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Burning and warm sensation in rash, blotchy face, not itching, taking Flexeril. Could you help me diagnose it?

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ENT Specialist
Practicing since : 1991
Answered : 2397 Questions
Attn: Dr. XXXXXXX Bhatti:

You helped me a few days ago regarding a rash that I am having and you asked for a picture. Could you please help me diagnose it? The rash does not itch, but there is a burning sensation and it feels very warm. My face also blotches up and is very warm as well. I have uploaded a picture to this message and below is a summary of our recent conversation:

I take flexeril nightly for my neck pain from fibromyalgia. I did not realize that it had an affect on histamine in my body. I take the other drugs all for my allergies but I guess that it is possible to be overkill. I will talk to my doctor regarding these medications and will ask him about your recommendations.

1. The burning in my nose and flushing is from the dryness of the environment and change of temperature? What is the cause of the tingling of my face and sinuses? Could you please explain how they affect flushing if they are supposed to be “anti-cholinergic?”

I do not have any dental caries or gum inflammation but I do suffer from GERD from time to time. I take zantac with my zyrtec everyday because I read that stopping the H2 histamine will help with the flushing. I do have 3 cats at home and one sleeps in my bedroom. My allergist says that I am allergic to cats but I am not sure if they bother me or not.

My dermatographic urticaria is new to me. I never had this trouble before. It seems even a slight scratch from my hairbrush on my face will cause a red XXXXXXX Is this usual?

2. Can dermatographic urticaria cause facial flushing and warm skin? Is it possible that I may be suffering from another type of urticaria which is causing my face to get warm and red and flush? This is what I am really concerned about. I don’t understand why I get flushed and I would like to understand more about it so when it occurs, I won’t get so anxious about it. If you could please try and explain this, I would feel much better. I can give you more information if necessary.

I do not have detailed clinical examination notes but recall my doctor telling me that my “nose was so swollen that the turbinates inside were almost touching.” That is why he prescribed the steroids. I also have a slight deviated septum on the left side of my nose. I do have some sneezing and am very stuffy and do have some nasal discharge.

3. Could you further explain the burning inside my nose when I change environments (go from cool to warm?)

4. Could you help me understand why I would flush randomly like lying in my bed—is this from histamine?

Thank you so much for your help. I really appreciate it.


Thank you for writing back,

1. Chronic cholinergic or stress induced urticaria may result from stress, sweating, changes in temperature and also explains your skin rash even when you are warm or in bed. Such rashes are typically smaller than hives or angioedema and are not considered XXXXXXX Stimulation of the parasympathetic nervous system leads to release of histamine leading to dryness, tingling, burning and flushing. It may help to see close up images of the skin rash if possible. It responds to anti-histaminics (which you are already taking like Zyrtec / cetrizine).

2. Anti-cholinergics may not always block and may even enhance this response because of the following reasons:
a. There are different types of anti-cholinergic receptors. Each drug has a different modes of action.
b. Parasympathetic suppression leads to relative over-activity of the sympathetic nervous system.
c. After a severe episode there may be temporary depletion of histamine leading to a symptom free period in spite of exposure to triggers.

3. After an allergic response as started, histamine is only one of the cocktail of substances released when mast cells burst. These include cytokines, interleukins, leukotrienes, and prostaglandins, tumour necrosis factors, SRS-A (Slow reacting Substance of Anaphylaxis) into the surrounding tissue causing dilation and leakage of blood vessels leading to flushing, mucous secretion, nerve stimulation (tingling), and smooth muscle contraction. This results in rhinorrhea, itchiness then dryness, burning and many other responses. In chronic allergy, cell mediated immunity is also involved.

4. All these factors make it extremely difficult to explain all the effects, which may seem paradoxical to you at times. Once allergy has developed, only blocking histamine will not counteract all these inflammatory mediators. The only other drugs that we have at this point in time are anti-leukotrines and steroids. This explains why we cannot control all the effects of allergy after it develops. This is where avoidance of triggers, steroid nasal sprays and sodium cromoglycate (mast cell stabilizer) are helpful.

Thank you for your help. XXXXXXX
Posted Mon, 30 Apr 2012 in Skin Rash
Answered by Dr. Sumit Bhatti 6 hours later

Thank you for sharing the image of the rash.

