Understanding facial flushing and blushing: From symptoms to solutions

Facial blushing is fairly common and an involuntary reddening of the face oftentimes triggered by embarrassment or stress [1][2]. It can be a distressing experience, disrupting social interactions and impacting self-confidence. While you're engaged in a pleasant conversation, an unexpected surge of warmth floods your face, causing visible redness that feels impossible to control. It can lead to embarrassment and a desire to find effective ways to manage or prevent such episodes.
 
Excessive facial flushing is more than just a cosmetic concern; significantly affecting one's quality of life and social interactions. While surgical intervention exist and effective, they often come with high costs and potential risks. Fortunately, there is a range of less invasive approaches to manage this condition.
 
SYMPTOMS
Severe facial blushing is often associated with social anxiety disorder (SAD), can manifest through various physiological and psychological symptoms:
 
1. Intense reddening of the face, neck, and chest [3][4]
2. Sensation of heat or warmth in the affected areas [4]
3. Increased blood flow to facial blood vessels [3][5]
4. Elevated skin temperature in the face [3]
5. Perspiration, particularly in the face and palms [6]
6. Increased heart rate and blood pressure [6]
7. Feelings of embarrassment or self-consciousness [3][4]
8. Avoidance of social situations or eye contact [4][7]
9. Heightened awareness of one's own blushing [3][8]
10. Persistent worry about blushing in social situations [7][8]
 
UNDERSTANDING FACIAL FLUSHING
The face has more capillary loops per unit area and generally more vessels per unit volume than other skin areas. Blood vessels in the cheeks are wider in diameter and closer to the surface.
 
There are several factors contributing to blushing or flushing:
1. Neurovascular dysregulation: Research suggests that individuals prone to facial flushing may have heightened sensitivity in the neural pathways controlling blood flow to the face [9].
2. Genetic predisposition: A study published in Nature Genetics (2015) [10] identified genetic variants associated with rosacea, a condition often characterized by facial flushing.
3. Environmental triggers: Factors such as temperature changes, spicy foods, alcohol, emotional stress and exercise can exacerbate flushing [11].
4. Underlying medical conditions: In some cases, facial flushing may be a symptom of conditions like rosacea, menopause, carcinoid syndrome or hyperthyroidism [12].
5. Certain medications for diabetes, bloodpressure or cholesterol can excercabate flushing.
 
The blushing response is primarily mediated by the sympathetic nervous system. When triggered by social stimuli or self-conscious emotions, facial blood vessels dilate (expand), increasing blood flow to the skin [3][5]. This process is regulated by beta-adrenergic sympathetic nerves, which are responsible for the dilation of blood vessels in the face [6].

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​MENOPAUSE
Facial flushing is a common symptom experienced by women during menopause, often associated with hot flashes. This is primarily attributed to hormonal changes, particularly the decline in estrogen levels.
 
1. Prevalence: Approximately 75% of perimenopausal and menopausal women experience flushing [13].
2. Mechanism: Flushing occurs due to vasodilation of dermal and subcutaneous blood vessels, likely caused by the loss of peripheral vascular control associated with estrogen deficiency [13].
3. Duration: Hot flashes, including facial flushing, can persist for years after menopause. Among women 5-9 years postmenopausal, over 20% still report clinically significant hot flashes [14].
4. Associated symptoms: Flushing is often accompanied by sensations of heat, sweating, anxiety, and chills [15].
5. Impact on skin: Menopausal hormonal changes affect the skin barrier, making it more sensitive and vulnerable to irritation [16].
6. Treatment: Estrogen therapy is generally effective in managing menopausal flushing [13]. However, for women who cannot use estrogen, alternative treatments are necessary [17].
7. Persistence: In a study of women with significant hot flashes at baseline, 50% reported unchanged or worsened symptoms after 3 years [14].
8. Risk factors: Women who are more recently menopausal, have previously used estrogen, or have undergone hysterectomy are more likely to experience persistent hot flashes [14].
 
