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Non-carcinoid flushing
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Non-carcinoid flushing

Contributors: Jonathan Webster, Susan Burgin MD
Other Resources UpToDate PubMed

Synopsis

Non-carcinoid flushing is characterized by episodic erythema and warmth of the head, neck, and arms. Flushing is caused by rapid vasodilation in the skin, typically mediated through either the autonomic nervous system or vasoactive molecules. While carcinoid tumors are sometimes the cause of these episodes, there are many other etiologies.

Flushing can be constant or episodic. Vasoactive mediators, either endogenous or medications, are usually the cause of episodic flushing. Flushing due to autonomic causes is often associated with sweating. Patients with persistent flushing may have fixed facial erythema with telangiectasias. Rarely, patients can develop a cyanotic change, which is caused by large cutaneous blood vessels that contain slow-flowing deoxygenated blood.

Initial history and physical is important and may give the diagnosis before any tests are ordered. Some common causes that do not require additional testing include rosacea, fever, emotional flushing, menopause ("hot flashes"), anaphylaxis, medication, diet, or alcohol.

Anaphylaxis is a can't-miss diagnosis and should always be in the differential diagnosis of a patient presenting with acute hypotension, difficulty breathing, and angioedema.

Mastocytosis (urticaria pigmentosa, mastocytoma, diffuse cutaneous mastocytosis) is an important diagnosis to consider in children with flushing, especially if these flushing episodes are associated with hypotension.

Codes

ICD10CM:
R23.2 – Flushing

SNOMEDCT:
238810007 – Flushing

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

The most common causes of flushing:
  • Benign cutaneous flushing – Caused by emotion, temperature, food, or beverages.
  • Fever
  • Alcohol – May cause flushing directly or via its metabolite acetaldehyde. More common amongst patients from Asian backgrounds that may have aldehyde dehydrogenase-2 deficiency. Certain drugs combined with alcohol may cause flushing.
  • Drug-induced flushing – See list below.
  • Menopause – Can be provoked by warmth, hot drinks, alcohol, and mental stress.
  • Rosacea
  • Cluster headache
Uncommon, serious, and malignant causes: Neurologic causes: Other causes: Drugs commonly associated with flushing:
  • Vasodilators – nitroglycerin and nitric oxide releasers, sildenafil citrate, amyl nitrite, butyl nitrite
  • Calcium channel blockers
  • Oral steroids
  • Beta blockers
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Opioids
  • NSAIDs
  • Prostaglandins
  • Nicotine
  • Niacin
  • Cholinergic drugs
  • Bromocriptine
  • Chemotherapeutics – tamoxifen, cyclosporine doxorubicin, mithramycin, dacarbazine, cisplatin, interferon alfa-2, flutamide
  • Vancomycin
  • Rifampin
  • Anesthesia
  • Leuprolide
  • Contrast media

Best Tests

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Therapy

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References

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Last Reviewed:06/25/2018
Last Updated:10/22/2019
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Non-carcinoid flushing
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Non-carcinoid flushing : Flushing, Skin warm to touch
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