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Blushing: an embarrassing condition, but treatable

The Lancet 2006; 367:1297-1299
"Blushing: an embarrassing condition, but treatable"
Marios Nicolaou a, Trevor Paes a and Sarah Wakelin b

Blushing is common, but in most individuals infrequent. However, in some individuals blushing is severe enough to become a debilitating disorder, with devastating outcomes socially and in the workplace. [1] Individuals who seek help might find that health-care professionals are poorly informed about treatment options and are often told that there is nothing that can be done or that they will “grow out of it”. Fortunately, the internet has become an easily accessible resource for information on disorders that people might find embarrassing to discuss with their doctors. Analysis of internet searches shows that not only is blushing a common problem, but also that the prevalence of troublesome blushing is similar in men and women.[2] There have been reports describing detrimental effects of blushing,[1,3] and on its psychiatric, psychological,[4] medical, and surgical treatments.[5]
What is known about the nature and cause of blushing? Many people feel that because it is a visible disorder, individuals affected avoid social contact. However, an element of social phobia might be implicated.[6] Blushing can be characterised by episodic attacks of redness of the face, ears, and often the neck, accompanied usually by a tingling or burning sensation in these areas. Blushing is involuntary, uncontrollable, cannot be inhibited, and can be triggered by the mildest of emotions.
Darwin characterised blushing as “the most peculiar and most human of all expressions”. [7] Blushing is seen in all races and although those with darker skin do not find it as much of a problem, because the visible changes are less striking,[8] we have found the associated tingling and burning sensation of the skin is often just as troublesome.
There are non-emotional causes of blushing, which should be excluded. Physiological facial vasodilation is caused by exercise or hot environments. Postmenopausal flushing takes place in response to a fall in oestrogen concentrations. Many drugs and alcohol can trigger blushing, in addition to some foods. A good history, dermatological examination, and special investigations should diagnose rosacea (which might be preceded by a long tendency to blushing), or systemic abnormalities, such as carcinoid syndrome and mastocytosis.

For those with severe blushing induced purely by emotion, several treatment options can be considered. Some choose simply to use camouflaging make-up or high-necked clothing. Others might benefit from cognitive behavioural treatment and task-concentration training. [9–11] Medical treatment with drugs such as Beta-blockers might reduce blushing,[12] although clinical studies have yet to be reported. Clonidine is licensed for use in postmenopausal flushing. Anxiolytics and antidepressants can help alleviate anxiety associated with colour change, but no published studies show that these agents affect the intensity of blushing itself. There have been isolated reports of the use of intradermal botulinum toxin-A injection to treat neck and facial blushing.[13,14] However, this type of treatment only gives temporary relief and can be expensive in the long run. This indication is not a licensed use of botulinum toxin-A and further studies are needed to assess its efficacy.
Bilateral endoscopic transthoracic sympathectomy is the only option for blushing when non-surgical treatments have failed. The procedure has a reported success rate in reducing blushing of 80–90% of patients, with substantial improvement in quality of life.[5,15,16] The procedure is safe in the hands of skilled surgeons; serious complications are rare but have been described. [17] The most common drawback with endoscopic transthoracic sympathectomy is compensatory sweating, the cause of which is uncertain. Compensatory sweating is characterised by postoperative increased abnormal sweating in other areas of the body, particularly the trunk. The severity is variable and has been reported in 44–86% of patients,[18] with 1–2% of patients being severely affected and regretting having had the operation.[17] The potential disabling complications of endoscopic transthoracic sympathectomy have been reviewed [19] and detailed informed consent is recommended before this procedure is done.
An unsuccessful sympathectomy for blushing can actually heighten the depression associated with this problem, even in the absence of side-effects because the patient feels that they have tried all available treatment with no hope of a cure. It is important to discuss this potential effect before surgery. The figure summarises our treatment guidelines on the basis of our experience.
Over the past 5 years those with severe blush have seen some light at the end of their tunnel. The internet provides much useful information and there is now a growing awareness among health professionals that blushing can be a debilitating problem, and that patients should be counselled sympathetically and informed of the available therapeutic options. With increasing awareness of this poorly appreciated condition, there will hopefully be greater effort and research put into developing more effective treatments.
We declare that we have no conflict of interest. TP and MN run with no outside funding.

