Facial Plethora

What Is Facial Plethora? Its Causes, Symptoms, and Treatment

By definition, facial plethora refers to a localized redness, usually caused by the increased blood volume or higher blood flow. The facial plethora itself is not a medical condition. It was described as a clinical sign of a variety of diseases since ancient times. It is one of the oldest reported clinical signs in medicine, dating back to the times of Hippocrates. [1]

Facial Plethora And Cushing Syndrome

Facial plethora is often regarded as a clinical sign of Cushing’s syndrome. It is more prevalent in people suffering from a severe case of Cushing’s syndrome. Variations in the clinical manifestation of facial plethora may exist among different patients. Certain people may be more prone to the development of facial plethora because of genetic or other predisposing factors that typically affect vascular blood circulation.

However, the pathophysiology of facial plethora in Cushing’s syndrome remains unclear. And its link to increased blood flow also remains unproven.

Facial plethora mainly resembles another condition called erythema.

One of the classic symptoms is that patients feel the tension on the face, and their facial veins will protrude. The skin also becomes highly sensitive and may be damaged even with the slightest of pressure. 

Facial Plethora Causes

As already stated, facial plethora can be caused by several conditions, Cushing’s syndrome being the most common one.

Other potential causes include:

  • Excessive Red Blood Cells
  • Familial polycythemia
  • Different drugs reactions

The body may react in such a manner to a couple of drugs, such as antimalarial therapy, including clofazimine. The infection around the eye may also cause this condition.

What Is Cushing’s Syndrome?

Cushing’s syndrome also referred to as hypercortisolism, is a medical condition characterized by abnormally high cortisol levels in the body. That may develop due to numerous different reasons.

Symptoms of Cushing’s Syndrome

Cushing’s syndrome has a few characteristic symptoms that hallmark of this medical illness. Some of the most common symptoms, other than facial plethora, include:

  • Fatigue
  • Weight gain
  • Muscle weakness
  • Fatty deposits, particularly in the face (causing a round, moon-shaped face), in the midsection of the body, and also between the upper back and shoulders (causing buffalo hump)
  • Thinning of skin that bruises easily
  • Purple stretch marks on arms, breasts, thighs, and abdomen.
  • Skin injuries that heal slower
  • Acne


Weight gain is a common sign of Cushing’s syndrome. | Image: Freepik.com

Other than these symptoms, some other clinical symptoms may be observed in some people suffering from Cushing’s syndrome. These may include:

  • Increased thirst
  • A high blood glucose level
  • Hypertension
  • Osteoporosis
  • Increased urination
  • Anxiety
  • Headache
  • Irritability
  • Mood swings
  • Higher incidence of infections
  • Depression

Specific Manifestation of Cushing’s Syndrome In:

1. In Men

Some of the specific symptoms men experience in contrast to women and children are as follows:

  • Decreased fertility (seek help from an IVF or ICSI treatment centre)
  • Loss of sexual interest
  • Erectile dysfunction

2. In Women

According to the NIH, Cushing’s syndrome is about three times more common in women than men [2]. Women may experience extra growth of body hair in abnormal places such as:

  • Abdomen
  • Face and neck
  • Chest
  • Thighs

Moreover, women suffering from Cushing’s syndrome may also experience irregular menstruation. In some cases, they may even observe the complete absence of mensuration altogether.

3. In Children

Although it is less frequent, children can also develop Cushing’s syndrome. According to a recent study, almost 10 percent of the new cases occur in children each year [3].

In addition to the general symptoms mentioned above, children with Cushing’s syndrome may also experience:

  • Slower growth rate
  • Obesity
  • High blood pressure

What Causes Cushing’s Syndrome

The underlying reason for Cushing’s syndrome is the excess production of a hormone called cortisol. Your adrenal glands are responsible for their synthesis.

