Flushing
This symptom presents more often in women than in men, not only because of its cosmetic importance, but also because the menopause accounts for the vast majority of presentations. It is different from emotional blushing in its context, severity, duration and extent.
Differential diagnosis
Common Diagnoses
- Menopause
- Chronic Alcohol Misuse
- Rosacea
- Trauma: Pelvic or Spinal Fracture, Trauma to Penis, Post-TURP
- Anxiety
Occasional Diagnoses
- Polycythaemia Rubra Vera
- Hyperthyroidism
- Drug/Alcohol Interaction: Metronidazole, Disulfiram
- Mitral Valve Disease (Malar Flush)
- Hyperglycaemia and Hypoglycaemia
- Epilepsy (Aura)
- Dumping Syndrome (e.g. after Bariatric Surgery)
Rare Diagnoses
- Carcinoid Tumour
- Phaeochromocytoma
- Zollinger–Ellison Syndrome
- Systemic Mastocytosis
- ACTH-Secreting Bronchogenic Carcinoma and Cushing’s Syndrome
Ready reckoner
Key distinguishing features of the most common diagnoses
| Menopause | Alcohol | Rosacea | Iatrogenic | Anxiety | |
|---|---|---|---|---|---|
| Continuous | No | Possible | Possible | Possible | No |
| Weight Loss | No | Possible | No | No | Possible |
| Facial Papules | No | No | Yes | No | No |
| Tremor | No | Possible | No | No | Yes |
| Long History | Possible | Yes | Possible | No | Possible |
Possible investigations
Likely: None.
Possible: FBC, LFT, TFT, blood sugar, FSH/LH.
Small Print: Echocardiogram, EEG, urinary 5HIAA and VMA, gastrin level, further specialised endocrine tests.
- FBC: Raised haemoglobin and PCV in polycythaemia (may also be elevated platelets and WCC), raised MCV in chronic alcohol misuse.
- Biochemistry: LFT and γGT abnormal in alcohol misuse. TFT will reveal hyperthyroidism.
- Blood sugar: To reveal hypo- or hyperglycaemia.
- FSH/LH of limited use as does not correlate well with symptoms (useful only if premature menopause suspected).
- Echocardiography: If mitral stenosis suspected.
- EEG: For possible epilepsy.
- Specialist tests might include 24 h urinary 5-HIAA if carcinoid syndrome suspected, 24 h urinary-free catecholamines and VMAs if phaeochromocytoma suspected and further endocrine tests (e.g. for Cushing’s syndrome).
Top Tips
- Many women complaining of flushing will suspect the cause is the menopause. Address this possibility in the consultation, especially in young women fearing ‘an early change’.
- A constantly flushed face in older men is likely to be due to alcohol, polycythaemia or rosacea.
- Anxiety is likely if the circumstances fit – but bear in mind that hyperthyroidism can produce a very similar clinical picture.
- It can be difficult to distinguish anxiety from menopausal symptoms in a woman of menopausal age. Flushes with sweats waking the woman at night are more likely to be caused by the menopause – but a trial of treatment is the acid test (though beware of an initial placebo response).
Red Flags
- Diarrhoea and dyspnoea with flushing after alcohol, food and exercise suggest possible carcinoid syndrome.
- Flushing followed by an episode of altered consciousness points to a significant cause, such as recurrent hypoglycaemia or epilepsy.
- Do not be tempted to write this symptom off as the hot flushes of emotional blushing. While common, this problem is unlikely to present in daily practice.
- Recent onset of severe flushing which is not obviously menopausal or anxiety may have a significant cause, especially if the patient has other symptoms. Have a low threshold for investigations or referral in such cases.