1. Gawande A. Crimson tide In: Complications: a surgeon's notes on an imperfect science. London: Profile Books, 2003: 146-161.
2. Nicolaou M, Sterodimas A, Swan MC, Paes TR. Is the internet the best resource for blushers?. Clin Auton Res 2003; 13 (suppl 1): 171-173.
3. Edelmann R. Coping with blushing. London: Sheldon Press, 2004:.
4. de Jong PJ, Peters ML. Do blushing phobics overestimate the undesirable communicative effects of their blushing?. Behav Res Ther 2005; 43: 747-758.
5. Adair A, George ML, Camprodon R, Broadfield JA, Rennie JA. Endoscopic sympathectomy in the treatment of facial blushing. Ann R Coll Surg Engl 2005; 87: 358-360.
6. Gerlach AL, Wilhelm FH, Gruber K, Roth WT. Blushing and physiological arousability in social phobia. J Abnorm Psychol 2001; 110: 247-258.
7. Darwin C. Expression of emotions in man and animals In: Porter DM, Graham PW, eds. The portable Darwin. New York: Penguin books, 1979: 364-393.
8. Drummond PD, Lim HK. The significance of blushing for fair and dark skinned people. Personality Indiv Diff 2000; 29: 1123-1132.
9. Scholing A, Emmelkamp PM. Cognitive and behavioural treatments of fear of blushing, sweating or trembling. Behav Res Ther 1993; 31: 155-170.
10. Scholing A, Emmelkamp PM. Treatment of fear of blushing, sweating, or trembling. Results at long-term follow-up. Behav Modif 1996; 20: 338-356.
11. Mulken S, Bögels SM, de Jong PJ, Louwers J. Fear of blushing: effects of task concentration training versus exposure in vivo on fear and physiology. J Anxiety Disord 2001; 15: 413-432.
12. Drott C. Results of endoscopic thoracic sympathectomy (ETS) on hyperhidrosis, facial blushing, angina pectoris, vascular disorders and pain syndromes of the hand and arm. Clin Auton Res 2003; 13 (suppl 1): I26-I30.
13. Sterodimas A, Nicolaou M, Paes TR. Successful use of Botulinum toxin-A for the treatment of neck and anterior chest wall flushing. Clin Exp Dermatol 2003; 28: 592-594.
14. Yuraitis M, Jacob CI. Botulinum toxin for the treatment of facial flushing. Dermatol Surg 2004; 30: 102-104.
15. Drott C, Claes G, Rex L. Facial blushing treated by sympathetic denervation-long lasting benefits in 831 patients. J Cosmetic Dermatol 2002; 1: 115-119.
16. Drott C, Claes G, Olsson-Rex L, Dalman P, Fahlén T, Göthberg G. Successful treatment of facial blushing by endoscopic transthoracic sympathicotomy. Br J Dermatol 1998; 138: 639-643.
17. Ojimba TA, Cameron AE. Drawbacks of endoscopic thoracic sympathectomy. Br J Surg 2004; 91: 264-269.
18. Schick CH, Horbach T. Sequelae of endoscopic sympathetic block. Clin Auton Res 2003; 13 (suppl 1): I36-I39.
19. Furlan AD, Mailis A, Papagapiou M. Are we paying a high price for surgical sympathectomy? A systematic literature review of late complications. J Pain 2000; 1: 245-257.

“Reprinted from The Lancet, The Lancet 2006; 367:1297-1299, with permission from Elsevier.”
This permission is granted for non-exclusive world English rights only.

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