DIFFERENCE BETWEEN BLUSHING AND FLUSHING
While the terms 'blushing' and 'flushing' are sometimes used interchangeably, they can be distinguished based on their triggers. Blushing is typically associated with emotional responses, while flushing may have various physiological causes. Severe cases of facial blushing are known as idiopathic cranio-facial erythema [18][19].
 
Two types of blushing have been identified:
1. Wet blushing is associated with increased perspiration. This type is believed to result from an overactive sympathetic nervous system [20], which regulates various bodily functions, including the dilation of facial blood vessels. In some people, these nerves exhibit heightened sensitivity to emotional stress [21]. 
The blushing response is primarily mediated by the sympathetic nervous system. When triggered by social stimuli or self-conscious emotions, facial blood vessels dilate, increasing blood flow to the skin [3][5], resulting in visible reddening [22][23].  This reaction can extend to the ears, neck, and chest.
 
Mellander et al. discovered that facial veins possess unique characteristics, including beta-adrenoceptors or beta-adrenergic sympathetic nerves, responsible for the dilation of blood vessels in the face, in addition to alpha-adrenoceptors, which may contribute to emotional blushing [6][24].
 
2. Dry flushing is a form of flushing caused by circulating vasodilating mediators in the bloodstream and does not involve increased perspiration [19][20]. These mediators can be either exogenous (from ingested substances) or endogenous (associated with systemic disorders). This type of flushing is also referred to as "vasodilator-mediated flushing" and is distinct from autonomic neural-mediated flushing, which typically involves sweating [20].
 
PSYCHOLOGICAL IMPACT
Blushing may serve a regulatory role in social interactions, potentially mitigating incidents that could spark social conflicts. It signals awareness of social transgressions and may elicit more sympathetic responses from others [25][26].
 
Severe blushing can significantly impact an individual's quality of life [23], even lead to social anxiety and avoidance behaviours [7][8]. The fear of blushing itself known as erythrophobia can exacerbate the condition, creating a cycle of anxiety and increased blushing propensity [4][8].
 
Severe facial blushing is a common symptom of social anxiety disorder (formerly known as social phobia), characterized by intense fear of social situations and negative evaluation [23]. People with this disorder often experience heightened self-conscious emotional reactivity, with blushing being a core physiological symptom [3].
 
MEASUREMENT AND ASSESSMENT

Blushing can be assessed through various methods:

▌Self-report measures, such as the Blushing Propensity Scale [4][8]
Blushing Propensity Scale (Leary & Meadows, 1991) 
Indicate how often you feel yourself blush in each of the following situations using the scale below: 
 
1 = I NEVER feel myself blush in this situation.
2 = I RARELY feel myself blush in this situation.
3 = I OCCASIONALLY feel myself blush in this situation. 
4 = I OFTEN feel myself blush in this situation.
5 = I ALWAYS feel myself blush in this situation. 
 
____  1. When a teacher calls on me in class
____  2. When talking to someone about a personal topic
____  3. When I'm embarrassed
____  4. When I'm introduced to someone I don't know
____  5. When I've been caught doing something improper or shameful
____  6. When I'm the center of attention
____  7. When a group of people sings "Happy Birthday" to me
____  8. When I'm around someone I want to impress
____  9. When talking to a teacher or boss
____  10. When speaking in front of a group of people
____  11. When someone looks me right in the eye
____  12. When someone pays me a compliment
____  13. When I've looked stupid or incompetent in front of others
____  14. When I'm talking to a member of the other sex
 
The total score is obtained by summing the ratings across all items. 
For example:
Low blushing propensity scores ranged from 3-17, with a mean of 11.4
High blushing propensity scores ranged from 40-63, with a mean of 51.3
 
▌ Physiological measurements of blood flow and skin temperature [3][5]
▌ Observational assessments by trained raters [8]
 
Research has shown that the relationship between blushing and social anxiety is strong for self-perceived blushing, small for physiological blushing, and medium for observed blushing [8].
 
