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).

Division of Dermatology, Sunnybrook & Women’s College Health Science Centre, Toronto, ON, Canada

The Disease

Psoriasis is a chronic, unpredictable, T cell mediated, inflammatory, papulosquamous
condition that affects approximately 2%-3% of any population.

• The average age of onset is mid- to late-20s, although onset may occur at any age.
• Psoriasis is characterized by accelerated proliferation of epidermal cells (keratinocytes), vascular proliferation, and an influx of inflammatory cells (neutrophils, macrophages, and activated T cells).
• Involvement of the scalp may be minimal (few plaques) or more significant. The entire scalp can be involved.
• Hair loss may be seen with significant involvement of the scalp, and is non-scarring. Hair should regrow when the psoriasis clears.

Areas Affected

Psoriasis affects the skin, especially extensor surfaces and also the scalp, body folds, and nails. The scalp may be the most frequently involved area. Approximately 15%-30% of patients have an associated arthritis.

Cause

There is a genetic basis to psoriasis with an increasing risk of developing the disease if one or both parents have psoriasis. The activated T cell plays a pivotal role in the pathogenesis of the disease.

Symptoms

• Itch
• Psychosocial distress (markedly affects quality of life)
• Hair loss with severe involvement

Classic Lesion

The classic lesion is a well-demarcated, erythematous plaque with a silvery scale. When the scale is removed, bleeding points are seen (Auspitz sign). Psoriasis can develop after trauma and lesions worsen with rubbing or scratching (Koebner phenomenon).

Forms/Types of Lesions

• Chronic Plaque
• Erythrodermic
• Pustular – Localized or Generalized
• Guttate
• Inverse

Triggers

• Stress
• Hormones – Pregnancy
• Trauma
• Drugs – Beta-Blockers, Lithium, Anti-Malarials
• Systemic Steroid Withdrawal
• Infections – Viral and Streptococcal

Differential Diagnoses

• Seborrheic Dermatitis – common
• Lichen Planus – unlikely
• Fungal Infection – unlikely
• Lupus Erythematosus – unlikely

Scalp Psoriasis vs. Scalp Seborrheic Dermatitis

Seborrhiasis

Seborrhiasis presents with features of both psoriasis and seborrheic dermatitis. Psoriasis of the scalp is primarily treated locally with topical treatments. Systemic therapies are usually reserved for more widespread or severe forms of psoriasis.

Recalcitrant Psoriasis

Resistant or recalcitrant psoriasis of the scalp may require intralesional injections of corticosteroids, and less frequently a systemic treatment.

Treatments for Psoriasis

Topicals

• Tar
  • Coal Tar
    – Shampoo
    – Compounded with corticosteroids
  • Wood Tar
    – Anthralin (Infrequently used in North America; still popular in Europe)
• Corticosteroids
  • Lotion (e.g., betamethasone valerate)
  • Gel (e.g., fluocinonide)
  • Foam (Not available in Canada)
  • Shampoo (e.g., clobetasol propionate (Clobex®))
  • Oil and Corticosteroid (Dermasmoothe® FS oil)
• Vitamin D3 Analogues
  • Calcipotriol (Dovonex® Scalp Solution)
  • Calcipotriol + betamethasone dipropionate (Dovobet®)
• Salicylic Acid 5%-15% in mineral oil
• Shampoos
  • Tar (T-Gel® or Sebcur T®)
  • Salicylic Acid (Sebcur®)
  • Zinc Pyrithione (Dangard® or Head & Shoulders®)
  • Ketoconazole (Nizoral®) or Ciclopirox (Stieprox®)
  • Potent Corticosteroid (Clobex®/Clobetasol®)

Ultraviolet Light

• UVB
• Narrow Band
• PUVA – oral, bath, soaks
• Phototherapy (Rarely used for scalp) – Innovative “comb” to deliver ultraviolet light

Systemic Treatments

• Acitretin (Neotigason®)
• Methotrexate
• Cyclosporin – A
• Biologics
  • Alefacept (Amevive®)
  • Etanercept (Enbrel®)
  • Efalizumab (Raptiva®)

Intralesional Corticosteroid Injections (Triamcinolone / Kenalog Injections)

Combination or Rotational Treatments

Key Points

Mild-to-moderate cases of scalp psoriasis

• Gently shampoo scalp every morning (use palms NOT fingertips)
• Apply a corticosteroid gel or lotion once or twice per day
• Apply calcipotriol (Dovonex®) solution once or twice per day
• Antihistames (hydroxyzine or doxepin) at night for itching

Moderate-to-severe cases of scalp psoriasis

• Apply oil and salicylic acid or Dermasmooth FS® oil at bedtime and wear a shower cap
• Resistant plaques can be injected with Triamcinolone 2.5-4 mg/u every 3 or 4 weeks as necessary
• Antihistamines (hydroxyzine or doxepin) at night for itching

It should be noted that rarely scalp psoriasis is severe enough to require systemic agents such as methotrexate or acitretin.

Warnings

• Do not rub, scratch, pick, or brush/comb roughly.
• Treat gently.
• Do not pick off scale.
• Moisturize.
• Trauma or surgery will cause the plaques to flare (thicker, scalier plaques, larger areas).

Conclusion

Psoriasis remains a therapeutic challenge. Involvement of the scalp can be minimal (“dandruff”) or more significant and difficult to manage. Gentle treatment, reducing trauma, and treating the inflammation and pruritus will improve therapeutic results.