8.1 Red Face

Common skin symptom of several diseases. Within the spectrum rosacea represents 81% of the patients with red face. Prevalence of rosacea 10% and of seborrheic dermatitis 1-3% (young adults 7%). Others are atopic dermatitis and acute and chronic contact dermatitis, psoriasis, T-cell lymphoma, sunburn or autoimmune diseases, histamine induced flushing in mastocytosis or diamino oxidase deficiency, allergic drug reactions, PDE 4 drugs, systemic diseases with varying prevalence.

Although regarded as a simple finding, the condition may provide important health information. Everyday causes of minor temporary facial flushing include exogenous physical stimuli (mechanical irritation, heat, cold, sunlight, exercise, sexual act, alcohol, spicy foods or drugs) or endogenous ones (embarrassment, anger). A persistent red face may be:

• the major sign of a clinically distinct entity, such as eczema / contact dermatitis (most common), photo-contact dermatitis or long-term use of topical steroids,

• a manifestation of a particular skin disease, such as seborrheic dermatitis, rosacea, autoimmune diseases such as SLE, T-cell lymphoma, mast cell diseases, histamine induced flushing in mastocytosis or diamino oxidase deficiency, allergic drug reactions or infections,

• a sign of an internal disease, such as carcinoid tumor, cardiac or hematological diseases, sarcoidosis or diffuse mast cell diseases incl. malignant forms,

• drugs, or

• a sign of a rare disease.

In addition to erythema, warmth, edema, infiltration, teleangiectasias, scaling, serum exsudate, vesicles, crusts, lichenification and/or purple discolouration may occur depending on the etiology.

nflammatory skin diseases

• Facial allergic/toxic/irritant dermatitis: In acute cases ill-defined facial erythema, crusts and vesicles and in chronic cases skin lichenification.

• Seborrheic dermatitis: Erythematous areas in the nasal folds, easily spread to the surrounding areas, glabella, inner part of the eyebrows and along the frontal hairline (corona seborrheica) with overlying, non-adherent, yellowish greasy scales.

• Facial psoriasis: Erythema rather than thick erythemato-squamous plaques that characterize this condition elsewhere on the body.

• Acrodermatitis enteropathica: Centrofacial erythema, scaling.

• Rosacea: Frequent episodes of flushing followed by persistent erythema and telangiectasia in the center of the face (telangiectatica), which may proceed in a minority of erythrotic patients (19%) to formation of papules and pustules (papulo-pustulosa) and even nodules (rhinophyma; phymatous), conjunctivitis (ophthalmica) and mild facial edema persistent after successful treatment (Morbihan disease).

• Lichen planus actinicus: occasionally facial erythema.

• Erythroprosalgia: Flushing erythema with pain.

Infectious dermatoses

• Erysipelas: Well defined erythematous swelling without epidermal involvement.

• Acrodermatitis chronica atrophicans: Occasionally ill-defined livid coloured patches on the face.

• Mycobacterial infections (lupus vulgaris, leprosy).

1. Lupus vulgaris (commonest form of skin tuberculosis): One or a few well demarcated reddish brown patches containing apple jelly deep seated nodules around the nose and/or on the cheeks, superficial ulceration or verrucous thickening of the skin

2. Lepromatous leprosy: Multiple erythematous

• Measles: Patchy erythema involving the face and the mucous membranes.

• Fifth disease: Patchy erythema involving the face, ears and the mucous membranes.

• Tinea faciei (incognito): Occasionally pruritic facial erythema.

Vascular malformations

• Nevus flammeus: Well defined red patch of peculiar configuration, which blanches on pressure.

• Cavernous hemangioma.

Rare dermatoses

• Keratosis pilaris atrophicans (ulerythema ophryogenes): Facial erythema (eyebrows, cheeks), follicular hyperkeratosis, lateral eyebrow alopecia.

• Ichthyoses (bullous and non-bullous ichthyosiform erythrodermas and ichthyosis linearis circumflexa, incl. Netherton’s syndrome): Facial erythema, dry skin, lamellar thick or thin scales.

• KID syndrome (keratitis, ichthyosis and deafness).

• Photogenodermatoses (xeroderma pigmentosum, Cockayne syndrome, Bloom’s syndrome, erythropoietic protoporphyria, Hartnup disease): Early permanent facial erythema.

• Tuberous sclerosis.

