Facial Rosacea:
Progression of the Disorder

I.  Introduction

II.  Facial flushing can worsen over time

III.  Repeated flushing causes vascular hyper-responsiveness

IV.  Repeated flushing causes structural changes to blood vessels

V.  The vicious cycle: Stuctural changes lead to more flushing

VI.  Flushing disorders and rosacea

VII. References

I.  Introduction

Why does the innocent, transient flushing of pre-rosacea sometimes advance into the fire-red, long-lasting flush of the more severe stages? Although the exact cellular reasons are not yet fully understood, vascular specialists believe that flushing progressively worsens due to vascular changes that take place in areas of frequent flushing (i.e., hyper-responsiveness and structural damage). As vascular hyper-responsiveness and structural damage progress, bouts of flushing become more intense and longer lasting.

II.  Facial Flushing can worsen over Time

Medical experts stress that repeated flushing can worsen over time in some rosacea sufferers. Below are some important references on this important topic:

• Drs. Ellis and Stawiski stress that repeated flushing of any origin can exacerbate the underlying vascular disease, making subsequent flushing and rosacea symptoms much worse. (22)
  
  
• Dr. Greaves emphasizes that repeated flushing can lead to vascular changes, which in turn, can worsen the intensity and duration of subsequent flushing episodes. (23)
  
  
• Medical experts indicate that facial blushing can intensify over time due to vascular changes that take place in the face. (13)

Below are several medical case studies demonstrating the progressive nature of facial flushing and rosacea:

• In the first case report, medical physicians examined a rosacea sufferer with a 5-year history of flushing. (24) The patient reported that facial flushing started out quite innocently; exposure to warm environments caused a red, blotchy discoloration on his left cheek. Over time, the flush slowly spread to the other cheek, chin, nose, and forehead. As it worsened, the patient began to experience skin tingling and pulsatile sensations (due to large increases in blood flow through the affected skin). Upon examination the physicians found that the patient's facial blood vessels were so reactive that any mild trigger resulted in severe facial flushing that lasted for several hours. The physicians noted that these flushing episodes continued to worsen despite the patient's otherwise normal health.
  
  
• In a second case report, physicians evaluated a 60-year old white female with a 7-year history of frequent flushing to hot drinks and emotions. (24)  Over the years, her flushing episodes became more frequent and intense, advancing to the stage of permanent redness. Physicians reported that her flushing progressively worsened despite her perfect health.
  
  
• In a third case report, physicians examined a 58-year old white man with a 9-year history of facial flushing. (24) The patient indicated that flushing was triggered by hot food and temperature changes. The intensity and duration of the flushing worsened over this 9-year period, eventually causing permanent facial redness and inflammation. Physicians noted that facial flushing worsened despite the patient's clean bill of health.

In moderate to severe rosacea sufferers, facial flushing can become frequent, intense, and long lasting:

• In a National Rosacea Society survey of 2,083 rosacea sufferers, rosacea flushing (flare-ups) was reported in a whopping 1,813 rosacea sufferers (87%).    In 46% of the sufferers, flushing episodes lasted for over a week. In this survey, 64% of the sufferers reported their flushing as moderate to severe. (25)
  
  
• In a recent clinical study, 10 patients reported daily debilitating flushing attacks. The physicians who examined these patients noted that some of the flushing episodes were extremely long in duration -- lasting for up to two days. (26)
  
  
• In a study of 62 rosacea patients, one-third of the sufferers reported severe bouts of flushing, three or more times a day! (2)

Let's now discuss in detail the effect that frequent flushing has on blood vessel responsiveness/structure and its impact on subsequent flushing episodes.

III.  Repeated Flushing Causes Vascular Hyper-Responsiveness

Normal blood vessels dilate to a wide variety of substances circulating in the blood stream, and released from nearby skin and nerve cells. Normal blood vessels can also produce dilator substances from within their own walls. Studies have shown that repeated flushing can enhance production of dilators from within the blood vessel wall resulting in exaggerated dilation and prolonged skin flushing:

1. Repeated flushing causes blood vessels to be more sensitive to triggers by changing the threshold for production of dilators from within their walls. (27, 28)  In effect, blood vessels dilate more easily because they now release dilator substances much more quickly.
   
   
2. Repeated flushing causes blood vessels to open up much wider to flushing triggers by increasing the concentration of dilator substances produced from inside their walls. (27-29), (30, 31)   In effect, blood vessels dilate to a much greater extent because they now release a greater concentration of dilator substances.

IV.  Repeated Flushing Causes Structural Changes to Blood Vessels

Vascular specialists indicate that repeated flushing can also damage or change the structure of the blood vessel wall:

• In an excellent medical chapter, "Flushing, Flushing Syndromes, Rosacea, and Perioral Dermatitis", Dr. Greaves indicates that repeated flushing over a prolonged period of time can cause structural damage to the small blood vessels of the face. (23)
  
  
• In a medical article, "Rosacea: A Chronic Disease of the Skin which, if not Treated, can Cause Permanent Damage", physicians stress that facial flushing can cause serious permanent damage to facial blood vessels. (32)
  
  
• Other experts state, "Every stimulus that is capable of causing skin redness, is a stimulus capable of causing local damage. Such injury has an effect upon the functioning of single cellular elements (i.e. blood vessels) which can be damaged or destroyed." (33)
  
  
• Dr. Panconesi indicates that frequent blushing can lead to structural damage of facial blood vessels and permanent facial redness. (13)
  
  
• Several experimental studies demonstrate that repeated flushing can damage the inside of the blood vessel wall. (34-38)

V.  The Vicious Cycle: Structural Changes then lead to more Flushing

Vascular specialists warn that blood vessel damage and growth of new blood vessels can make flushing much worse because the vessels that are present are now structurally weak, and are in greater numbers. This is directly relevant to rosacea flushing because all of these changes have been shown to occur. (1, 8, 40-46)

VI.  Flushing Disorders and Rosacea

Medical experts point out that systemic diseases that cause facial flushing, such as carcinoid syndrome, mastocytosis, and pheochromocytoma, can cause structural damage to facial blood vessels. (8, 47, 48)  Over time, these vascular changes can worsen the intensity of facial flushing. These patients (who usually have no predisposition to rosacea), sometimes show all the classic symptoms of rosacea -- facial redness, telangiectasia, inflammatory papules, and rhinophyma. (8), (47), (48)  These findings demonstrate the importance of facial flushing to the progression of rosacea symptoms, no matter what the cause of flushing.

VII. References

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