacea can thicken the skin on the nose, causing the nose to appear bulbous (rhinophyma). This occurs more often in men than in women.

Rosacea is often characterized by flare-ups and remissions, especially in the early stages. Initially the redness on the cheeks, nose, chin or forehead may come and go. Over time, the redness tends to become ruddier and more persistent, and visible blood vessels may appear. Left untreated, bumps and pimples can often develop. Although rosacea can affect all segments of the population, individuals with fair skin who tend to flush or blush easily are believed to be at greatest risk. The disease is more frequently diagnosed in women, but more severe symptoms tend to be seen in men -- perhaps because they often delay seeking medical help until the disorder reaches advanced stages (source and source).



What can distinguish rosacea from many other flushing disorders discussed here is:

*Rosacea usually developing in your 20's or 30's, or even during menopause for women
*The rosacea redness usually worsens with time
*The redness can be seen on the cheeks but also the chin and nose (and even forehead and ears for some)
*People with rosacea often have a pale complexion and a tendency to blush
*In the earlier stages the skin can become red, yet it also can look pale again once a flare is over. Flushing flares can last short or longer. Only with time the redness usually can become more permanent.
*Generally occurance of worsening of symptoms after sun exposure, drinking alcohol or eating certain foods.
*Skin becomes often dry and flaky
*Flushing isn't accompanied by sweating
*Papulas may appear on the face

*The face can become a bit swollen from the redness, called oedema.

* In a very recent survey, conducted by the NRS nearly 93 percent of 1,709 rosacea patients said they had experienced physical discomfort as a result of the disorder, with burning and stinging the most commonly cited pain sensations. Among the other physical discomforts experienced by the survey participants were tightness, cited by 45 percent; swelling, named by 44 percent; tenderness, mentioned by 41 percent; tingling, 32 percent; prickling, 25 percent; and headache, 19 percent.




Pictures of rosacea patients












David Pascoe wrote a post about potential causes for facial flushing.  

In this post he included a table with potential flushing causes:

Table II
Differential diagnosis of flushing
Common Causes

    Benign cutaneous flushing
        Emotion
        Temperature
        Food or beverage
    Rosacea
    Climacteric flushing
    Fever
    Alcohol

Uncommon, serious causes
    Carcinoid
    Pheochromocytoma
    Mastocytosis
    Anaphylaxis

Other causes
    Medullary thyroid carcinoma
    Pancreatic cell tumor (VIP tumor)
    Renal cell carcinoma
    Fish ingestion
    Histamine
    Ciguatera

    Psychiatric or anxiety disorders
    Idiopathic flushing
    Neurologic
        Parkinson’s
        Migraine
        Multiple sclerosis
        Trigeminal nerve damage
        Horner syndrome
        Frey syndrome
        Autonomic epilepsy
        Autonomic hyperreflexia
        Orthostatic hypotension
        Streeten syndrome
    Medications

    Very rare causes
    Sarcoid, mitral stenosis, dumping syndrome, male androgen deficiency, arsenic intoxication,
    POEMS syndrome, basophilic granulocytic leukemia, bronchogenic carcinoma, malignant histiocytoma, malignant neuroblastoma, malignant, ganglioneuroma, peri-aortic surgery,
    Leigh syndrome, Rovsing syndrome



Steps to take for Evaluation Of The Patient With A Flushing Disorder

These are some tips for doctors about diagnosing patients with flushing symptoms. He or she needs to first look at clinical characteristics. Are there certain agents that trigger the flushing? This would suggest an underlying systemic disease as the cause for the flushing, such as mastocytosis and carcinoid syndrome.

Morphology
  • Is there a basic feature that comes and goes?
  • Is the redness patchy or confluent?
  • What is the color of the flush?
  • Is there cyanosis?
  • Is the flushing preceded or followed by paleness?
The morphology of the flushing may suggest not only the cause of the flushing but also, in the case of carcinoids, the anatomic origin of the disorder.
Associated Features. These may include respiratory symptoms, gastrointestinal symptoms, headache, urticaria, facial edema, hypertension, hypotension, palpitations, or sweating.
Temporal Characteristics. Temporal characteristics are the frequency of the flushing and the timing of the specific features during each flushing reaction. Important information can be obtained from a 2-week diary in which the patient records how long and how severe the flushing events were, and lists exposure to all outside agents. When the diagnosis remains obscure after evaluation of the 2-week diary, the patient can be given an exclusion diet, listing foods high in histamine, foods and drugs that affect urinary 5-HIAA tests, and foods and beverages that cause flushing. If the flushing reactions completely disappear, the doctor can start to reintroduce the excluded items individually, one by one, to identify the food item that causes the flushing. If the flushing reactions continue unchanged, then further metabolic workup may be undertaken.