Sign of internal diseases/disorders/conditions

• Exercise, embarrassment, anger, stress, anxiety, guilt, pregnancy, peri-menopause, heatstroke, sunburn, x-ray, UVB, wind, cold/heat exposure, sexual act, fever: Temporary/ transient erythema

• Cutaneous T-cell lymphoma (erythroderma): Permanent erythema.

• Hodgkin’s disease, hyperthyroidism, chronic oxygen deprivation, polycythemia, leukemia, pheochromocytoma, carcinoid tumor, carcinoid syndrome,

• Systemic mastocytosis: Flushing erythema.

• Deaminodesoxidase deficiency: flushing erythema

• Autoimmune disorders

1. Systemic lupus erythematosus: Butterfly erythema or discrete maculopapular eruption with fine scaling on the butterfly area.

2. Dermatomyositis with or without myositis (dermatomyositis sine myositis): Heliotrope or dusky red facial erythema.

3. Maxillary sinusitis, mitral valve stenosis: Livid erythema with plethoric facies.

4. Sarcoidosis: Granulomatous centrofacial (nasal) infiltrate (lupus pernio).

Drugs and toxins

• Alcohol ingestion: Transient or permanent erythema (with unpleasant feeling after disulfiram administration). Flushing under concomitant intake with cephalosporins, griseofulvin, metronidazole, and sulfonylureas.

• Rubeosis diabeticorum (alcohol and chlorpropamide): Occasionally periorbital erythema with spreading to the temple.

• Vancomycin i.v.: Red man syndrome.

• Ciclosporin: Occasionally flushing with anaphylactic symptoms.

• Rifampicin overdose: Glowing red face in children.

• Calcium channel blockers (nifedipine, verapamil, diltiasim), quinidine,

• Vasodilator drugs (nitroglycerine, amyl nitrite, butylnitrite, PDE5 antagonists), opiates, cholinergic drugs, contrast media: Flushing.

• Steroid-induced rosacea: Rebound phenomenon of intense redness, scaling, crusting and sometimes pustulation following discontinuation of steroids after long-term topical use.

• Steroid-induced Cushing: Permanent erythema after long-term administration of systemic corticosteroids.

• Food ingestion

• ◦ Allergic or pseudoallergic reactions to food allergens (peanuts, egg, fish, walnuts), sulfites, monosodium glutamate, tartrazine, scombroidosis (and other seafood poisoning): Rapid onset (minutes) of flushing, bronchospasm and hypotension (sulfite reaction). Erythema, burning, pressure in the face, neck, and upper chest (monosodium glutamate in chinese food). Facial erythema and swelling (Quincke edema), bronchospasm and urticaria (aspirin intolerance, tartrazine sensitivity). Flushing, urticaria, pruritus, gastrointestinal complaints, or bronchospasm (scombroidosis, ciguatera or other seafood poisoning). Facial erythema, severe headache or hypertension [naturally occurring amines, such as tyramine (cheese, red wine) and phenylethylamine (chocolate).

Depending on differential diagnoses: skin biopsy, allergy skin testing, photo-patch testing, RAST, serum zinc, blood leucocytes, blood neutrophils, erythrocyte sedimentation rate, TBC-PCR, herpes simplex virus-PCR, morbillivirus-PCR, human parvovirus B19-PCR, deaminooxidase and histamine. tryptase, alcohol and drugs concentration in serum, dermatophyte culture, Sézary cells in blood, lymphocyte sub-populations. ANA, ENA, complement, ACE, IL2 receptor.

Dependent on the facial localisation and classification of erythema, additional symptoms, case history and results of skin biopsy and clinical and laboratory test.

Facial flushing often represents a complaint for the patient. However, depending on the course and intensity it requires treatment by dermatologists.

Depending on the pathogenesis of the many different differential diagnoses a causative or symptomatic treatment is possible. Together with the specific treatment of the provoking disease and the avoidance of contact with responsible exogenous agents, the recent widespread use of cosmetics with permanent over the day colouring may be helpful. Avoidance of blood flow and vessel width provoking agents, hyperthermia and other physical and chemical exogenous and endogenous factors a quite successful prevention is achievable.

Facial erythema can further be symptomatically improved by brimonidine tartrate, an alpha 2-adrenergic receptor antagonist administered topically in a 0.33% gel. The compound is registered for rocasea.

Further, cosmetics based on a green extract of tomatoes reduce the visibility of erythema.