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 ...