Flushing
Differential Diagnosis
Common Diagnoses
- Menopause and Perimenopause
- 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.