Always make sure when you have rosacea that you maintain a gentle skin care regimen. 

Try to identify your triggers and avoid them. Look together with your dermaologist for treatment options. For instance medication, natural anti inflammatory treatment options, diet or laser/IPL. Treating your rosacea successfully will help you achieve and hopefully maintain remission.




Erythematotelangiectatic rosacea

while considered by many to represent a separate entity, may in fact be difficult to distinguish from normal facial flushing and sun-damaged skin. In attempting this distinction, it may be useful to assess the extent of baseline facial telangiectasia, hypopigmentation and hyperpigmentation. However, since these 3 conditions are all common, they may coexist in many patients.


So, in summary:

Rosacea is said to typically start in people's late twenties, thirties, forties or even onwards. Some doctors insist they don't see it in teenagers or youngsters, but the forums are proof that this is not correct. I developed rosacea virtually out of the blue at age 19. However, the sudden onset can be a clue for rosacea. Other patients had a long standing tendency to blush or get red as a youngster and found that this developed into rosacea with age. A good portion of rosacea patients also seem able to trace the rosacea back in their family history, and know parents or grand parents who had rosacea symptoms. However, this definitely isn't the case for everyone. (Nobody in both my families have rosacea, only eczema issues). The use of Accutane/Roaccutane or (Hydro)cortisone cream can also have been the trigger for rosacea to erupt. When people develop red, burning and flushed skin or bad skin rashes after use of any of these creams, steroid induced rosacea should be the first suspect.
Rosacea tends to wax and wane, and can flare badly, only to calm down again some time later. Flushing also tends to be temporary initially. Some people with rosacea have a lot of baseline redness, but those mainly affected by the flushing can have relatively pale and normal looking skin when not flushing. This is another characteristic of rosacea.

The redness of rosacea is usually not sharply marked from unaffected skin. So the redness usually blends in somewhat, and the flushing can affect only part of the cheeks, usually the inner cheeks closest to the nose. With exception of those with permanent redness (which normally takes time to gradually build up with rosacea), this redness can also subside rather quickly when you cool the face. People with rosacea have typically different parts of the face affected. Redness and
flushing tend to to start on the cheeks for many, although especially males also find their nose and ears affected quickly. The chin can also get red with time, and even the forehead. This is another characteristic of rosacea, although not an entirely exclusive one. (Flushing, burning, swelling and redness of the hands and feet is usually Raynaud's Syndrome, and has to do with unwanted widening of the blood vessels there. It usually occurs in winter and many rosacea patients have Raynaud's on top. I got tested for it in my university linked hospital and tested positive). Rosacea tends to give both facial flushing and redness ánd small red paps and pimple like eruptions, generally without white heads. Some people mainly get the one, others the other (subtype 1 and 2) but most people with rosacea experience both symptoms at some point, more or less severe. For instance, I have subtype 1, with erythema, burning, redness and flushing and very little outbreaks, but when I flush badly or eat something wrong, I also get red dots that look like little red pimples without a real white head (but often with some fluid or very fluid thin puss inside).

Most flushing reactions result from benign causes. However, since flushing may be the presenting sign or symptom of several life-threatening conditions, it it important to discuss your symptoms with your doctor. If needed, he or she will do more tests to rule out some other diseases. For instance systemic mastocytosis, carcinoid syndrome and other tumors. Read also this link from the Rosacea Org.









Coexisting health problems which people with rosacea often mention

Many people with rosacea face coexisting health problems at some point. Bowel conditions are most mentioned, as well as allergies, thyroid problems, hormone disturbances and .... 
One of the problems most rosacea patients will encounter, is that most dermatologists are not very receptive to these coexisting conditions. Many patients have complained about dermatologists who are unwilling to listen to their worries about this, are unwilling to send them to collegues, like an immunologist or neurologist, for further diagnostics and even if patients have a diagnosis of conditions like Raynaud's syndrome or colitis or Crohn's Disease, many doctors will fail to see them as potentially related to the rosacea symptoms. This is very frustrating.

