Editors

AlexanderSalava

Episodic Attacks of Flushing

Sudden capillary dilatation on the skin caused by a variety of irritants.
Flushing is a physiological process regulated by the autonomic nervous system; hereditary factors also play a part.

Sudden patchy redness on the face, particularly on the cheeks, neck or upper body.
Preceding symptoms frequently include a feeling of warmth and tightness often accompanied by sweating.

In most cases the diagnosis can be made after a comprehensive history and physical examination.
Flushing on other skin areas and systemic symptoms (fever, diarrhoea, respiratory tract problems) suggest a secondary cause.
Apprehension, anxiety and panic attacks may be suggestive of a psychiatric aetiology.
Should serious secondary causes be suspected or the symptoms become progressively worse, targeted follow-up investigations should be carried out.

Social blushing (erythema e pudore)
Physiological: emotional reaction, physical exertion, hot environment, spicy food, alcohol
Fever: increased body temperature, infection
Rosacea Rosacea
- Rosacea commonly presents with flushing which usually is of longer duration than physiological flushing.
- Typical triggering factors
- Family history
- Papules, pustules and telangiectasia on the face
- Flushing limited to face
Menopause Menopausal Symptoms and Hormone Therapy “hot flushes”, frequent brief episodes, profuse sweating, flushing also of the head, neck and chest

Psychiatric causes Anxiety Disorder: panic disorder, social phobia and other phobias, apprehension as part of other psychiatric diseases
Medications: can be caused by several medicines, e.g. ACE inhibitors, calcium-channel blockers, nitroglycerine, PDE5 inhibitors, glucocorticoids, antioestrogens, tamoxifen, stopping hormone replacement therapy, disulfiram, disulfiram-alcohol reaction, combined use of e.g. metronidazole and alcohol, opioids.
Anaphylaxis Anaphylaxis: urticaria, angioedema, hypotension, bronchial obstruction, abdominal symptoms, elevated serum tryptase only during the reaction. Skin prick tests or serum allergen-specific IgE testing.
Neurological causes: Parkinson's disease Parkinson's Disease, migraine Migraine, multiple sclerosis Multiple Sclerosis (Ms), facial nerve damage
Systemic mastocytosis: abdominal symptoms, fatigue, weight loss, hypotension, mastocytomas on the skin or urticaria pigmentosa, persistently elevated serum tryptase levels.
Rare endocrine tumours Rare Endocrine Tumours

The mainstay of treatment is the avoidance of factors that, based on the patient's observations, aggravate the condition.
Concealing cosmetics may be used.
The flush reaction in rosacea generally reacts fairly poorly to topical treatment.
Some patients benefit from a low-dose beta blocker, e.g. propranolol 10-40 mg 2-3 times daily, carvedilol 3.125-6.25 mg 1-2 times daily or atenolol 12.5-25 mg once daily to attenuate the flushing reactions.
Prophylactic beta-blocker medication has also been used, e.g. propranolol 10-40 mg 1 to 2 hours before entering a situation that is expected to cause flushing.
Menopausal hot flushes can be managed with hormone therapy Menopausal Symptoms and Hormone Therapy
Patients with symptoms of apprehension, anxiety and panic may benefit from antidepressive medication, primarily selective serotonin reuptake inhibitors (SSRIs).

An appropriate specialist should be consulted, if necessary, regarding the treatment of an underlying cause.

Logger JGM, Olydam JI, Driessen RJB. Use of beta-blockers for rosacea-associated facial erythema and flushing: A systematic review and update on proposed mode of action. J Am Acad Dermatol 2020;83(4):1088-1097. [PubMed]