How do you manage patients with chronic flushing that do not respond to beta-blockers?

Firstly, I like to make sure the cause of flushing isn't something systemic like carcinoid, mastocytosis, or paraneoplastic.

If the patient does have rosacea, I like to get the inflammatory part of rosacea under control with topicals like azelaic acid, a topical TCI (like Elidel), or topical ivermectin or oral medication (low dose doxy or ivermectin). Treating even the subclinical inflammation in the absence of papules and pustules can help with facial redness.

If the flushing is from rosacea or dilated vasculature, laser surgery can be very helpful. I always say it is not just a one-and-done treatment and may need yearly or biyearly treatments to help sustain a result.

I also like topical oxymetazoline, a vasoconstrictor, that can help wi...