Skin Changes During Seizures May Help Find Seizure Source

What was studied

This paper was a systematic review and meta-analysis. The researchers gathered published studies of people with focal epilepsy whose seizures showed visible skin-related autonomic signs on video-EEG, such as goosebumps (piloerection), sweating, pallor, or flushing. They searched PubMed and EMBASE through June 1, 2025, and reviewed how well these signs helped point to the epileptogenic zone, the brain area where seizures start.

The review included mostly case reports and small case series rather than large controlled studies. The largest evidence base was for piloerection, with 31 studies covering 100 patients. The other signs were much less common in the literature: pallor was reported in 3 studies with 13 patients, flushing in 4 studies with 9 patients, and sweating in 9 studies with 11 patients.

What they found

Goosebumps during a seizure had the strongest evidence. In this review, 92% of patients with ictal piloerection had temporal lobe involvement, and the authors rated this evidence as high certainty.

Pallor during a seizure was also associated with temporal lobe epilepsy. About 76.9% of reported cases involved the temporal lobe, and the reports suggested a tendency toward the left side and favorable outcomes after surgery, although the number of patients was small.

Flushing during a seizure was associated more with the posterior quadrant of the brain than with the temporal lobe, and the authors rated the posterior quadrant association as high-certainty evidence.

Sweating during a seizure was seen mostly in temporal lobe cases, but the evidence was limited because there were very few patients, the studies differed a lot, and many cases did not have strong surgical validation.

Limits of the evidence

The evidence has important limits. Most of the included studies were retrospective case reports or small case series, which can overrepresent unusual or striking cases. The authors judged many studies to have high risk of selection bias and assessment bias.

The sample sizes were very small for pallor, flushing, and sweating, so those findings are less certain. Even for piloerection, this review can show an association, not prove that the skin sign alone identifies where seizures start. These signs are best seen as supporting clues, not stand-alone proof for surgery planning.

For families and caregivers

For families, this study suggests that certain visible body changes during a seizure may give doctors helpful clues about where in the brain the seizure begins. Goosebumps and pallor may point toward the temporal lobe, while flushing may point more toward the back part of the brain.

This may matter during presurgical evaluation, where doctors combine many pieces of information such as seizure history, video-EEG, MRI, and sometimes surgery results. The study does not mean that any one sign can diagnose seizure location by itself, but it supports careful observation of what a seizure looks like.

What to watch next

Stronger evidence would come from larger, prospective studies with consistent video-EEG review and better validation of epileptogenic zone localization.

Terms in this summary

focal epilepsy

Epilepsy in which seizures start in one area of the brain.

video-EEG

A test that records brain waves and video at the same time to match body signs with seizure activity.

epileptogenic zone

The area of the brain believed to be causing seizures.

autonomic signs

Body changes controlled automatically by the nervous system, such as sweating, skin color change, or goosebumps.

ictal

Happening during a seizure.

piloerection

Goosebumps or hair standing up on the skin.

temporal lobe

A part of the brain near the sides of the head that can be a common starting point for focal seizures.

posterior quadrant

The back part of one side of the brain, including areas such as the parietal and occipital regions.