Episodic facial flushing

Specialty: Skin.

• sudden facial redness
• transient facial blushing
• facial vasomotor hot flashes

Why it occurs

• Dysautonomia or idiopathic vasomotor lability (common physiological transient emotional flushing)
• Erythematotelangiectatic rosacea (neurovascular dysregulation of the central facial vasculature when faced with physical triggers)
• Consumption of alcohol or foods rich in histamine or irritating spices
• Malignant carcinoid syndrome (secretion of serotonin, bradykinin and histamine due to intestinal or bronchial neuroendocrine tumors)
• Menopause and climacteric transition (decrease in estrogen that alters the hypothalamic thermoregulatory center)
• Adverse reactions to drugs (vasodilators, calcium channel blockers, nicotinic acid).

Initial workup

Analytical measurement of 5-hydroxyindoleacetic acid (5-HIAA) in 24-hour urine (marker of serotonin metabolism to rule out carcinoid syndrome), serum levels of chromogranin A, thyroid-stimulating hormone (TSH), chorionic gonadotropin (if applicable) and serum levels of FSH and LH to confirm menopausal transition. Abdominal ultrasound or CT if suspicion of neuroendocrine tumor is high.

Standard management

• Brimonidine tartrate gel 0.33% — selective alpha-2 adrenergic agonist applied to the face to induce transient local vasoconstriction of erythema due to rosacea
• Propranolol — non-selective beta blocker used to mitigate flushing of emotional or adrenergic origin, dose of 10 to 40 mg before the stressful event
• Clonidine — central alpha-2 agonist indicated to reduce climacteric hot flashes and idiopathic vasomotor crises
• Octreotide (somatostatin analog for subcutaneous use strictly indicated for the control of symptoms of metastatic carcinoid syndrome).