Flushing is often due to blushing in social situations, physiological blushing, 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 severe causes or 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, the symptoms become progressively worse or the patient also have symptoms other than flushing, 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
Some patients react to preservatives, e.g. foods containing nitrates (dried meats) or sulphites (shellfish, dried fruit).
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.
Other causes
Psychiatric causes Anxiety Disorder: panic disorder, social phobia and other phobias, apprehension as part of other psychiatric diseases
Medications: the most common are antihypertensive drugs, hormone therapies, glucocorticoids, chemotherapy and opioids, e.g. ACE inhibitors, calcium-channel blockers, nitroglycerine, metoclopramide, PDE5 inhibitors, glucocorticoids (also joint injection), 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.
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).
Used symptomatically e.g. 30-60 min before the factor causing flushing (e.g. anxiety, performance, alcohol).
Some patients benefit from a low-dose beta blocker (especially blushing in social situations, anxiety-related), 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.
Patients with symptoms of apprehension, anxiety and panic may benefit from antidepressive medication, primarily selective serotonin reuptake inhibitors (SSRIs).
Flushing associated with drugs usually subsides over time (e.g. calcium blockers).
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]
Yu WY, Lu B, Tan D, et al. Effect of Topical Brimonidine on Alcohol-Induced Flushing in Asian Individuals: A Randomized Clinical Trial. JAMA Dermatol 2020;156(2):182-185 [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]