My personal experience with coexisting health conditions
I have seen 3 immunologists and the last one was a professor who did extensive bloodwork to see what auto immune and inflammation makers would come up, and they were very few actually, despite us expecting a lot more. I have been tested on ANA levels and they have been creeping up over the years, from 0:20 to 0:40 to 0:80 now (equals a positive for auto immune activity, but it didn't worry the immunologist one bit). I was sent to all of them by my prof dermatologist, a good one who kept an open view and ackowledged he didn't know enough about it all and tried to cooperate with some other specialists (immunologist, internal health doc and a neurologist) but nobody really worked together in the end and it resulted in some independant tests from all involved, diagnosis Raynaud's, colitis, arthritis onset, slightly raised ANA markers, some pro-inflammatory T-cells etc, - all half vague, slightly out of whack stuff but nothing alarming enough - and that was it; no plan of action, no further cooperation and no treatment, apart from the anti flushing medication I already took.

I think this is too vague for most scientific based specialists and demands too much speculation from them to even want to dive into the cosharing of diagnostics with other specialists. I doubt many will come up with alarming coexisting health issues, apart from some people with clear cut thyroid problems amongst other things. I think often people with rosacea here complaint about other halth problems, like bowel issues and allergies and inflammation issues, but not many doctors are paying much attention to that. That makes me pretty disappointed and demoralized. I wished just more doctors were willing to step up and really aspire to get a better overall picture of all the other little things going wrong inside ua, which seems to eventually result in the rosacea a.o.



A little summary of the experience rosacea patients have with diagnosing their rosacea and at times underlying coexisting health problems

Froggirl wrote on May 23th 2014: "It seems to be pretty well accepted in the medical literature that a diagnosis of rosacea can only be made once a multitude of other conditions are first ruled out. My doctor did but i wondering if everyones doctor or derm are ruling these things out to? Especially for people for who redness and flushing are the key symptoms (rather than P&P). I remember back when i first started getting flushing that the only thing that came up on the internet for flushing was rosacea, but have since found out there are many many things which can look like rosacea, so thought i'd put it out there.
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. Since rosacea is typically limited to the face, extra facial erythema is generally an exclusionary sign. Rosacea flushing is associated with burning or stinging but not sweating, lightheadedness, or palpitations. http://rosacea.ii.net/news/2006/08/r...t-rosacea.html
Most of these are unlikely or rare but there are also some pretty common conditons that can cause
flushing or make it worse, such as allergies, food intolerances, thyroid issues, oestrogen imbalance (for women), lactose intolerance, fructose intolerance and coeliac disease. Of course all of the above generally cause other symptoms aside from flushing or redness, most commonly GI issues, but some of these can be symptom less, like Coeliac disease, which is why only about 1 in 1000 people are diagnosised with it despite approx 1 in 100 having it. And the fact that lot's of rosacea say they improve when cutting out wheat or dairy products makes me wonder if some of us also have other things going on, aside from rosacea. Anyway most of these are simple blood tests, so is everyone getting checked out for these things?"

Melissa W. replied: "Hi Kate, My derm diagnosed rosacea without any workup to rule out other diseases. It wasn't until I got chilblains that the drs ordered the whole series of connective tissue blood tests to R/O all the other stuff. And that was months after I was formally diagnosed with rosacea. Best wishes, Melissa"   

Patty replied: "I was diagnosed with rosacea by my primary dr. who sent me for more blood tests to test for lupus, and other auto-immune type diseases. I have had more done with my derm, and also a more complete workup done by a rheumotologist. My ANA was on the high side of normal, which is why all the blood work. I've been told I have a mild case of Raynauds, very common in rosaceans from what I see."

Froggirl wrote: "Oh and i forgot erythromelgia as a very rare cause of facial flushing. So i guess it's not so common to get tested straight away, maybe my doctor did because my facial flushing came so suddenly and rapidly got worse and worse? And then i developed flushing in other areas, like my knees, hands, feet and chest which is when he started testing me for the rarer and more obscure things. So many tests and still no answers for me which means there is at least one other thing missing form this list, so if anyone knows what it is that would be great!
[..] "Unfortuently having triggers doesn't automatically mean rosacea. Carsnoid (sic) and mastocytosis both get triggered by many of the same things as rosacea, ie stress, heat, cheese, alcohol to name a few, with the result being flushing, wheezing, and GI issues. Most of the rosacea food triggers are on the list because they are high in serotonin, histamine or msg, so if you have food intolerances to these chemicals than eating them can cause flushing (and other things like headaches) even without rosacea. Plus any conditons that involve inflammation in the skin, like seb derm (or most other things on Brady Barrows list), will get redder with anything that increases blood flow in the skin, so with heat, alcohol, or even with the same foods to avoid for rosacea. And then this inflammation can trigger flushing. It all gets so complicated but i guess this range of things is why it's not always so straight forward to get a diagnosis of rosacea, or anything else on this list!"