1. This rash is definitely not severe urticaria, hives or rosacea. This rash is like stress induced or cholinergic urticaria.

2. You must get a dermatologists opinion. The skin texture seems even, and the rash consists of small multiple units. This may be drug induced.

3. Avoidance of triggers in your case and medication along the lines suggested above should help control this problem.

I suggest that you follow up after your dermatologist's opinion.

Hope, this explains your query.

Wish you good health.

Above answer was peer-reviewed by
Follow-up: Burning and warm sensation in rash, blotchy face, not itching, taking Flexeril. Could you help me diagnose it? 7 hours later
Hi Dr. Bhatti,

Thank you for your reply. The rash definitely stings and burns but does not itch. What is the difference between cholinergic urticaria and hives? Could it be an allergic reaction to environmental allergies.

Thank you, XXXXXXX

Answered by Dr. Sumit Bhatti 16 hours later

Thank you for writing back.

1. Cholinergic or stress induced urticaria is a milder type of hives.

2. If it is an allergic reaction to environmental allergies, I would expect it to be on the exposed skin and not skin areas covered with clothes. In any case it should respond to non-sedating anti-histaminics and anti-leukotrienes as mentioned above.

3. Omalizumab is a Monoclonal Antibody which may help if everything else fails, with high cost and due risk though.

Please discuss this with your physicians.

Hope this helps to solve your doubts. Wish you good health.

Above answer was peer-reviewed by
Follow-up: Burning and warm sensation in rash, blotchy face, not itching, taking Flexeril. Could you help me diagnose it? 17 hours later
Dr. Bhatti,

Thanks for your responnse. Often times I will wake up with a red hot cheek if I have been ssleeping on that cheek. Do allergies also cause this? I know we have talked a lot about allergies and you have explained things very well. What causes the warm cheek from laying down on it?

Answered by Dr. Sumit Bhatti 9 hours later

Thank you for writing back.

1. Temperature change on contact of the cheek with the pillow can trigger heat induced urticaria. Pressure on a large amount of delicate facial skin may be another cause. This may also explain why it may not occur easily on the scalp, body and limbs, where the skin is thicker.

2. Another possibility is contact urticaria, which may not be itchy and will be short lasting as compared to contact allergic dermatitis which will itch a lot, resemble full blown hives and may last for many days.

3. You must change pillows, pillow covers, detergents and use anti-dust mite covers to confirm whether it is contact urticaria or contact dermatitis to an allergen and whether it can be controlled.

Unfortunately, there is no cure. However with the above mentioned measures and medication, you will be able to control your condition. Remember to let me know the dermatologist's opinion.


Above answer was peer-reviewed by
Follow-up: Burning and warm sensation in rash, blotchy face, not itching, taking Flexeril. Could you help me diagnose it? 7 hours later
Dr. Bhatti,

​Thank you for your response.

​i change my pillowcase every other day so I doubt that it could be contact dermatitis, but I guess always a possibility. it seems like when I have my cheek pressed against my pillow, it heats up and turns red. It burns a little. I do not think that it is rosacea because I have the same sensations on other parts of my body, one being my chest and you said the chest rash does not look like rosacea.

​It does sound like contact urticaria because it is short lived. Because I do have dermatographic urticaria and possibly cholinergic urticaria, I suppose that it is possible to have another form of it? Do you find it odd that I do not get full blown hives? Is this common?

​I take a lot of antihistamines.. zyrtec and zantac twice a day and benadryl. My skin has become very dry and itchy. Could this be the culprit? I also was taking steroids from a nasal infection and have been advised that my skin may be acting up due to the steroids. I have been off of them for 10 days but was on higher doses: 60 and 50 mgs tapering down to 0mgs in 10 days. I guess my adrenal glands may not be back to normal yet?

​What is Omalizumab?

​Thank you for your continued help. I just want to feel better.
Answered by Dr. Sumit Bhatti 8 hours later

Thank you for writing back.

1. Different forms of urticaria can co-exist.

2. Urticaria as against full blown hives is common, especially if you are on so many forms of anti-histaminics. They tend to modify the response. Differing levels of stress also modify the response at different times to the same stimulus.

3. The is a mechanism of 'competitive inhibition' of histamine receptors with these multiple drugs. The final result is difficult to predict unless your physicians review your medication. Avoid self medication.

