Hi

Thanks for the query

The flushing of the face could be due to the following reasons:
1. Use of high dose of steroids
2. Acute sinusitis

Please do not worry; you seem to be having features of Allergic Rhinosinusitis with active infection. Allergic Rhinosinusitis is a condition of the nose characterized by nasal block, discharge from the nose, headache, sneezing with or without fever.

Oral steroids are indicated in those conditions refractory to the normal treatment regimen. Ideally, the oral steroids are given for 3-4 days and usually combined with the regular medicines such as an antibiotic, mucolytic, steroid nasal spray and saline nasal spray. Oral steroids alone can cause allergic reaction as well as the thickening of the mucus secretions and worsening of sinusitis. Also, you need to get either X-ray or CT scan of the paranasal sinuses done to confirm any sinus blockage or collection in the sinuses.

Drink plenty of warm water to keep yourself hydrated and to reduce flushing of the skin. You need to do steam inhalations 2-3 times a day in order to reduce the nasal blockage, clearing of the mucus and opening of the sinuses. Avoid coffee, chilled food and beverages.

Q: Could the sinus congestion cause my eye to twitch and face to tingle and burn?

A: Twitching and tingling of the eyes is due to lack of sleep whereas the burning sensation of the eyes and face could be due to the active infection.

Q: Could anxiety alone be the cause of all of this?

A: Not exactly; anxiety alone is not the sole cause of all your problems. Your anxiety has increased because of the infection.

Hope I have answered your query; I will be available for the follow-up queries.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon

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Hi,

Welcome back.

I regret for the delayed response.

To make things more clear, using large doses of steroids for a few days, or smaller doses for more than two weeks, leads to a prolonged decrease in the Hypothalamic-Pituitary-Adrenal Axis" (HPAA) function. The Hypothalamic-Pituitary-Adrenal Axis" (HPAA) is a chain of connection involving the adrenal glands, the pituitary gland, and the hypothalamus in the brain, the production of corticosteroids is controlled by a "feedback mechanism," involving this chain. Abrupt stopping of the steroid leads to a break in this HPPA and thus the symptoms of steroid withdrawal such as irritability, flushing of face, tremors, etc. will be present.

Moreover, you had allergy for steroids also, hence it is difficult to pinpoint the exact reason because both allergy and withdrawal symptoms present with almost similar features. In case of steroid withdrawal, the body of every individual behaves in a different fashion, hence it is difficult to predict how long the effect will last; it can be there for a few days to few weeks

Q: Even though I have been off steroids for 5 days, could I still be reacting to the steroids? Is it possible that I was weaned too fast off of them? What is causing the burning, painful itch, do you think? The steroids, my allergies? Why do you think my face feels so tight? It is incredibly uncomfortable as my face also feels sore and tingly.

A: It could be more of a withdrawal symptom rather than the drug reaction alone. In general, any drug reaction will usually subside within a couple of days. Burning and itching sensation could be due to the hormonal imbalance in the body secondary to the abrupt withdrawal of the steroids. The nerve endings under the skin are inflamed and sore, hence even with mere touch, stretching of the skin or scratching there is severe irritation.

Q: What do you think is causing the warmness to my face? I know that prednisone can cause flushing, but I have been off of them for 5 days.

A: Facial flushing could be because of the hormonal imbalance following steroid withdrawal, as I mentioned before or because of the allergic sinusitis which has to be confirmed with a CT scan and a nasoendoscopic examination.

Q: Could you please explain the types of allergic reactions steroids can cause?

A: Any drug related allergy, including steroids fall under the category of Type 1 Hypersensitivity reaction involving immunoglobulin E (IgE)–mediated release of histamine and other mediators from mast cells and basophils. As you are already suffering from allergic mediated response (dermatographism), this steroid allergy would have further worsened the symptoms.

Q: why does the itching and burning worsen when I scratch it?

A: Itching or scratching will release histamine from the damaged blood capillaries leading to the irritation of the inflamed nerve endings causing burning sensation and more itching.

For the irritation and itching you can start with emollients (moisturizers). You can apply it as often as you need, at least 2-3 times a day or more if your skin becomes irritating and itchy. Also, you can continue with some potent antihistaminic such as fexofenadine which will give you some relief.

Wish you good health.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon

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Hello.

Thanks for writing back.

Q: Would you say that being on 60 mgs for a couple of days then 50 mgs are higher doses. I was only on the steroids for 10 days but like you said, using them at higher doses even just for a few days can cause to a decrease in the HPAA function? 2. Is it possible that my adrenal glands are not back to normal yet?

A: Yes, 60mg – 50 mg of prednisolone per day is quite a higher dose and 10 days of duration is quite a long period, enough to derange the HPAA. Also, there seems to be a mild dysfunction of the adrenal gland, because of the abrupt stoppage of the oral steroids.

The outer part of the adrenal gland also called the adrenal cortex produces steroid hormones that are involved in regulating a number of different body functions. So, when these hormones are suppressed by giving oral steroids, there will be disturbance in the physiology of hormonal production. And once the supplements are stopped without tapering there will be excessive cortisol and aldosterone production as a rebound phenomenon. This leads to retention of salt and water in the body and also increase of blood pressure. The water retention in turn causes facial puffiness, flushing and tightness in the skin of the face.

Q: My face also feels a bit tight and swollen. Would that also be from the hormonal imbalance? I do suppose that it could be from my sinuses as well.

A: Yes, as mentioned above, the hormonal imbalance could be the prime reason for swelling and tightness of the face. Regarding the sinuses, you need to confirm with a complete nasal examination and a CT scan of the paranasal sinuses.

Q: Can dermatographism cause facial flushing? Just wondering.

A: It is very unlikely that dermatographism can cause facial flushing.

Finally if you are not able to attach the photo to the query, you can just mail it to me at YYYY@YYYY with Sub as "Attn to Dr. Naveen Kumar N"

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon

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Hi,

Thank you for the photography. I must say that it has made my things much easier.

I also had a curbside discussion regarding this with a reputed dermatologist. The lesion in the photograph does not seem to be related to steroid withdrawal. It could be due to 'flared up' dermatographism.

My suggestions to you are
1. You may need to get Serum Immunoglobulin- E (IgE) levels checked for further management.
2. You can try taking antihistaminic (such as Fexofenadine/Levocetrizine), Mast cell stabilizers (such as Ketotifen). A dermatologist / primary physician can help in prescribing them to you.
3. Topical calamine lotion will also help in reducing the irritation.

Q: Is recovery from this a straight line or do symptoms ebb and flow?

A: Please do not worry, you will definitely recover from all the above symptoms it is just a matter of time.
But regarding dermatographism, it is difficult to get rid off as there is no cure for allergy. Consulting a dermatologist will be useful and helpful.

Thanks again for the query. I hope I was able to clarify a few issues here.

Wish you good health

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon

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