This hormone is involved in helping several essential functions of your body, including:

  • Responding to stress
  • Regulating blood pressure
  • Maintaining cardiovascular system
  • Converting carbs, fats, and proteins present in the food to energy
  • Reducing your immune system’s inflammatory response
  • Balancing the effects of insulin produced by your body

Your adrenal glands may produce excess quantities of cortisol for a variety of reasons, such as:

  • Malnutrition
  • Depression
  • Panic disorder
  • High-stress levels, like in surgery, acute illness, injury, or even pregnancy
  • Alcoholism



Depression can play a crucial role in elevating cortisol levels in your body. | Image: Freepik.com


One of Cushing’s syndrome’s most prevalent causes is corticosteroid medicines in high doses for an extended period, like prednisone. 

High doses of injectable steroids often prescribed by healthcare providers for the treatment of back pain may also end up causing Cushing’s syndrome. However, if consumed in the form of inhalants, and low doses like in asthma, or creams (likes ones prescribed for eczema patients), can’t cause this syndrome.


Another significant cause of the development of Cushing’s syndrome is tumors. Several different types of tumors can lead to increased production of cortisol in your body.

Some of these are as follows:

  • Ectopic tumors: Such tumors are present in the pancreas, thyroid, lungs, or thymus gland.
  • Pituitary gland tumors: The pituitary gland may release too much ACTH; this stimulates increased production of cortisol hormone via adrenal glands.
  • Familial Cushing’s syndrome: Though it’s not typically inherited, there is a tendency that endocrine tumors may have genetic prevalence.
  • Adrenal gland tumor: A tumor within the adrenal gland can lead to abnormal production of cortisol hormones that can eventually lead to Cushing’s syndrome.

What Is Cushing’s Disease?

Cushing’s disease is different from Cushing’s syndrome. If the overproduction of ACTH by pituitary glands causes Cushing’s syndrome (which indirectly stimulates the excessive synthesis of cortisol), it’s known as Cushing’s disease. Like Cushing’s syndrome, a higher percentage of women are affected by Cushing’s disease than men. 

Treatment For Facial Plethora 

There’s no better method of treating Facial Plethora rather than treating the underlying problem. As already stated, this condition is often a clinical manifestation of Cushing’s syndrome. So, ideally, you would want to look into sorting out the Cushing’s syndrome to treat facial plethora eventually.

The main objective of treating Cushing’s syndrome is to reduce the levels of cortisol in your body. This goal can be achieved in several different ways. The route of treatment is highly dependent on the underlying cause of Cushing’s syndrome.

Your doctor may prescribe some medicines to manage the level of cortisol in your body. Some of these prescriptions are focused on decreasing the production of cortisol in your adrenal glands or lower the synthesis of ACTH from your pituitary gland. On the other hand, numerous medications work by blocking the effects of cortisol on your body; they alter your body tissues’ sensitivity, hampering the impact of the hormones.

Some of the examples include:

  • mitotane (Lysodren)
  • pasireotide (Signifor)
  • metyrapone (Metopirone)
  • ketoconazole (Nizoral)
  • mifepristone (Korlym, Mifeprex)

If a tumor causes the disease, your doctor would suggest removing cancer surgically. However, if, for some reason, the surgery can’t be performed, your healthcare provider will recommend chemotherapy or radiation therapy.


Surgery may be a viable option if the underlying cause is an operatable tumor. | Image: Freepik.com


Potential Complications

If Cushing’s syndrome is not treated, it may end up causing some severe health complications. Some of them are listed below:

  • Frequent infections
  • Type 2 Diabetes
  • Bone loss (osteoporosis)
  • Loss of muscle mass and strength

Cushing’s Syndrome Diagnosis

This condition can be incredibly tricky to diagnose, as most of the clinical symptoms such as fatigue and weight gain are common in many illnesses. Cushing’s syndrome can have numerous different causes.

Your doctor will need to review your medical history. You may be asked about your symptoms and any other health conditions that you might have. They’ll look into your medications and look out for any potential lead.

