A 40-year-old Native American woman is referred by her Indian Health Service provider for evaluation of a facial condition she has had for several years. The condition, which is characterized by pustules and cysts, is slowly worsening over time. Acne medications (oral antibiotics, topical retinoids), oral spironolactone, and birth control pills have all been tried to no good effect.

Additional history-taking reveals that the patient, as well as several close relatives, are "flushers and blushers," readily turning red from exertion, anger, and embarrassment. Alcohol consumption and sun exposure are also exacerbating factors.

On examination, the patient's face is profoundly and uniformly red, sharply sparing the perioral and periocular areas. Many cysts, scars, and pustules are scattered about the face, but there is a notable lack of comedones. On palpation, there is no increased warmth or focal tenderness.