Grace replied: "Froggirl, Thank you for your post, for I have been fustrated by this also. GP and derms have taken one look at me, no more than a foot away, and have diagnosed me with rosacea and quicklyl walked out the door. Yet I have questioned this, it may very well be, yet I do believe there are other things going on, for like you, I started flushing very suddenly and very badly and the progression has been a bit severe I now get very bad swelling in my nose, feet and hands, and my nose is constantly running - symptoms I have never had before. Sometimes I wake up in the middle of the night and it hurts to make a fist, due to the swelling in my fingers. I had to adamantly request blood tests to screen out lupus and autoimmune conditions. I know for me hormones are part of it. For about 9 months ago my menstration stopped, suddenly, even though i'm only 42. And I think since people react so differently to so many things, we all have different things going on in our bodies that is causing these similar sypmtoms clumped as "rosacea". Grace" 

Burnt1970 replied: "This is what I'm dealing with right now. When my first derm diagnosed me with Rosacea 4 years ago, it was at first sight with no testing. My grandmother had Lupus pretty severe, and though I was tested for that 2 1/2 years ago (which came back negative), something else could be very much at work. The derm I saw a couple of weeks ago questions if I do have Rosacea since he was concerned about how sharply my redness cuts off. There are very defined borders on my neck. Also, my level of photosensitivity to fluoro lights concerned him, (he watched me turn 20 shades of red right in front of his eyes). Another thing that's been happening over the past few months is red, blotchy rashes under my eyes. They have a bit of a sting and scaliness to them. IN FACT, just yesterday I laughed so hard about something that I cried. The result of the tears were nasty rashes appearing immediately under each eye, which is still somewhat there today. If this is auto immune, or allergy related, I've been eating asprin like candy and taking antihistamines daily. I'm noticing some relief in color and other issues because of it. I see a new 'special' derm on June 15. Hopefully, this will be a start to determine what it is I actually have." 

Bluesky replied: "Hi, I found this to be very interesting, so thanks for bringing this topic up again Melissa... I'm going to the university derm center but my insurance will not cover it, so I would like to go to my regular doctor and get some testing done as opposed to at the derm. What kind of testing is suggested?? I would like to rule out any of these diseases or anything else that might be causing this awful flushing and redness, so can someone please provide a list of what should be tested for, deficiencies etc.and also diseases?? Thankyou!! Something I notice also, I flush in my feet. What is that?? Lol! Really though, when I'm outside in the sun or the heat, or even if no heat and I'm walking or doing some kind of vigorous exercise, my feet will turn really red and flush, at first I thought, oh no it's sunburn, but my feet have never burned at all like that, and afterwards they always go back to white again. Is that a normal rosacea sign? Any thoughts? Thanks! Bluesky"

Melissa W. replied: "Flushing hands and feet could be related to Raynauds as well I believe."

Meg replied on February 15th 2011: "Originally Posted by Mogge: i have the same, but not just my feet. My face, back of the hands and top of my chest also gets really red. At first i thought of Lupus but since im a caucasian man in my 20's its highly unlikely. Does yours feel like "pulsating" or "throbbing" when they get really red? feels like some sort of swelling That may be Erythromelalgia (EM)  - look at www.erythromelalgia.org. It's usually hands and feet, but faces can be involved too. Meg."
Mogge replied back: "EM is rare though (about 1 in 100.000) which makes even Lupus Erythematosus more likely. My hands and feet tend to "flare" when im drinking alcohol,shower in warm water or even by wearing a long-sleeved sweater indoors so it kind of fits with EM but it seems unlikely to have such a rare disease."

