College students' use of strategies to hide facial flushing: A target for alcohol education

Alcohol-related facial flushing occurs in individuals who are unable to metabolize ethanol effectively and is associated with increased cancer risk. This study describes college students' understanding of the meaning of flushing for how much alcohol a person should drink and their use of over-the-counter medications and other strategies to reduce its visible effects. Participants: The sample includes 335 White and Asian college students who reported facial flushing after an alcoholic drink. Methods: Students completed an online survey in the spring of their junior year. Results: Most students reported that flushing had no special meaning for drinking or that they did not know what it meant. Six percent reported ever using strategies to hide facial flushing; they were mostly Asian, and those using these strategies drank more alcohol. Conclusions: Findings identify a need for targeted alcohol education with Asian college students who drink alcohol despite experiencing the flushing response.

Cost reduction from resolution/improvement of carcinoid syndrome symptoms following treatment with above-standard dose of octreotide LAR

AIMS

To calculate the cost reduction associated with diarrhea/flushing symptom resolution/improvement following treatment with above-standard dose octreotide-LAR from the commercial payor's perspective.

MATERIALS AND METHODS

Diarrhea and flushing are two major carcinoid syndrome symptoms of neuroendocrine tumor (NET). Previously, a study of NET patients from three US tertiary oncology centers (NET 3-Center Study) demonstrated that dose escalation of octreotide LAR to above-standard dose resolved/improved diarrhea/flushing in 79% of the patients within 1 year. Time course of diarrhea/flushing symptom data were collected from the NET 3-Center Study. Daily healthcare costs were calculated from a commercial claims database analysis. For the patient cohort experiencing any diarrhea/flushing symptom resolution/improvement, their observation period was divided into days of symptom resolution/improvement or no improvement, which were then multiplied by the respective daily healthcare cost and summed over 1 year to yield the blended mean annual cost per patient. For patients who experienced no diarrhea/flushing symptom improvement, mean annual daily healthcare cost of diarrhea/flushing over a 1-year period was calculated.

RESULTS

The economic model found that 108 NET patients who experienced diarrhea/flushing symptom resolution/improvement within 1 year had statistically significantly lower mean annual healthcare cost/patient than patients with no symptom improvement, by $14,766 (p = .03). For the sub-set of 85 patients experiencing resolution/improvement of diarrhea, their cost reduction was more pronounced, at $18,740 (p = .01), statistically significantly lower than those with no improvement; outpatient costs accounted for 56% of the cost reduction (p = .02); inpatient costs, emergency department costs, and pharmacy costs accounted for the remaining 44%.

LIMITATIONS

The economic model relied on two different sources of data, with some heterogeneity in the prior treatment and disease status of patients.

CONCLUSIONS

Symptom resolution/improvement of diarrhea/flushing after treatment with an above-standard dose of octreotide-LAR in NET was associated with a statistically significant healthcare cost decrease compared to a scenario of no symptom improvement.

Pharmacologic Therapies in Women's Health: Contraception and Menopause Treatment

Female hormones play a significant role in the etiology and treatment of many women's health conditions. This article focuses on the common uses of hormonal therapy. When prescribing estrogen-containing regimens throughout the span of a woman's life, the risks are similar (ie, cardiovascular risk and venous thromboembolism), but the degree of risk varies significantly depending on a woman's particular set of risk factors and the details of the hormone regimen. In addition to estrogens and progestogens, this article also touches on the use of selective steroid receptor modulators in emergency contraception and in treatment of menopause symptoms.

Botulinum Toxin A in Treatment of Facial Flushing

Flushing is a condition with episodic attacks of redness of the skin with a sensation of warmth or burning, this disease causes emotional and functional problems in patients. There is various treatments for this condition; one of them is the use of botulinum toxin-A (BTA). In this prospective pilot study we studied the effect of Botulinum toxin-A (BTA) effect on DLQI of patients with facial flushing, we compared the DLQI before and after treatment. The number of 24 women with facial flushing admitted to the department of dermatology of Hamadan Farshchian Hospital, with the age range of 18 to 60 was enrolled in the study. Patients completed Dermatology Quality of life Index questionnaire before and one month after treatment. In our study 1 unit of BTA was injected intracutaneously per square cm in both sides of cheeks, to a total dose of 30 units per session. All of 24 patients completed the study. The mean age was 37.79±13.13. In all patients, DLQI decreased, and in two months follow up, the mean of DLQI improved from 8.08±1.17 to 4.5±1.21 (P.value<0.005). Based on this study BTA is an effective and safe treatment for facial flushing.

