Flushing

Definition

• Blush: A transient, mild redness of the face (often emotional or environmental triggers).

• Flush: A more intense redness sometimes accompanied by warmth, sweating, or piloerection (goosebumps).

• Common Sites: Primarily affects the face, neck, upper chest, and external ears.

Aetiology & Causes

• Common

  • Menopause (vasomotor symptoms, hot flushes)

  • Rosacea (persistent facial flushing with telangiectasia)

  • Emotional stress, temperature changes (heat, direct sunlight)

  • Hot or spicy foods, alcohol, exercise

  • Medications:

    • Calcium channel blockers (e.g. amlodipine)

    • Sildenafil (and other PDE5 inhibitors)

    • Corticosteroids

• Less Common

  • Carcinoid syndrome (episodic flushing, diarrhoea, wheezing)

  • Phaeochromocytoma (spells of headache, sweating, palpitations, hypertension)

  • Neurological disorders (e.g. autonomic dysregulation, rare)

  • Systemic mastocytosis (flushing with itching, possible anaphylactoid episodes)

  • Food additives: MSG, nitrates/nitrites (some patients may be sensitive)

Management

1. Treat Underlying Cause

   • Menopause: Consider short-term hormone replacement therapy (HRT) if appropriate and no contraindications.

   • Rosacea: Topical metronidazole or azelaic acid, lifestyle modifications (avoid triggers like hot drinks, spicy foods).

   • Suspected endocrine tumour: Carcinoid or phaeochromocytoma → Endocrine referral and imaging/biochemical tests.

2. Review & Discontinue Triggering Medications

   • Re-evaluate the need for any medication that commonly causes flushing (e.g. vasodilators, PDE5 inhibitors, steroids).

   • Adjust doses if feasible.

3. General Flushing Management

   • First-line: Propranolol 10 mg BD or as needed (helps dampen sympathetic overdrive).

   • If no response or intolerant to propranolol: Clonidine 25–50 mcg BD (can help reduce vasomotor instability).

   • Lifestyle: Avoid known triggers (alcohol, very hot beverages, excessive heat, harsh spicy foods).

   • Response Time: Flushing is episodic; assess improvement over 4–6 weeks.

4. Dermatology Referral

   • For refractory rosacea or persistent flushing not responsive to basic measures.

   • Some specialists use carvedilol for severe cases, off-label (monitor blood pressure and side effects).

Notes

• Menopause-related flushing is one of the most common presentations in middle-aged women; ensure thorough risk-benefit discussion regarding HRT.

• Evaluate for serious endocrine causes (carcinoid, phaeochromocytoma) if flushing is severe, unexplained, or accompanied by systemic symptoms (e.g. palpitations, BP changes, bowel changes).

• Psychological support or CBT can help if anxiety or stress triggers flush episodes (blushing).