Meg wrote back: "EM is not as rare as once thought, although it is considered a rare disease according to NORD. With that said, I have never heard of hands or feet involvement when it comes to Lupus, although I may be wrong. It you have flushed extremities that turn red and burn, then it qualifies as EM. You can have varying underlying causes and it's still considered EM if you have these combined symptoms. Meg"

Mogge replied: "The most common rash in lupus is the butterfly on the face. Rash on the back of the hands and on the V-neck area are sometimes presented as well. But that is usually efter being exposed to UV-light. It could be EM but even if its more common than 1 in 100.000 the chance is still pretty slim. Something like Histaminosis (histamine intolerance) would be more likely. Anyway i think im going to get a new appointment with my dermatologist and show her all the rashes and not just the one on my face"

Shantelle replied to this thread: "Hi all In regards to the above posts...Yes, Lupus is not as common in males as it is in females (Ratio Females 9:1 Males). Lupus can present itself in may different forms, and symptoms (all inflammatory) often masquerade as other diseases or health issues. The butterfly rash is not seen in every Lupus patient, but if it does appear it can certainly masquerade itself as Rosacea (Type 1). Inflammatory hand and and feet symptoms are common symptoms of lupus, particular if the person has systemic lupus, or Raynards (Raynards is often seen in patients with autoimmune disease) or chronic cutenous lupus affecting the hands or feet (lupus chillblains/ lupus pernio). If anyone thinks that they might have lupus they should see their GP for a referall to a Rheumatologist (multiple inflammatory symptoms) or Dermatologist (symptoms all skin related). Lupus symptoms information:
http://www.dermnet.org.nz/immune/cutaneous-lupus.html
http://www.lupus.org/webmodules/weba...268&zoneid=526
http://www.hopkinslupus.org/lupus-info/"

Mogge replied: "Lupus is a possibility, but my symptoms are usually induced by stress, heat, alcohol, caffeine and eating which indicates Systemic Mastocytosis. My symptoms are: swelling of the hands,feet and face, chronic diarrhea,stomach pain,blodshot eyes,weightloss,joint pain, myalgia, malar rash+rash on chest,hands and feet,vertigo,vomiting,blurry vision and fatigue. Those are very common in Lupus but mine are triggered by the environment which is why i think its Mastocytosis. Both are uncommon diseases, Lupus is pretty rare in caucasian males and Systemic Mastocytosis affects about 1 in 1.000.000 people."

GiGi replied: "I have never had any specific blood tests nor other check ups done, though I have some other symptoms. (Fatigue, foggy brain and digestive issues.) I am wondering, who do you ask to run those tests? My NHS GP didn't show any interest/knowledge, and the private dermatologist I consulted seems to be not aware of any tests neither... If someone who lives in the UK is reading this thread, I would greatly appreciate recommendations for a good private GP/specialist doctor who does run these kind of tests and is willing to investigate possible underlying illnesses. Many thanks."

Brady Barrows replied: "Two recommendations:

*Professor Tony Chu, FRCP
West London Dermatology Centre
227-229 Chiswick High Road, Chiswick, W4 2DW
(I agree, he is my doctor too and a great one).

*Frank Powell, M.D.
Consultant Dermatologist
Regional Centre of Dermatology
Mater Misericordiae Hospital
Dublin, Ireland
Leading European authority on rosacea

Also these posts:
What to ask my physician?
What should I know about diagnosing rosacea?"

John111 wrote on November 27th 2011: "Hi im 25 years old and have a condition which came on
My theory is that call these symptoms relate to an auto immune disease. I have been to a endoconologist and he tested me for carcinoid cancer and pheos which are adrealan tumours. He tested my urine with 24hr tests and my thyroids and both came back fine. Last week i also went to get tested for diabietes and the nurse said that the blood tests, test for thyroids and covered everything. My question is would lupus show up on a standard blood test for diabietes or on a thyroid test or is there any specific test for lupus. Also can anyone help me with my condition and does anyone know if my symptoms are like lupus or an auto immume disease? I dont have any pastules, raised skin or red spots on face , my skin is smooth but red and can become imflammed on exposure to hot and my complexion can become much redder on exposure to cold.I also have a shy personality and can flush easily. The only time my cheeks turns pale is when i feel sick or when ive taken stimulants like speed and mdma.does anyone know why this is?is this a hormonal problem or does anyone know a supplement that will help with the redness.i just have red cheeks with a red nose,redness on neck and upper body wit no bumps or roughness.any help would b welcome as i dont know why i turn pale.Any replies would be welcome. Thanks, John"

Emlarkin replied: "I'm 16 and I've had this problem develop from about 8 years old. My mum keeps saying she doesn't think it is rosacea but it's getting worse. What do you think? I am so sick of looking orange when I cover it up with makeup. [...] the worst is in the evening, usually gets really hot and red almost like it's burning. When it's not so red there are white splotches in between but if its flushing then it completely covers my cheeks and sometimes under my chin. No my face doesn't sweat really. I would say it is rosacea as looking at some of the seborrhoeic dermatitis information, it is not affected by diet whereas I get worse when eating hot food like curries or too many fatty foods. It is generally best first thing in the morning but as soon as I get too hot I will flush for hours after. So embarrassing and no one understands that I'm NOT blushing! It's good to know other people understand here."