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.

Formulation and in vitro evaluation of niacin-loaded nanoparticles to reduce prostaglandin mediated vasodilatory flushing

OBJECTIVE

Niacin, activating G-protein coupled receptor (GPR) 109A, stimulates release of vasodilatory prostaglandins (PGs) such as PGE2 which can elicit niacin-associated flushing side effects. Poly-lactic-co-glycolic acid (PLGA) and poly-lactic acid (PLA) are used in nanoparticle (NP) drug delivery to reduce adverse effects and modulate drug release. Our study evaluated the in vitro effects of niacin-loaded PLGA or PLA-NPs on PGE2 expression in whole human blood as a model for niacin-induced flushing.

MATERIALS AND METHODS

NPs were formulated using a solvent evaporation process and characterized by size, polydispersity, zeta potential, drug entrapment, morphology, and drug release. NP in vitro effects on PGE2 release were measured via ELISA analysis.

RESULTS

PLGA-NPs demonstrated the lowest NP size (66.7 ± 0.21 nm) with the highest zeta potential and percent drug entrapment (42.00 ± 1.62 mV and 69.09 ± 0.29%, respectively) when compared to PLA-NPs (130.4 ± 0.66 nm, 27.96 ± 0.18 mV, 69.63 ± 0.03 %, respectively). In vitro release studies showed that PLGA-NPs underwent significant reductions in cumulative drug release when compared to PLA-NPs (p < 0.05). Furthermore, when compared to plain niacin, PLGA-NPs significantly reduced in vitro PGE2 release (p < 0.05).

CONCLUSIONS

These results support the use of PLGA-NPs as a novel method of delivery for reducing niacin-associated flushing.

Telotristat etiprate for carcinoid syndrome: a single-arm, multicenter trial

CONTEXT

Carcinoid syndrome (CS) is associated with elevated serotonin, diarrhea, flushing, and increased risk of valvular heart disease. Many patients respond to somatostatin analogs initially, but response diminishes in most patients. Additional options are needed.

OBJECTIVE

To assess whether telotristat etiprate (TE) can reduce gastrointestinal symptoms in CS and reduce urinary 5-hydroxyindoleacetic acid (u5-HIAA; a biomarker of serotonin).

DESIGN

A prospective, exploratory, dose-escalating 12-week, open-label, multicenter study of TE with efficacy and safety analyses.

SETTING

A multicenter study.

PATIENTS

Eligible patients had metastatic, well-differentiated, neuroendocrine tumors and CS with ≥ four bowel movements (BMs) per day. Somatostatin analog use was allowed.

INTERVENTIONS

TE, a novel oral inhibitor of peripheral serotonin synthesis.

MAIN OUTCOME MEASURES

Primary: safety. Secondary: daily BMs, stool form, and u5-HIAA.

RESULTS

Fifteen patients were enrolled, and 14 completed the treatment period. All patients experienced reductions in BMs per day (mean decrease, 43.5%). A 74.2% mean reduction in u5-HIAA, the main metabolite of serotonin, was observed, with generally greater reductions in patients with greater reductions in BMs per day. Nine patients (75%) reported "adequate relief" of gastrointestinal symptoms at 12 weeks, compared with two (17%) at baseline. Stool form and flushing also improved. Adverse events were mostly gastrointestinal (n = 10; 67%), consistent with underlying illness; three adverse events were serious (abdominal pain, diarrhea, and gastroenteritis) but were judged unrelated.

CONCLUSION

TE was generally safe and well tolerated. Patients experienced substantial improvement in CS and reductions in u5-HIAA, consistent with the mechanism of action of TE. These results support further evaluation in phase 3 studies.

[Identification of mesenteric traction syndrome using laser speckle contrast imaging]

A mesenteric traction syndrome manifests in some patients undergoing major abdominal surgery and is identified by flushing, accompanied by hypotension and tachycardia. We used laser speckle contrast imaging to quantify blood flow in forehead skin of patients undergoing Whipple's operation. In two patients with similar blood pressure (-50 mmHg) and profound drop in systemic vascular resistance (-40%), forehead skin perfusion increased three-fold in one patient, while it was unchanged in a patient for whom flushing was not evident.

