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The Red Face and Its Management

G.D. Schachter, MD
Division of Dermatology, Sunnybrook & Women’s College Health Science Centre, Toronto, Canada

The Problem(s)

Red face is commonly seen, can be transient and come and go (flushing), or be persistent. Sometimes it can be scaly (dermatitis), or there may be papules and pustules (rosacea) present. Red face is occasionally seen in infants or neonates.

Flushing/Blushing

  • Transient redness of face and/or neck and upper trunk due to vasodilatation
  • Blushing is flushing due to emotion.

Causes of Flushing

  • Emotional (blushing)
  • Menopausal
  • Neurologic
    • e.g., migraine, Parkinson’s disease
  • Foods and food additives
  • Drugs
    • Vasodilators including alcohol
    • Calcium channel blockers
    • Corticosteroids
  • Systemic Disease
    • Carcinoid
    • Pheochromocytoma
    • Mastocytosis
    • Cushing’s syndrome
    • Polycythemia vera
    • Hyperthyroidism
  • Rosacea
    • Persistent and transient

Common Causes of Red Face

  • Rosacea (erythema, papules, pustules, telangiectatic vessels, swelling, rhinophyma)
  • Acne
  • Seborrheic Dermatitis (other types of dermatitis or psoriasis are less common)
  • Emotions
  • Menopause
  • Sunburn
  • Keratosis Pilaris
  • Systemic Lupus Erythematosus (SLE) (less common)
  • Dermatoheliosis/photoaging
  • Psoriasis

Important Questions to Ask

  • Does the redness come and go or is it persistent?
  • Is it exacerbated by temperature change, food, drugs, or emotions?
  • Are there visible vessels on the face?
  • Is there scaling in addition to redness?
  • Is this acne-like with papules and pustules?
  • Any symptoms? (e.g., itchy with dermatitis)
  • Is the patient menopausal?
  • What creams are being applied to the face?
  • Are other areas of the body involved?
  • Is flushing more generalized?
    • Systemic causes
    • Superior vena caval obstruction

Make a Diagnosis

  • History
    • Food, drugs, other diseases
    • Physical exam
  • Acne-like, suggestive of rosacea
  • Scaly eyebrows and sides of nose, suggestive of seborrheic dermatitis
  • Butterfly distribution of acne, suggestive of SLE
  • Other areas involved, suggestive of:
    • Psoriasis (nails, scalp, extensor limbs)
    • Keratosis pilaris (upper arms)
    • Atopic dermatitis (other atopic features)

Acne and Rosacea

Acne can be confused with, or coexist with, rosacea particularly in fair-skinned individuals. In some of these patients topical retinoids can be irritating and increase redness. Anecdotally, topical gels combining benzoyl peroxide and antibiotics, e.g., clindamycin 1% + benzoyl peroxide 5% (BenzaClin®); erythromycin 3% + benzoyl peroxide 5% gel (Benzamycin®) and 1% clindamycin phosphate + 5% benzoyl peroxide (Clindoxyl®) may be helpful.

Treatment of Red Face

  • Camouflage make up (Cover Fx®, Covermark®, Dermablend®, Dormer®)
  • An esthetician may be helpful
  • Stop the flush:
    • Clonidine, 0.05mg, twice daily
    • Treat other symptoms, e.g., scaling/dermatitis
    • Weak, non-fluorinated topical steroids for short term flare
    • Moisturize with non-comedogenic products
  • Control
    • Hydrocortisone 1%, (Desonide®)
    • Topical calcineurin inhibitors
    • Tacrolimus (Protopic®), Pimecrolimus (Elidel®)
  • Rule out underlying disease, e.g., SLE, carcinoid

Red Face in Infants or Neonates

Vascular Abnormality

  • Hemangiomas
  • Port wine stain/nevus flammeus
  • Vascular malformations

Inflammatory

  • Dermatitis
    • seborrheic
    • atopic
  • Keratosis Pilaris
  • Uncommon: acute contact dermatitis, psoriasis, erythroderma, etc.

Treatment of Rosacea

Treatment of Rosacea (Acne-like features and flushing)

  • Keep cool
  • Topical applications
    • Metronidazole cream (Noritate® 1%; MetroCream® 0.75%), lotion (MetroLotion® 0.75%), gel (MetroGel® 1%)
      • A cornerstone for the treatment of rosacea
    • Sulfacetamide sodium (Sulfacet-R® 25g, Novacet® 30g and 60g generic)
    • Rosacure®, Rosaliac®
  • Non-comedogenic make up and cosmetic products
  • Systemic medications
    • Tetracycline, doxycycline, minocycline
    • Clonidine
    • Isotretinoin (Accutane®)
  • Stop topical corticosteroids
  • Trigger avoidance: Avoid hot foods, fluids, alcohol, spicy foods
  • Sunscreen use
  • BLU-U® + photodynamic therapy (Levulan®)

Treatment of Rosacea (flushing, erythema, telangiectatic vessels)

  • Lasers
    • Pulse dye
    • ND:Yag
    • KTP
    • CO2, Erbium-Yag for rhinophyma
  • Intense Pulsed Light (IPL)

Note: One can treat the entire red face with laser or IPL, or one can trace out only the prominent vessels by laser.

Treatment of Infants, Children With Red Face

Vascular Abnormalities

  • • May need workup for underlying abnormalities.
  • • Laser, e.g., pulsed dye for port wine stain and some hemangiomas
  • • Rapidly growing hemangiomas require expert assessment and treatment.

Inflammatory

  • Mild topical steroids for dermatitis

Key Points

  • Make a diagnosis and follow up for results of treatment
  • Many of these causes are common, e.g.,
    • Rosacea
    • Seborrheic Dermatitis
    • Emotions and menopause
    • Flushing
  • Take a good history
    • Drugs, foods, and food additives
  • Look for other underlying diseases.
  • Camouflage redness while deciding on diagnosis and treatment.
  • Definitive treatment (topical, systemic, or laser/IPL) may be lengthy and involve several treatment sessions (laser/IPL) and/or several modalities.
  • Redness may occur and require additional treatment in the future (topical, systemic, laser/IPL).