J1992 replied: "Emlarkin, you skin is red in exactly the same areas as mine. Im 19 years old, male but my skin is a complete red mass where as yours seems to have small white areas around your redness. Im in two minds as to whether I have Rosace or Sebbhoric dematisis, my face is cold at 2am to 6am, feels normal no tingling, or heat, cold & normal. I believe thats due to the body temperature decreasing naturally at that time, worst is 6pm to 11pm. Do you feel the same? I also dont sweat on my face anymore :? Joe."

Scully555 had a skin sensitivity for shampoo after all: "Hi, I was diagnosed with Rosacea many years ago and lived with it for a long time believing my doctor even though he did nothing other than ask me a few questions and peek at my skin from 4 feet away. No blood tests, nothing like that. I was in and out of his office in less then three minutes. It took him longer to write up the prescriptions than it did to discuss the symptoms with me. I had previously been diagnosed with having a rash from shaving but when a years worth of treatment for that failed I consulted another doctor as I was a little suspicious of his diagnosis since I had the rash all over my forehead as well as large areas of my cheeks. After a years worth of expensive treatments for rosacea I learned from a coworker that some soaps and shampoos can cause long term rashes. After learning this, I went home and read all the labels on my soap packaging and on my shampoo bottle. It turns out that I was using a medicated dandruff shampoo that was not intended for daily use. I was using it every day and sometimes twice a day. It was only supposed to be used two or three times a week when dandruff was visible and only monthly if no dandruff was visible as a preventative measure.and the disclaimer on the label specifically warned of the possibility of a rash occuring and expressed the need to stop using the product immediately if a rash did appear and to consult a doctor if the rash persisted. I should have consulted that label before I consulted two or three dermatologist as well as my general practitioner. The rash went away 100% within two weeks and never came back or at least has not reappeared for 15 years. I lived with it for at least three or four years. I highly recommend that all of you who have been diagnosed with Rosacea but have not been tested for it check your hair care and skin care products as well as consult a good doctor. [...] I had very similar rashes that I lived with for many years that were so severe I stopped going out with friends on the weekends and avoided social contact with anyone but my closest friends because I was tired of the "What's wrong with your face?" comments and having people say EEEEEEIIIIIIIIIWWWWW. After years of misdiagnosis from two or three "specialists" I finally did what a coworker suggested. I read all the labels on my bath soap packaging and on my hair care products. It turns out I was using a heavily medicated dandruff shampoo loaded with "tar" that was only supposed to be used a few times a week when dandruff appeared and once or twice a month when dandruff was not visible, as a preventative measure. I was using it daily and sometimes twice a day for years. When I stopped using the shampoo, my face cleared up 100% within a few weeks and never came back."


You didnt cure your Rosacea.You cured something else which you or your Dermatologist thought was Rosacea.Thats the biggest problem with rosaceagroup and why the cure for Rosacea has eluded us for so long.So many people here should not be here.Your condition sounds something like Dermatitis Herpeticum or an intolerence to certain food groups which,like sooo many other conditions can mimic Rosacea depending on the strength of your facial skin.Dermatologists charge so much more for their service than a G.P and I have no idea why.Is it because they memorise the thousands of pictures of certain skin disorders.Because thats all they do when they examine us.Or maybe were paying extra for the 100 watt light that they shine in our faces.Im glad you cured your problem,whatever it was. 

