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Burning red face syndrome: a heterogeneous group of facial erythrodysaesthesias

We congratulate Parkins et al. for their case report and discussion of so-called ‘neurogenic’ rosacea. It is important to raise awareness amongst dermatologists of this symptom complex, which has been recognised for many years, although under-reported and under-researched. Prior to 2011, dermatologists used terms such as ‘facial erythrodysaesthesia’ or ‘rosacea with functional overlay’. The case series from 2011 is very interesting to scrutinise. The authors found that 12/14 patients had > 2 coexisting diagnoses that may have been contributory or sharing the same aetiology: with 6 having migraine, 4 chronic pain, 5 depression, 1 anxiety, 1 obsessive compulsive disorder, 1 bulimia, 5 Raynaud phenomenon and 4 conditions that could be termed somatoform. Attempting to make this a specific entity appear to be too simplistic. Use of the adjective ‘neurogenic’ implies one cause that does not fit with the multifactorial nature of rosacea (and many other inflammatory dermatoses). Notably, the diagnosis of neurodermatitis has gone out of favour in this regard. As the patient’s skin often appears normal between acute flares, their associated symptoms may trigger referral to a number of different medical specialists. We suggest that the diagnostic label the patient is likely to receive depends on the specialist they attend. Cognitive bias and human factors, as well as the physician’s clinical experience, will influence the chosen diagnosis. Therefore a neurologist may diagnose facial migraine and consider multiple sclerosis, while a psychiatrist may suggest depression with prominent somatic symptoms or social anxiety disorder. In a patient with parkinsonism attending a department of medicine for the elderly, the symptoms may be considered to be part of this disorder. Should the patient be attending rheumatology with systemic lupus erythematosus, a diagnosis of secondary erythromelalgia may be favoured, while if the patient attends specialist pain services, their symptoms are likely to be considered part of the chronic pain syndrome. Patients with Raynaud phenomenon may be considered to have primary vasomotor instability. As the symptom complex is nonspecific, it is impossible to reach a definitive diagnosis in many cases, and differential diagnoses will include all the entities noted above. Other accurate descriptions would be neurological flushing or somatoform burning skin. The use of ‘syndrome’ emphasises that there are likely to be many causes for the same symptom complex. We note the patient’s disproportionate sensory symptoms, distress and internet searching for a possible cure – typical findings in illness anxiety disorder. It is perhaps no coincidence that both pregabalin and duloxetine, reported to help in 7/14 patients, are also used to treat generalized anxiety disorder. We suggest that the symptom complex lies best, and is analagous to, other forms of localized cutaneous erythrodysesthesias e.g. angry red scrotum syndrome and burning red ear syndrome. We agree that a biopsychosocial approach to management is desirable, with a detailed psychiatric/psychological assessment and tailored individual therapy, keeping an open mind as to the underlying cause. The goal of treatment is to reduce pain and distress, improve functioning and well-being, and help the patient achieve a sense of control. In our view, a multifactorial management approach is most likely to succeed, and input from clinical psychology and/or liaison psychiatry are often helpful.