Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
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Sarah A. Stechschulte, Calvin O. McCall and Jonathan K. Wilkin
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Flushing is a transient reddening of the face and frequently other areas, including the neck, upper chest, pinna, and epigastric area. Flushing is the visible sign of a generalized increase in cutaneous blood flow despite the limited distribution of the erythema.
The first step in the management of a patient with a flushing disorder is a specific diagnosis, because therapy is individualized according to the specific factors causing the flushing, and there is no broad-spectrum antiflushing treatment. The first algorithmic step is to distinguish between autonomic neural-mediated flushing, in which eccrine sweating occurs at the time of the flushing (‘wet flushing’), and direct vasodilator-mediated flushing, in which there is no accompanying eccrine sweating (‘dry flushing’). The dry flushing reactions are further divided into those with prominent dysesthesia and those without.
Patients with dry flushing and no dysesthesia have circulating vasodilator substances that are either exogenous or endogenous. Exogenous vasodilator agents are almost always elicited from the patient’s history. Patient diaries listing all foods, beverages, medications, activities, etc., can not only pinpoint the inciting agent, but also the temporal relationship can be convincing for both the patient and physician. The usual strategy for most vasodilator agents is simple avoidance of the agent, although niacin (nicotinic acid) therapy for hyperlipidemia and tamoxifen for breast cancer are important exceptions for which antiflushing therapies can permit continued treatment with the offending agent.
Finally, endogenous circulating vasodilator agents, typically from underlying neoplasias, are suggested by both multiple stimuli that provoke flushing and prominent features associated with the flushing attack (e.g., itching, urticaria, hypertension, sweating, and diarrhea.) Prominent features associated with the flushing can occur with cholinergic urticaria, cholinergic erythema, anxiety reactions, intolerance to foods, menopausal flushing, the dumping syndrome, diabetes mellitus, pancreatic cholera, medullary carcinoma of the thyroid, pheochromocytoma, multiple endocrine neoplasia syndromes II and III, mastocytosis, and carcinoid syndrome.
5-Hydroxyindoleacetic acid urine test
Histamine urine test
Serotonin blood/platelet test
Histamine plasma test
Wilkin JK. Clin Dermatol 1993; 11: 211–23.
The first step in diagnosing a flushing reaction is to determine the mechanism: autonomic neural-mediated flushing, which includes eccrine sweating (wet flush), versus flushing from agents that act directly on vascular smooth muscle (dry flush). This review describes the three types of blushing, including the type that responds to a low-dose, long-acting non-selective β-blocker such as nadolol 40 mg every morning. The use of aspirin to block niacin-induced flushing, and amitriptyline to treat facial dysesthesia, is described.
Wilkin JK. Arch Dermatol 1992; 128: 1387–9.
Chemotherapy causes of flushing are reviewed, along with other drugs that cause flushing.
Wilkin JK. In: Rook AJ, Maibach H, eds. Recent Advances in Dermatology. New York: Churchill Livingstone, 1983; 157–87.
This reviews categories of flushing reactions with catalogs of specific causes.
Kema IP, Schellings AM, Meiborg G, Hoppenbrouwers CJ, Muskiet FA. Clin Chem 1992; 38: 1730–6.
Kema IP, de Vries EG, Slooff MJ, Biesma B, Muskiet FA. Clin Chem 1994; 40: 86–95.
The platelet serotonin level has a higher sensitivity for the detection of carcinoid tumors and is more consistently elevated than urinary 5-HIAA (5-hydroxyindoleacetic acid). Also, in contrast to urinary 5-HIAA, platelet serotonin is not influenced by the consumption of a serotonin-rich diet.
The quantitative 24-hour urinary 5-HIAA level is useful in the follow-up of carcinoid tumors with a high serotonin production rate. It is also useful initially for diagnosis, but only when it is positive during a low-serotonin diet. If the urinary 5-HIAA level is not elevated in a patient with flushing and other features characteristic of carcinoid, the platelet or blood serotonin level should be obtained.
Doggrell SA. Expert Opin Pharmacother 2005; 6: 75–84.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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