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Saturday, August 23, 2025

Blushing


Introduction

Blushing is a physiological response triggered by activation of the sympathetic nervous system, leading to vasodilation in the facial skin. It is commonly associated with emotions such as embarrassment, shame, anxiety, or attraction.

Although normal, some people experience excessive blushing that interferes with their social and professional life, a condition often linked to social anxiety disorder.

Mechanism of Blushing

  • The sympathetic nervous system releases norepinephrine, which dilates cutaneous blood vessels.

  • The face has a rich vascular supply and is more sensitive to vasodilation, hence visible redness.

  • Emotional triggers activate the amygdala → hypothalamus → autonomic response → flushing.

Causes of Blushing

1. Physiological / Emotional

  • Embarrassment, shyness, anxiety.

  • Romantic or sexual arousal.

  • Anger, guilt.

  • Sudden stress (public speaking).

2. Medical Causes (Pathological Flushing)

  • Rosacea: Chronic skin condition with facial flushing, redness, papules.

  • Menopause: Hot flushes due to estrogen decline.

  • Carcinoid syndrome: Paroxysmal flushing due to serotonin-secreting tumor.

  • Pheochromocytoma: Catecholamine-secreting tumor.

  • Mastocytosis: Histamine release.

  • Hyperthyroidism: Increased sympathetic activity.

  • Medications: Niacin, calcium channel blockers, nitrates.

  • Alcohol intolerance (Asian flush): Aldehyde dehydrogenase deficiency.

3. Psychological Disorders

  • Social anxiety disorder (fear of embarrassment → exaggerated blushing).

  • Erythrophobia (specific phobia of blushing).

Clinical Features

  • Sudden reddening of face, neck, ears, or upper chest.

  • May last seconds to minutes.

  • Triggered by emotional or physical factors.

  • Associated symptoms (if pathological):

    • Burning sensation (rosacea).

    • Sweating, palpitations (pheochromocytoma).

    • Diarrhea, wheezing (carcinoid syndrome).

    • Hot flushes + night sweats (menopause).

  • Psychological distress, avoidance of social situations.

Diagnostic Approach

1. History

  • Onset, frequency, duration of blushing.

  • Emotional vs physical triggers.

  • Associated systemic symptoms (palpitations, flushing at rest, diarrhea).

  • Medication and alcohol use.

  • Menopausal status.

  • Family and psychosocial history (social anxiety).

2. Examination

  • Facial skin: signs of rosacea.

  • Vitals: hypertension, tachycardia.

  • Thyroid enlargement.

  • Carcinoid signs: flushing, wheeze, diarrhea.

3. Investigations (if secondary cause suspected)

  • Blood tests: CBC, thyroid function, fasting glucose.

  • Hormonal tests: 24-h urinary 5-HIAA (carcinoid), plasma metanephrines (pheochromocytoma).

  • Skin biopsy: If rosacea or mastocytosis suspected.

  • Psychological assessment: Screen for anxiety disorders.

Management and Treatment

Treatment depends on whether blushing is normal, excessive, or secondary to disease.

A. General Measures

  • Reassurance (normal physiological blushing needs no treatment).

  • Avoid known triggers (alcohol, spicy food, caffeine).

  • Stress reduction: mindfulness, breathing exercises, yoga.

  • Good skin care (for rosacea).

B. Psychological and Behavioral Therapy

1. Cognitive Behavioral Therapy (CBT)

  • Effective for social anxiety disorder.

  • Helps reframe negative thoughts, reduces anticipatory anxiety.

2. Exposure Therapy

  • Gradual exposure to anxiety-inducing situations.

3. Relaxation Training

  • Meditation, progressive muscle relaxation.

C. Pharmacological Treatment

1. Beta-blockers (for performance-related blushing/anxiety)

  • Propranolol 10–40 mg orally 1 hour before stressful event.

  • Useful in situational anxiety (public speaking).

2. Anxiolytics

  • Benzodiazepines (short-term):

    • Lorazepam 0.5–1 mg orally as needed.

  • Not for long-term use due to dependence.

3. SSRIs (for social anxiety disorder/erythrophobia)

  • Sertraline 50–100 mg orally daily.

  • Paroxetine 20 mg orally daily.

4. For Pathological Causes

  • Rosacea:

    • Topical metronidazole 0.75% gel twice daily.

    • Oral doxycycline 100 mg daily × 6–12 weeks.

  • Menopausal hot flushes:

    • Hormone replacement therapy (estradiol + progestin).

    • Non-hormonal: Venlafaxine 37.5–75 mg daily.

  • Carcinoid syndrome:

    • Octreotide 100–500 mcg SC every 8–12 h.

  • Pheochromocytoma:

    • Phenoxybenzamine 10 mg orally twice daily, then surgical removal.

D. Surgical / Interventional Options

  • Endoscopic thoracic sympathectomy (ETS):

    • Surgical interruption of sympathetic nerves.

    • Effective for severe refractory blushing.

    • Risks: compensatory sweating, nerve damage.

Complications

  • Social and professional impairment.

  • Anxiety, depression, avoidance behavior.

  • Misdiagnosis: pathological flushing mistaken for benign blushing.

Prognosis

  • Normal blushing: Harmless, reassurance sufficient.

  • Excessive emotional blushing: Improves with CBT, SSRIs, beta-blockers.

  • Pathological blushing (rosacea, carcinoid, menopause): Prognosis depends on underlying cause and treatment.

Patient Education

  • Blushing is a normal human response in most cases.

  • Excessive blushing is often linked to anxiety rather than disease.

  • Avoid triggers like alcohol, caffeine, spicy foods, hot environments.

  • Relaxation and breathing techniques help reduce episodes.

  • Seek medical advice if blushing is frequent, severe, or associated with systemic symptoms.





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