MANAGEMENT STRATEGIES 
It´s important to understand why this is happening to you and address contributing factors or triggers. Persistent or severe facial flushing should be evaluated by a dermatologist, as it may be a symptom of underlying conditions like for example rosacea [27], especially when accompanied by other symptoms. 
 
1. Topical treatments: 
▌Brimonidine gel (Mirvaso®) has shown efficacy in reducing facial erythema in rosacea patients [28] and might help to reduce redness from facial flushing.
▌Oxymetazoline cream (Rhofade®) is another FDA-approved topical treatment for persistent facial erythema [29].
 
2. Oral medications:
▌Low-dose oral beta-blockers, such as propranolol, have demonstrated effectiveness in reducing blushing and flushing [30].
▌Clonidine (antihypertensive), is a centrally acting alpha-adrenergic agonist, has shown mixed results in treating some types of flushing, with positive results in menopausal women. However it failed to reduce flushing provoked by red wine, chocolate, and hot weather in rosacea studies or in rosacea patients. [31].
 
3. Laser and light therapies:
▌Pulsed dye laser and intense pulsed light treatments can help reduce visible blood vessels and overall redness [32].
 
4. Cognitive Behavioral Therapy (CBT):
▌CBT has shown promise in helping individuals manage the psychological aspects of blushing and reduce its frequency [33].
 
5. Skincare routine and lifestyle modifications:
▌By simplifying your routine, use gentle, non-irritating skincare products, daily (tinted) broadspectrum sunscreen and avoid known triggers can help manage symptoms [34]. 
▌Regular exercise and stress-reduction techniques like meditation may help regulate the body's response to flushing triggers [35].
 
6. Dietary adjustments:
▌Reducing intake of spicy foods, alcohol, and hot beverages may help [11].
 
7. Botulinum Toxin injections:
▌Small doses of botulinum toxin have shown potential in reducing facial flushing in some studies [36].
 
8. Vasoconstriction can help against facial flushing, and there are several methods to achieve this effect using topical ingredients and cooling techniques:
▌Topical vasoconstrictors:
Oxymetazoline, an alpha-adrenergic agonist, has shown effectiveness in reducing facial redness and flushing associated with rosacea by constricting blood vessels when applied topically [37]. This ingredient is available in some countries as a prescription cream under the brand name Rhofade.
The active compound in Visine eye drops, tetrahydrozoline hydrochloride, is a vasoconstrictor that constricts blood vessels to reduce redness [38]. While primarily used for eye redness, it may potentially help with facial flushing due to its vasoconstrictive properties. Visine is not approved, specifically researched or recommended for use on facial skin [38], however might give a very temporary positive effect. Be aware that prolonged use of vasoconstrictors like tetrahydrozoline can lead to rebound dilation of blood vessels, potentially worsening redness over time [38].
▌Cooling therapies:
Localized cooling can induce vasoconstriction and reduce skin blood flow. A study using cryotherapy demonstrated that skin cooling produced a significant reduction in cutaneous vascular conductance (CVC) that persisted even after the active cooling period [39]. This suggests that cooling therapies, such as using ice packs or cooling pads, could be effective in managing facial flushing.
▌Thermoelectric cooling devices:
An on-site thermoelectric cooling device was tested for its efficacy in regulating skin blood perfusion. The study showed that when active cooling was applied, there was a significant drop in skin temperature and perfusion, indicating vasoconstriction [40].
▌Skincare ingredients:
Caffeine is found in many creams and serums, has anti-inflammatory properties and constricts microcapillaries (bloodvessels). This might eliviate the redness temporarily, however can cause irritation in higher concentrations, especially in sensitive skin.
 