A physical exam may be performed, in which the health professional will look for signs that are characteristic of Cushing’s syndrome, such as buffalo hump, bruises, and stretch marks.

Some necessary laboratory tests that might be ordered include:

  • Salivary Cortisol Measurement: In healthy people, the cortisol level drops in the evening. So this test measures the level of stress hormone in saliva samples, which is often collected late at night.
  • 24-hour Urinary Free Cortisol Test: The levels of cortisol in the urine sample are tested.
  • Low-dose Dexamethasone Suppression Test: The subject is given a dose of dexamethasone in the evening. The blood is then tested for the cortisol levels in the morning. In healthy individuals, dexamethasone causes cortisol concentration to drop. However, in people suffering from Cushing’s syndrome, this won’t happen.

Once Cushing’s Syndrome Is Confirmed, How Is The Cause Diagnosed?

The relevant tests for making the final diagnosis regarding the cause of the Cushing’s syndrome include:

  • CRH stimulation test: A shot of CRH is given to the patient. It causes the cortisol and ACTH concentration to increase in people with Cushing’s syndrome caused by pituitary tumors.
  • Blood ACTH test: This test measures the levels of ACTH in the blood. If the ACTH levels are low, but the cortisol is high, it indicates that the underlying cause for Cushing’s syndrome is an adrenal tumor.
  • Petrosal sinus sampling: A blood sample is collected from two points: from a vein close to the pituitary and another far away. A shot of CRH is given. If the level of ACTH is high near the pituitary gland, it indicates a pituitary tumor. However, if the level of ACTH is similar on both points, it refers to the presence of an ectopic tumor.
  • Imaging studies: The healthcare provider may ask for a CT and MRI scan. The imaging studies help to visualize the adrenal and pituitary glands of the patient. Health professionals can then look for tumors.

Cushing’s Syndrome Risk Factors

Cushing’s syndrome’s most critical risk factor is the intake of high dose corticosteroids for an extended time. If your doctor has prescribed such medications to treat a health condition, stick to the recommended dosing, and not alter it on your own.

Other potential risk factors for Cushing’s syndrome can include:

  • Obesity
  • High blood pressure
  • Type 2 diabetes

As stated earlier, there is an individual genetic predisposition to the development of tumors of endocrine glands causing Cushing’s syndrome. However, you can’t prevent tumors from forming.

Bottom Line

The facial plethora is just a clinical manifestation of a medical disorder, particularly Cushing’s syndrome. The sooner you begin its treatment, the better outcomes you can expect. The symptoms of your condition may take up some time to improve. You must stay in touch with your healthcare provider and follow carefully upon their advice.


Bonus video: “Beyond The Pearls: Cushing’s Disease”



What is facial plethora?

A facial plethora is a clinical sign of Cushing’s syndrome (CS). It is characterized by redness of the face due to increased blood flow.

What causes facial plethora?

Plethora can also be caused by mitral stenosis and different dermatological diseases (such as rosacea or lupus, which generally produce distinct erythema).

What is plethora disease?

A bodily condition characterized by an excess of blood and marked by turgescence and a florid complexion.

What is Buffalo Hump syndrome?

A hump behind the shoulder, also called a buffalo hump, can develop when fat gathers together behind your neck. This condition is not necessarily serious. Tumors, cysts, and other abnormal growths can also form on your shoulders, creating a hump. Other times a hump can be the result of a curvature in the spine.

What does moon face mean?

Moon facies occurs when extra fat builds up on the sides of the face. It is often related to obesity but can be from Cushing’s syndrome. That’s why people sometimes refer to it as a Cushingoid appearance.

What medications can cause facial flushing?

Common medications that trigger a flushing reaction include nicotinic acid (niacin), vasodilators, calcium channel blockers, nitroglycerin, anti-inflammatories, cholinergic, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors.

What is facial flushing a symptom of?

