Blushing: an embarrassing condition, but treatable

The efficacy of oral anticholinergics for sympathetic overactivity in a thoracic surgery clinic

OBJECTIVE

Little is known of the success rates of oral anticholinergics for the treatment of primary hyperhidrosis and facial blushing as alternatives to surgical intervention. We examine predictors of success with these medications.

METHODS

A retrospective review was performed at a single institution, including all patients presenting with symptoms of primary hyperhidrosis, facial blushing, or both from 2004 to 2015. All patients were offered a trial of oral anticholinergics. If oral anticholinergic therapy was not successful, patients were offered surgery. Statistical analyses were performed to compare patients who declined surgery given the trial of oral anticholinergics with those who proceeded with surgery.

RESULTS

A total of 381 patients presented with symptoms of primary hyperhidrosis (86.6%), facial blushing (2.4%), or both (11.0%). A total of 230 patients (60.4%) declined surgery after using oral anticholinergics, and 151 patients (39.6%) chose surgery. Patients who declined surgery were more likely to have symptoms of primary hyperhidrosis without facial blushing (89.6% vs 82.1%; P = .02) or have primary symptoms involving the axilla, torso, scalp, or groin. Patients who proceeded with surgery had higher rates of palmar symptoms as a primary site (77.6% vs 61.1%; P = .01) and were more likely to have facial blushing alone or in combination with primary hyperhidrosis. Presentation with palmar symptoms and greater number of prior therapy attempts were independent predictors of proceeding with surgery after controlling for concomitant symptom type and location (P = .01 and P < .0001, respectively).

CONCLUSIONS

The majority of patients presenting with sympathetic overactivity decline surgery when a trial of oral anticholinergics is included in the treatment algorithm. Facial blushing and palmar symptoms were each associated with choosing surgery.

Thoracic sympathectomy: a review of current indications

BACKGROUND

Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice.

METHODS

The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required.

RESULTS AND CONCLUSIONS

Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Open-label treatment with escitalopram in patients with social anxiety disorder and fear of blushing

Fear of blushing (FB) is a form of social anxiety disorder (SAD) characterized by an intense and obsessive threat of blushing in front of other people. No data are available on the specific efficacy of antidepressants on FB. This open-label pilot study investigated whether the selective serotonin reuptake inhibitor escitalopram specifically improves symptoms of FB in SAD patients. Thirty-nine patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for SAD and presenting a significant FB according to the Salpêtrière Erythrophobia Questionnaire (SEQ) were administered open-label escitalopram (10-30 mg/d) for 12 weeks. A systematic assessment, at baseline and at week 12, included the SEQ, the Liebowitz Social Anxiety Scale, and the Hospital Anxiety and Depression scale. From the 39 patients included, 31 attended the week 4 visit, and 28 the week 12 visit. Significant reductions of FB were observed after 4 weeks of treatment and were more pronounced at the end of the 12-week treatment since patients experienced a 60% decrease in their FB symptoms (P < 0.001). Nineteen subjects (67.8%) reported a 50% decrease or more of their SEQ score, and 14 (50%) met criteria for remission of FB (SEQ score <7). The effect sizes of changes on SEQ, Liebowitz Social Anxiety Scale, and Hospital Anxiety and Depression scale scores were high, with η² ranging between 0.53 and 0.86. Results of this open-label study suggest that escitalopram can be a useful treatment for FB associated with SAD, even if large controlled trials are now needed to further evaluate this result.

[Results of video-assisted thoracoscopic sympathectomy for facial blushing]

BACKGROUND

Involuntary craniofacial erythema, or blushing, due to autonomic dysfunction can be a cause of psychological distress. Although anecdotal reports have suggested that pharmacologic treatments or cognitive behavioral therapy can be used to treat the condition, no rigorous analyses of their efficacy have been reported.

OBJECTIVES

To assess the efficacy of video-assisted thoracoscopic sympathectomy and to study phobic anxiety and other personality traits in a series of patients with involuntary facial blushing.

MATERIALS AND METHODS

We carried out a retrospective observational study of patients treated with bilateral video-assisted thoracoscopic sympathectomy for blushing over a 7-year period (2001-2008). All the patients were treated by a dermatologist, a psychologist, and a thoracic surgeon and were informed of the predicted outcomes.

RESULTS

A total of 204 patients with a mean age of 34 years (range, 15-67 years) were included; the numbers of males and females were similar. Only 10% had unpredicted outcomes; in such cases, either the procedure was insufficiently effective or postoperative reflex sweating developed (and was considered serious in 2%). There were no deaths and only 1 case of transient Horner syndrome. Video-assisted thoracotomy was required for pleural symphysis in 1 patient; 5 patients developed pneumothorax, but only 1 of them required pleural drainage.

CONCLUSIONS

Video-assisted sympathectomy is a safe, effective and definitive treatment for disabling blushing. Anxiety that is detected before surgery is a reaction to blushing rather than a cause of it.