While not directly causing vasoconstriction, certain skincare ingredients can help manage facial redness:
 
Silymarin, a compound derived from milk thistle has demonstrated potential benefits. A double-blind, placebo-controlled study found that a topical treatment combining silymarin and methylsulfonylmethane was particularly effective for rosacea subtype 1, which is characterized by facial flushing and persistent redness [41]. Silymarin's has anti-inflammatory and antioxidant properties, which help modulate cytokines and angiokines involved in skin redness [42]. A systematic review of polyphenols (including silymarin) in rosacea treatment found evidence that these compounds may be beneficial, especially in reducing facial erythema [42], confirmed by in vivo by studies I´ve done myself on patients with couperose and ageing related facial redness [43]. We´ve proven Silymarin´s effect on improving skin´s microcirculation and microcapillaries including strenghtening of microcapillary walls.
 
Licochalcone A works as a powerful anti-oxidant has anti-ínflammatory properties and proven to significantly improve redness, including in patients with rosacea and couperose [43].
 
Menthoxypropanediol (MPD) is a synthetic derivative of menthol that can be beneficial for reducing skin redness. MPD provides a cooling sensation when applied to the skin, which can help soothe irritated and red skin, however particurlarly effective I relieve from itch associated with atopic dermatitis [44].
 
There are more “anti-redness” ingredients available in skincare products, usually tested and suitable for rosacea or couperose prone skin, thus unfortunately not specifically intended to improve blushing or flushing.
 
9. Color cosmetics and skincare: Foundation or skincare products containing colour pigments unify the skin tone and can help to cancel out some of the redness.
 
10. Surgery: Endoscopic thoracic sympathectomy (ETS) is an operation to treat severe facial blushing, performed under general anesthesia as a last resort when other treatments have failed. 
 
The cure rate for facial blushing with ETS is high, but varies across studies. A case series of 831 patients reported a mean symptom improvement score decrease from 9 to 3 (on a 10-point scale) at 29 months follow-up, which was statistically significant (p<0.0001) [45]. Another study found that 85% of 244 patients with facial blushing reported being "totally satisfied" at a mean follow-up of 8 months [45].
 
While initial results are often positive, long-term outcomes may vary. A study with a median follow-up of 19.6 months found that complete resolution of blushing was achieved in 48% of patients, with significant differences based on the type of blushing (emotional: 55%, thermoregulatory: 28%, constant: 15%, P = .03)[46]. The most common side effect is compensatory sweating, reported in up to 90% of patients [47]. In a long-term follow-up study, 6.3% of patients who had ETS for hyperhidrosis regretted having the operation [48]. Thus, while ETS can be effective for many patients with severe facial blushing, it's crucial to carefully consider the potential risks and long-term outcomes before proceeding with this invasive treatment.
 
11. Hormone replacement therapy
HRT can effectively reduce facial flushing in menopausal women. HRT is highly effective in alleviating hot flushes and night sweats, which are common vasomotor symptoms experienced during menopause [52][53]. These symptoms often manifest as facial flushing.
▌HRT significantly reduces the frequency of hot flushes compared to placebo, with a 77% reduction in frequency observed in clinical trials [52].
▌The severity of vasomotor symptoms, including facial flushing, is also significantly reduced with HRT compared to placebo [2]. The benefits of HRT in reducing vasomotor symptoms are often seen within a few weeks of starting treatment [54].
▌Estrogen, a key component of HRT, helps regulate vascular function. During menopause, the decline in estrogen levels can lead to increased blood flow and dilated blood vessels, potentially worsening flushing. HRT can help stabilize these hormone levels.
 
It's important to note that while HRT is effective, it does come with potential risks and benefits that should be discussed with a healthcare provider to determine if it's the right treatment option for an individual.
 
PREVALENCE
In a study of patients undergoing anesthesia, 47% of women and 33% of men reported blushing easily[49]. Blushing is (more) common in young people and women [49]. In a surgical study for facial blushing treatment, 82% of patients had emotional blushing, 58% had thermoregulatory blushing, and 32% had constant blushing [50]. While these figures don't provide a definitive prevalence for the general population, they suggest that facial blushing and flushing are relatively common, especially among those with social anxiety disorders where blushing is reported to affect up to 50% of patients [51].
 
Always consult a qualified professional for a proper diagnose, guidance and support.
 
Take care
Anne-Marie
 
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