Flushed skin is a typical physical response to anxiety, stress, embarrassment, anger, or another extreme emotional state. Facial flushing is usually more of a social worry than a medical concern. However, flushing may be linked to an underlying medical issue, such as Cushing disease or a niacin overdose.

What are the symptoms of Cushing’s disease in humans?

  • Weight gain.
  • Thin arms and legs.
  • A round face.
  • Increased fat around the base of the neck.
  • A fatty hump between the shoulders.
  • Easy bruising.
  • Wide purple stretch marks, mainly on the abdomen, breasts, hips, and under the arms.
  • Weak muscles.

Does Cushing’s Syndrome go away?

The treatment for Cushing syndrome depends on the cause. Exogenous Cushing syndrome goes away after a patient stops taking the cortisol-like medications they were using to treat another condition.

What is the difference between Cushing disease and Cushing syndrome?

Cushing’s disease is not the same as Cushing’s syndrome. Cushing’s syndrome refers to the general state characterized by excessive levels of cortisol in the blood. Elevated cortisol levels can occur for reasons other than a pituitary tumor, including Tumors of the adrenal glands producing cortisol.

What happens if Cushing’s is left untreated?

If left untreated, Cushing syndrome can result in exaggerated facial roundness, weight gain around the midsection and upper back, thinning of your arms and legs, easy bruising, and stretch marks. Cushing syndrome occurs when your body is exposed to high levels of the hormone cortisol for a long time.

Is Cushing disease genetic?

Most cases of Cushing’s syndrome are not genetic. However, some individuals may develop Cushing’s syndrome due to an inherited tendency to develop tumors of one or more endocrine glands.

How is Cushing’s syndrome diagnosed?

Diagnosis of Cushing’s syndrome is based on a review of your medical history, physical examination, and laboratory tests, which help to determine the presence of excess levels of cortisol. Often X-ray exams of the adrenal or pituitary glands are useful for locating tumors.

What happens if Cushing’s is left untreated?

If left untreated, Cushing syndrome can result in exaggerated facial roundness, weight gain around the midsection and upper back, thinning of your arms and legs, easy bruising, and stretch marks. Cushing syndrome occurs when your body is exposed to high levels of the hormone cortisol for a long time.

How do you lower cortisol levels quickly?

Here are 11 lifestyle, diet, and relaxation tips to lower cortisol levels.
  1. Get the Right Amount of Sleep
  2. Exercise, but Not Too Much
  3. Learn to Recognize Stressful Thinking
  4. Learn to Relax
  5. Have Fun
  6. Maintain Healthy Relationships
  7. Take Care of a Pet
  8. Be Your Best Self

Is Cushing’s serious?

Cushing’s syndrome and Cushing’s disease are severe conditions. Without treatment, they can be fatal. However, if a person has a proper diagnosis in good time, surgical or medical treatment can enable them to return to a healthier life.


  1. Afshari, A., Ardeshirpour, Y., Lodish, M. B., Gourgari, E., Sinaii, N., Keil, M., Belyavskaya, E., Lyssikatos, C., Chowdhry, F. A., Chernomordik, V., Anderson, A. A., Mazzuchi, T. A., Gandjbakhche, A., & Stratakis, C. A. (2015). Facial Plethora: Modern Technology for Quantifying an Ancient Clinical Sign and Its Use in Cushing Syndrome. The Journal of clinical endocrinology and metabolism100(10), 3928–3933. https://doi.org/10.1210/jc.2015-2497
  2. Cushing’s Syndrome. National Institute of Diabetes and Digestive and Kidney Diseases. Assessed on 11-08-20, retrieved from: https://www.niddk.nih.gov/health-information/endocrine-diseases/cushings-syndrome
  3. Lodish, M. B., Keil, M. F., & Stratakis, C. A. (2018). Cushing’s Syndrome in Pediatrics: An Update. Endocrinology and metabolism clinics of North America47(2), 451–462. https://doi.org/10.1016/j.ecl.2018.02.008

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