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Episodic Attacks of Flushing

Essentials

  • Flushing is often due to blushing in social situations, rosacea or menopause.
  • No further investigations are needed in typical cases.
  • Treatment is based on avoiding provoking factors.
  • A serious underlying cause may rarely be discovered.

Aetiology

  • 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.

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.

Diagnosis

  • 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.

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, flushing also of the head, neck and chest

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, 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

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.
  • 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]