4. Dry skin and excoriation (due to itching) makes matters worse. Moisturizers and barrier creams may help. However blockage of sweat pores may be a problem (which may cause the skin to heat up).

5. There is an HPA Axis (Hypothalamus-Pituitary-Adrenal Axis) which is suppressed by large steroid intake. Steroids are essential for life. Steroids are produced daily by the adrenal glands under the influence of the hypothalamus and pituitary gland. As the steroid intake surpasses the local adrenal production of steroids, XXXXXXX production is suppressed. A short term tapering dose of steroids should not be a problem.

6. Omalizulab is an injectable Monoconal antibody, a new recent class of drugs. Before you look at Omalizulab, take a supervised trial of oral medication such as Montelukast, Zafirlukast or Zileuton, preferably in this order (along with your other medications).

Urticaria is a clinical diagnosis and lab tests rarely uncover any cause.

Hope, this helps to solve your query.

Wish you good health.

Above answer was peer-reviewed by
Follow-up: Burning and warm sensation in rash, blotchy face, not itching, taking Flexeril. Could you help me diagnose it? 17 hours later
Dr. Bhatti,

Thank you for your response. Any idea what causes this burning itch on my face that comes and goes. Sometimes my face feels warm. My nose is stuffy at times. There is no visible rash on my face most of the time when this occurs. It is very irritating. Sound like allergies?

Answered by Dr. Sumit Bhatti 12 hours later

Thank you for writing back.

1. As I have explained earlier, there are many mediators of inflammation and allergy which are released and there is no antidote to many of these. Some act over days to weeks. Therefore, once allergy or inflammation develops it is more difficult to control.

2. That is why you need to take a long term course of anti-allergics, mast cell stabilizers and avoid challenge to known triggers for some time. A trial of desensitization therapy is only possible with specific allergens.

3. All this means that you may be in a continuous series of waves of urticaria which overlap at times, or in intervals where there is histamine depletion, but not the other mediators of inflammation and allergy which creates refractory periods of time where there is no strong response; only a mild discomfort.

4. It may also be important to look at minor deficiencies of vitamins and minerals which can aggravate your discomfort. There is bound to be a psychological overlay in your case, where you expect an attack well in advance. Stress and psychosomatic influence on urticaria and allergy are seen in a majority of patients (up to 70 %) however they cannot be quantified.

5. Have you had an opportunity to try out traditional herbal remedies? I recommend Neem (Azadirachta indica), Tulsi (Holy Basil) and Turmeric (Cucurmin). You will have to read more about the various forms in which these herbal extracts are effectively used.

It would be interesting to know your response to the different treatment strategies that I have recommended over the past few days. Hope you get satisfactory relief from your distressing symptoms.

Above answer was peer-reviewed by
Follow-up: Burning and warm sensation in rash, blotchy face, not itching, taking Flexeril. Could you help me diagnose it? 35 hours later
Hi Dr. Bhatti,

​I will try some of the herbal remedies that you recommened. I just wish that I could find something to help my tight, dry skin. Is it normal for skin to feel tight and itchy in the fall/winter months after being outside in cooler weather? The skin on my face just feels so uncomfortable. I know that a lot of this could be allergies, I just feel so itchy and and icky. It's hard to explain, really.

​I do know that anxiety plays a huge part in this. I anticipate feeling bad so then I do. I am working on this aspect of it all, but it isn't easy. I plan to ask my doctor for a beta blocker to help me with my worry about turning red. Is there one that you recommend?

Thank you, XXXXXXX
Answered by Dr. Sumit Bhatti 10 hours later

Thank you for following up.

1. It is normal for skin, especially delicate facial skin to feel tight, dry and itchy as cold weather has a desiccating (drying) effect. Without moisturizers, it is almost impossible to keep skin supple. Added to this is your skin 'atopy' which makes your skin feel uncomfortable.

2. Beta blockers have been used safely for many decades by individual patients. Remember that they do have side effects. A mild anxiolytic may also help instead. However, all the medications should be taken under the supervision of your physician. I would recommend only short term use, in any.

Have you scheduled your dermatologist's visit?

Hope, this answers your query.

Wish you good health.

Above answer was peer-reviewed by
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