Bumpy face You will have to change your name since you found your cure.I dont see where your empathy is since you seem to be criticising everything I said.You are the perfect example of the people I mentioned who suffer for a long time trying different things to cure their problem.Here you are today and you dont know what you cured.Does it have a name.Is what you have the real rosacea.Will the real rosacea sufferers please stand up.Now I know that there are a lot of people that this site has helped and its a great source of information.I believe that there are connections between rosacea,seb derm and perioral dermatitis(rosacea variant) and the people that have these conditions can benefit greatly here.But they can also suffer here.If you have something that looks like one of these then you could be stuck here for years,spending endless amounts of money treating something that is not R,seb derm or P.D or treating something that is rosacea with something that you shouldnt use,because someone who didnt have rosacea endorsed it. Some people seem to think that we are all made up in a different way and what works for one may not work for another.I dont agree with this.I think that what works for one but doesnt work for another means that these two individuals have two different conditions.But having all of us bundled here together,is that a help or a hindrance.This would be just a guess but I believe that this site is full of people with facial tinea infections,dermatitis herpeticum,perioral bacterial infections,perioral fungal infections,candida induced facial dermatitis and rosaceiform and many other conditions of which the morphology has changed from use of steroids or topical immuno modulators.Every now and then there is a rave over something and we all jump on the band wagon hoping that this will cure us.But so many here dont know what they got or have been misdiagnosed or self diagnosed or they put up pictures and we try to guess what they have.If this is the only way that it can work then I think that a lot of people will suffer for a long time here.
Well I can argue with that.I think that the first thing that people should learn when coming here is to educate themselves on the tests that they should carry out if conventional methods of treatment are not working.They should insist on a skin biopsy and tape test and be tested for food intolerences and food allergies and whatever else.Every derm has access to a microbiologist but its up to us to make sure that they test us properly and insist on it.Its almost impossible for a mechanic to know whats wrong with my car by looking under the bonnet(hood) and I think the same applies to dermatology.There is too much guessing.Look for instance at seb derm.This,like rosacea is chronic but its irrefutable that this condition can be controlled by certain topical antifungals.By eliminating the malassezia you will see a marked improvement in this condition and this is a fact for all of us that suffer this.If you dont then you dont have seb derm.But I would bet that there are people here who are taking antibiotics and using topical metronidazole to treat this fungal infection.And similar tinea infections.All they are doing is adding to their woes and the confusion.Now I know that these tests can be costly but so can visiting 10 different derms and getting different diagnoses along the way.Some people can feel quite inhibited when visiting a derm especially when your young and inhibited.So I think a list of derms that carry out these tests on request and without dispute should be compiled.Every country,every state and every province.People should know exactly where to go in every corner of the rosacea world.They should know exactly what tests need to be carried out to find the rosacea mimic.In my opinion rosacea is one of a handful of conditions that is caused by over sensitive skin.It can be congenital or self induced.Diet can help to reduce inflammation and symtoms but is not a cure.For those who have been totally cured by diet then I will say it again.You dont and never did have rosacea.Of course this is just my opinion.I respect your opinions Bumpy (but now clear) face and I admire you for staying on here and helping others that have your condition even though you have cured yours.But it would be a whole lot easier if you had the proper name for this.In my humble opinion I would guess at a form of dermatitis herpeticum.But lets do away with the guesswork.

Refacegirl wrote: I hate that doctors really don't understand rosacea. I have seen two derms and both of them told me food does not matter and kept giving me different creams that never worked. Food does matter for me so much and I wish I knew that months ago. I'm 15 and they look at me like I'm crazy but I know so much more then they do about rosacea and I have only had rosacea and seb derm for about a year. And for most of that time nobody even believed there was anything wrong with me. Also, many doctors I've been to are so rude to me, unless you have this then you can not understand. If I met someone with rosacea or any skin disorder before this happened I would NEVER understand or pretend that I know more then the person who has it does. Haha sorry needed to vent.

Tom Busby replied: " Sorry to hear about your difficulties. I think that derms have too little education or training about immune responses to anything, including food, so their only reaction is to look at the patient like he or she is crazy. Along the same line of thinking, I asked a friend of mine, with a Masters in Nursing degree, why dermatologists seemed so incompetent. She said that derms usually appeared to be the dumbest doctors and immunologists always appeared to be the smartest. A wisecrack, but apropos. I don't have rosacea but I'm certainly sympathetic to your condition, and I so often see similar posts about rosacea and food triggers, I'm curious if anyone with rosacea has ever had a chance to see an immunologist instead of a dermatologist. I've never seen a post stating, "My immunologist says ..." 

Mistica replied: "I have heard the same thing many times. A profressor mentor of mine, who spent years teaching medical students thinks of many derms as amateur doctors. Sounds insulting, but well, it would appear that many here have various stories to tell which support that observation. Alas.
In addition, my old derm who I had in teenage years has kept in touch with me even though I am now in a different country. He is a dear, kind man and I respect him even though he can not help me. He has said, that derms don't have a very good understanding of internal medicine, which is quite an admission!
I have been seen by immunologists. I have some abnormalities. I lack CD8 positive lymphocytes. It is a minor deficiency. There are a few other minor things.
I also have intermittent low white counts. Usually lymphocytes and neutrophils.
The CD 8 play a role in resolving inflammation. Many of these are made in the gut, so there is another clue highlighting the gut connection. In my case, I have also had elevated levels of ACE. I'd be very interested to hear who else has had that particular test? It is not one that is commonly performed, and while indicative of inflammation, it is usually linked to more sinister diseases. My ACE levels dropped within range after a couple of months on the GAPS diet.
Nat (she has posted about her immune assay, so I am not breaking a confidence), has also had full immune assays, and some of her results are the opposite to mine. Yet, we are both severe flushers and have similar physical issues."





