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Episodic Attacks of Flushing

Essentials

  • Flushing is often due to blushing in social situations, redness caused by rosacea, or menopause.
  • No further investigations are needed in typical cases.
  • Treatment is based on avoiding provoking factors.
  • Other underlying causes (e.g. internal diseases, medicines) may rarely be discovered, but then the patient usually has other symptoms in addition to the flushing.

Aetiology

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

Clinical picture

  • 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. The skin may be damp and cold.

Diagnosis

  • In most cases the diagnosis can be made after a comprehensive history and physical examination.
    • In the examination, assess whether the redness is suited to have a common benign cause or whether the patient also has other symptoms that could be indicative of internal diseases or other conditions that cause redness.
  • 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 may be necessary.

Most common benign causes

  • 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 (sweating spells), heavy sweating especially in the upper body and neck, redness on the face, neck and chest. Strong sensation of internal heat. Later, the skin feels damp and clammy.

Rare causes

  • 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, metoclopramide, PDE5 inhibitors, glucocorticoids, antioestrogens, tamoxifen, stopping hormone replacement therapy, disulfiram, disulfiram-alcohol reaction, combined use of e.g. metronidazole and alcohol, opioids, SSRI medicines.
  • 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

Treatment

  • 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.
  • Brimonidine gel once daily (official indication for rosacea, may also help with other flushing)
  • 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).

Specialist consultation

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

    References

    • 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]
    • Sadeghian A, Rouhana H, Oswald-Stumpf B, et al. Etiologies and management of cutaneous flushing: Nonmalignant causes. J Am Acad Dermatol 2017;77(3):391-402. [PubMed]
    • Sadeghian A, Rouhana H, Oswald-Stumpf B, et al. Etiologies and management of cutaneous flushing: Malignant causes. J Am Acad Dermatol 2017;77(3):405-414. [PubMed]
    • Rastogi V, Singh D, Mazza JJ, et al. Flushing Disorders Associated with Gastrointestinal Symptoms: Part 1, Neuroendocrine Tumors, Mast Cell Disorders and Hyperbasophila. Clin Med Res 2018;16(1-2):16-28. [PubMed]
    • Rastogi V, Singh D, Mazza JJ, et al. Flushing Disorders Associated with Gastrointestinal Symptoms: Part 2, Systemic Miscellaneous Conditions. Clin Med Res 2018;16(1-2):29-36. [PubMed]