Journal Information
Vol. 106. Issue 5.
Pages 427-429 (June 2015)
Vol. 106. Issue 5.
Pages 427-429 (June 2015)
Resident's Forum
DOI: 10.1016/j.adengl.2015.04.014
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Facial Erythema: Keys to the Differential Diagnosis
RR - Eritema facial: claves para el diagnóstico diferencial
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N. Lamas-Doménech
Corresponding author
n.lamas.domenech@gmail.com

Corresponding author.
, H. Collgros
Servicio de Dermatología, Hospital Universitario Sagrat Cor, Barcelona, Spain
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Table 1. Flushing: Causes and the Diagnostic Tests Required.
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Facial erythema is a very common reason for consulting a dermatologist. While often a manifestation of a benign condition, in some cases it may be the first sign of a more serious disorder and specific diagnostic tests are needed to rule out these diseases. Flushing can be produced by agents acting on the vascular smooth muscle receptors or by signals sent by the vasomotor nerves. It can be episodic or persistent. Episodic flushing is usually caused by endogenous vasoactive mediators or medication. Persistent flushing is caused by successive episodes over long periods, which eventually lead to the appearance of telangiectasias and enlarged vessels with slow-flowing deoxygenated blood.1Table 1 shows the most common benign causes of flushing as well as other less common and potentially serious causes.2 The first step is to determine whether the patient's clinical history and a careful physical examination provide sufficient information to guide the diagnosis. If they do, we only have to decide whether or not additional tests are required to confirm the suspected diagnosis. Once the diagnosis is confirmed and the cause established, we can decide on an appropriate treatment. In more complex cases, the patient should keep a diary for 2 weeks and record when flushing occurs, the symptoms, any association with other symptoms (diarrhea, bronchospasm, headache, low blood pressure, tachycardia, abdominal pain, urticaria, or pruritus), and any external triggers (food, beverages, drugs, alcohol, exercise, emotions, stress, or occupational exposure). The data collected may provide the key to a suspected diagnosis, which can then be confirmed by the appropriate diagnostic studies. When the results obtained do not point to a possible cause or when the investigations undertaken do not support the suspected diagnosis, a more comprehensive battery of tests must be ordered to rule out the more common serious causes of flushing (Table 1). The recommended first step is to measure plasma levels of serotonin, tryptase, chromogranin A, and histamine and 24h-urine levels of 5-hydroxyindoleacetic, vanillylmandelic acid, norepinephrine, metanephrines, and prostaglandin D2. In the presence of elevated values, the suspected diagnosis would be carcinoid syndrome, pheochromocytoma, or mastocytosis.3 If the results are within normal limits, we would then check for the presence of the following: hematuria, which would be indicative of renal cell carcinoma; elevated vasoactive intestinal peptide, which would suggest pancreatic carcinoma; elevated calcitonin, which would point to a possible medullary thyroid carcinoma. If an anaphylactic reaction is suspected, we would measure immunoglobulin E or perform a skin prick test for a specific substance. If the findings do not clearly support a particular diagnosis, the next step should be to investigate the less common causes, such as anxiety, psychiatric disorders, idiopathic flushing, and mast cell activation syndrome.4

Table 1.

Flushing: Causes and the Diagnostic Tests Required.

  Tests Required 
Common Causes
Benign causes
Emotions   
Temperature   
Food and drinks   
Rosacea
Menopause  Follicle-stimulating hormone (plasma) 
Fever   
Alcohol   
Less Common, Serious Causes
Carcinoid tumor  5-Hydroxyindoleacetic acid (24-h urine) 
Pheochromocytoma  Metanephrines, norepinephrine, epinephrine, dopamine, and vanillylmandelic acid (24-h urine) 
Mastocytosis  Plasma tryptase (persistently elevation), n-methyl histamine, prostaglandin D2 (24-h urine) 
Anaphylaxis  Specific immunoglobulin E, skin prick test, elevated plasma tryptase during episode 
Other causes
Medullary thyroid carcinoma  Plasma calcitonin 
Pancreatic Tumor (VIPoma)  Plasma vasoactive intestinal peptide (VIP) 
Renal cell carcinoma  Hematuria and radiologic evidence 
Psychiatric disorders   
Idiopathic flushing   
Neurologic   
Parkinson   
Migraine   
Multiple sclerosis   
Trigeminal disease   
Horner syndrome   
Frey syndrome   
Autonomic epilepsy   
Autonomic hyperreflexia   
Orthostatic hypotension   
Streeten syndrome   
Mast cell activation syndrome   
Medication   
Rare causes
Sarcoidosis, mitral stenosis, gastric dumping syndrome, arsenic poisoning, ciguatera poisoning, POEMS syndrome, bronchogenic carcinoma, malignant histiocytoma, malignant neuroblastoma, malignant ganglioneuroma, preaortic surgery, Leigh syndrome, Rovsing syndrome   

Source: Izikson et al.2; Lafont et al.4

We currently have symptomatic treatment at our disposal: brimonidine tartrate 0.5% gel. This topical treatment, which has been shown to be safe and effective in controlled clinical trials and has recently become available in Spain, can help to control flushing and improve the patient's quality of life.5

The dermatologist plays a key role in the diagnosis of patients with flushing, since correct management may have implications for the morbidity and mortality of the condition.

References
[1]
J.Q. Del Rosso.
Advances in understanding and managing rosacea: Part 1: Connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema.
J Clin Aesthetic Dermatol, 5 (2012), pp. 16-25
[2]
L. Izikson, J.C. English 3rd, M.J. Zirwas.
The flushing patient: Differential diagnosis, workup, and treatment.
J Am Acad Dermatol, 55 (2006), pp. 193-208
[3]
M. Yuste-Chaves, P. Unamuno-Pérez.
Alertas cutáneas en malignidades sistémicas (parte I).
Actas Dermosifiliogr, 104 (2013), pp. 285-298
[4]
E. Lafont, H. Sokol, M.E. Sarre-Annweiler, E. Lecornet-Sokol, S. Barete, O. Hermine, et al.
Étiologies et orientation diagnostique devant un flush.
Rev Med Interne, 35 (2014), pp. 303-309
[5]
J. Fowler Jr., M. Jackson, A. Moore, M. Jarratt, T. Jones, K. Meadows, et al.
Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: Results of two randomized, double-blind, and vehicle-controlled pivotal studies.
J Drugs Dermatol, 12 (2013), pp. 650-656

Please cite this article as: Lamas-Doménech N, Collgros H. RR - Eritema facial: claves para el diagnóstico diferencial. Actas Dermosifiliogr. 2015;106:427–429.

Copyright © 2014. Elsevier España, S.L.U. and AEDV
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