Sources:

http://rosacea-support.org/red-face-when-flushing-isnt-rosacea.html

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/flushing/
http://site2012.sbd-sp.org.br/public/img/destaques/destaque06.pdf

http://en.diagnosispro.com/differential_diagnosis-for/facial-malar-flush-rash/33343-154.html

http://www.rosaceagroup.org/The_Rosacea_Forum/showthread.php?11993-When-a-red-face-isn-t-rosacea-is-everyones-doctor-checking

http://www.rosaceagroup.org/The_Rosacea_Forum/showthread.php?18568-Its-2009-stop-calling-facial-flushing-and-burning-rosacea!/page3
http://www.rosacea.org/weblog/lupus-or-rosacea-test-may-mislead
http://www.lupus.org/answers/entry/lupus-tests 
http://www.internationalrosaceafoundation.org/symptoms.php
http://www.stopthethyroidmadness.com/celiac/
http://www.reverta.com/blog/rosacea/rosacea-and-gluten/ 
http://www.erythromelalgia.org/WhatisEM.aspx
http://users.telenet.be/zeldzame.ziekten/Getuig/Get.Erythromelalgia.htm
http://www.webmd.com/cancer/features/what-is-carcinoid-syndrome 
http://www.patient.co.uk/doctor/carcinoid-tumours 
http://www.livingwitherythromelalgia.org/photo/182?context=latest 
https://www.mdguidelines.com/polycythemia-vera 
http://www.healthboards.com/boards/rosacea/707625-some-questions-polythemia-vera-sp-3.html
http://www.medicinenet.com/mixed_connective_tissue_disease/article.htm
http://www.the-dermatologist.com/article/3004
http://www.medhelp.org/posts/Thyroid-Disorders/shoulder-pain-and-flushing-sensation-with-hypothyroid/show/1142746
http://www.healthboards.com/boards/thyroid-disorders/292367-red-flushed-hot-face-thyroid.html
http://www.thyroid.org.au/Information/disorders.html
http://www.nlm.nih.gov/medlineplus/ency/article/000356.htm
http://www.healthline.com/health/photosensitivity#Types
http://dermnetnz.org/reactions/photosensitivity.html
http://en.wikipedia.org/wiki/Photosensitivity
http://en.wikipedia.org/wiki/Postural_orthostatic_tachycardia_syndrome
http://photographingpots.wordpress.com/tag/autonomic-dysfunction/
http://www.patient.co.uk/health/postural-orthostatic-tachycardia-syndrome
http://hyper.ahajournals.org/content/45/3/385.full
http://www.wisegeek.com/what-is-harlequin-syndrome.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699916/
http://www.parotid.net/freys-syndrome-treatment-surgery.php
http://www.sweathelp.org/en/where-do-you-sweat/other-sweating/gustatory-sweating.html
http://www.healio.com/endocrinology/news/print/endocrine-today/%7B6c614ea4-a89d-40d6-899c-852a148b3fde%7D/mamas-boy-has-hypogonadism
http://www.expertconsultbook.com/expertconsult/op/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-1-4160-4096-5..50054-X--cesec25&isbn=978-1-4160-4096-5
http://www.ncbi.nlm.nih.gov/pubmed/8945484
http://www.mayoclinic.org/diseases-conditions/pheochromocytoma/basics/definition/con-20030435
www.medlink.com/medlinkcontent.asp
http://en.wikipedia.org/wiki/Brunner_syndrome
 

 

 













2 comments:

  1. Thank you for taking the time to work all this out. it seems like a big job. I feel it is so helpful, as you combine this scientific approach with personal first hand experience and offer rosacea sufferers practical information and tips to work with. Very thorough work and its good reading something that surpasses the usual blog information How someone was miraculously cured with X/Y/Z. hope this helps people determine where their flushing might come from. Thank you!

    ReplyDelete
  2. Great post. Thanks for posting this article! It is very helpful for pregnant women. women hydration solutions

    ReplyDelete

Please email comments to scarletnat@gmail.com or add me at http://www.facebook.com/scarlet.nat.3