Is there a place for fear of blushing in social anxiety spectrum?

BACKGROUND

Fear of blushing (FB) in front of other people is a frequent and potentially incapacitating problem, but is not yet described as a specific diagnosis in psychiatric classifications. This can be explained by a lack of comparative studies with other forms of social anxiety disorder (SAD). Our aim was thus to explore the specificity of FB in patients with SAD.

METHODS

SAD patients with FB but without other social threat (n = 142), the majority of whom were referred by a department of surgery after an initial request of sympathetic block for facial blushing, were compared to SAD patients with FB and other associated social fears (n = 97), and to SAD patients without FB (n = 190). They were assessed and compared with a structured diagnostic interview for DSM-IV and various scales measuring social anxiety, other anxiety and depressive symptoms, impairment and personality traits.

RESULTS

The group with pure FB showed specific profiles when compared with the two other groups: later age of onset, less comorbidity, lower behavioral and temperamental inhibition, and higher self-esteem. However, their levels of social anxiety and impairment were high. No important differences appeared between the two other groups.

CONCLUSION

The specificity of FB should be considered in the social anxiety spectrum, and could be viewed either as a SAD subtype or as SAD form secondary to facial blushing. Further epidemiological and therapeutic studies on this disorder are necessary.

[Salpêtrière erythrophobia questionnaire validation]

OBJECTIVE

To study the main psychometric characteristics of the Salpêtrière Erythrophobia Questionnaire (SEQ) in a clinical and non-clinical sample.

METHOD

Patients with social phobia (SP) (n = 212), patients with other anxiety disorders (n = 146), and participants from the general population (n = 171) were distributed in the 3 study groups. They completed the SEQ as well as several anxiety and depression scales. Erythrophobia was diagnosed according to standardized criteria and assessed using the Clinical Global Impression Scale.

RESULTS

The SEQ scale factor pattern is clear, with only 1 factor explaining 83.9% of total score and a Cronbach's alpha consistency coefficient of 0.96. The SEQ score is significantly correlated to a dimensional hetero-evaluation of the fear of blushing (rho = 0.91) and SP measures (rho = 0.23 to 0.55). The SEQ mean score is higher in the SP group and even higher in the erythrophobia group. A score of 7 out of 24 makes it possible to identify erythrophobia with 92.1% sensitivity and 87.7% specificity. The SEQ test-retest reliability at 15-day interval is satisfactory (ICC = 0.83).

CONCLUSION

The SEQ is a valid and sensitive tool to screen and measure erythrophobia. It can be used in psychopathological and therapeutic studies of this pathology.

Social anxiety disorder: questions and answers for the DSM-V

BACKGROUND

This review evaluates the DSM-IV criteria of social anxiety disorder (SAD), with a focus on the generalized specifier and alternative specifiers, the considerable overlap between the DSM-IV diagnostic criteria for SAD and avoidant personality disorder, and developmental issues.

METHOD

A literature review was conducted, using the validators provided by the DSM-V Spectrum Study Group. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

RESULTS/CONCLUSIONS

Little supporting evidence was found for the current specifier, generalized SAD. Rather, the symptoms of individuals with SAD appear to fall along a continuum of severity based on the number of fears. Available evidence suggested the utility of a specifier indicating a "predominantly performance" variety of SAD. A specifier based on "fear of showing anxiety symptoms" (e.g., blushing) was considered. However, a tendency to show anxiety symptoms is a core fear in SAD, similar to acting or appearing in a certain way. More research is needed before considering subtyping SAD based on core fears. SAD was found to be a valid diagnosis in children and adolescents. Selective mutism could be considered in part as a young child's avoidance response to social fears. Pervasive test anxiety may belong not only to SAD, but also to generalized anxiety disorder. The data are equivocal regarding whether to consider avoidant personality disorder simply a severe form of SAD. Secondary data analyses, field trials, and validity tests are needed to investigate the recommendations and options.

Management of facial blushing

Patients complaining of facial blushing should be investigated by a dermatologist or an internist to rule out serious underlying disorders. Patients with emotionally triggered blushing should be encouraged to try nonsurgical options as the first line of treatment. Provided there is still an indication for treatment, facial blushing may be treated effectively by thoracoscopic sympathectomy. The type of blushing likely to benefit from sympathectomy is mediated by the sympathetic nerves and is the uncontrollable, rapidly developing blush typically elicited when one receives attention from other people. Side effects are frequent, but most patients are satisfied with the operation. In the short term, the key to success in sympathetic surgery for facial blushing lies in a meticulous and critical patient selection and in ensuring that the patient is thoroughly informed about the high risk of side effects. In the long term, the key to success in sympathetic surgery for facial blushing lies in more quality research comparing surgical, pharmacologic, and psychotherapeutic treatments.