[Mesenteric traction syndrome]

Mesenteric traction syndrome (MTS) manifests in 58-87% of patients undergoing upper abdominal surgery and is characterised by a triad of hypotension, tachycardia, and flushing. Prostacyclin is released from the gut mucosa following intestinal eventration and cyclooxygenase antagonists prevent the development of MTS. Also the use of remifentanil appears to increase the incidence of MTS and hypotension is aggravated by epidural analgesia. Yet, prostacyclin may be important for maintaining microcirculation within the splanchnic area and preserve its mucosal barrier.

Use of herbal remedies among patients undergoing hemodialysis

This study aims to determine the prevalence, types, and associated factors for the use of herbal remedies in hemodialysis patients. Two hundred participants were selected by stratified sampling and were systematically interviewed. One hundred and twenty-six patients (63%) had used herbal remedies some time since their initiation of dialysis treatment. The users of herbal remedies had a significantly older age than nonusers, but no other significant differences were observed. The most prevalent complaints that led to herbal remedies use were gastroenterological complaints, flushing, and excessive thirst. Cichorium intybus, Borage officinalis, Mentha longifolia, and Matricaria recutita were the most prevalently used herbs in our patients. More study should be done on safety and efficacy of these herbs for hemodialysis patients.

Pasireotide (SOM230) shows efficacy and tolerability in the treatment of patients with advanced neuroendocrine tumors refractory or resistant to octreotide LAR: results from a phase II study

Pasireotide (SOM230) is a novel multireceptor-targeted somatostatin (sst) analog with high binding affinity for sst receptor subtype 1, 2, 3 (sst(1,2,3)) and sst(5). Because of this binding profile, pasireotide may offer symptom control in patients with neuroendocrine tumors (NETs) and carcinoid syndrome no longer responsive to octreotide LAR. This was a phase II, open-label, multicenter study of pasireotide in patients with advanced NET whose symptoms of carcinoid syndrome (diarrhea/flushing) were inadequately controlled by octreotide LAR. Patients received s.c. pasireotide 150 μg twice daily (bid), escalated to a maximum dose of 1200 μg bid until a clinical response was achieved. Forty-four patients were evaluated for efficacy and 45 for tolerability. Pasireotide 600-900 μg s.c. bid effectively controlled the symptoms of diarrhea and flushing in 27% of patients. Evaluation of tumor response in 23 patients showed 13 with stable disease and ten with progressive disease at study end. The most common drug-related adverse events were nausea (27%), abdominal pain (20%), weight loss (20%), and hyperglycemia (16%) and most were of mild or moderate severity. Pasireotide 600-900 μg s.c. bid was effective and generally well tolerated in controlling the symptoms of carcinoid syndrome in 27% of patients with advanced NET refractory or resistant to octreotide LAR therapy.

Effectiveness and safety of laropiprant on niacin-induced flushing

Extended-release niacin (ERN) improves multiple lipid parameters but is underused owing to niacin-induced flushing (NIF). Laropiprant (LRPT) reduces NIF; however, its effects on chronic flushing (>6 months) have not been studied. We examined whether after 20 weeks of treatment with ERN/LRPT, patients who continued ERN/LRPT would experience less NIF than patients who stopped LRPT and continued ERN alone. A total of 1,152 dyslipidemic patients were randomized 2:2:1 to group 1, ERN/LRPT 1 g/20 mg/day from 0 to 4 weeks and then ERN/LRPT 2 g/40 mg/day from 5 to 32 weeks; group 2, ERN/LRPT 1 g/20 mg/day from 0 to 4 weeks, ERN/LRPT 2 g/40 mg/day from 5 to 20 weeks, and then ERN 2 g/day without LRPT from 21 to 32 weeks; or group 3, placebo for the entire study. The end points included the number of days each week with a moderate or greater Global Flushing Severity Score (GFSS) ≥4 (primary end point) and the percentage of patients with a maximum GFSS of ≥4 (secondary end point) during the postwithdrawal period (weeks 21 to 32). ERN/LRPT produced significantly less NIF than ERN alone during the postwithdrawal period, as measured by the number of days each week with a GFSS of ≥4 (p <0.001) and the percentage of patients with a maximum GFSS of ≥4 (p <0.001; ERN/LRPT 19.6%; ERN 48.9%; placebo 9.2%). Compared with ERN alone, ERN/LRPT produced fewer drug-related adverse experiences during the postwithdrawal period. After 20 weeks of stable maintenance therapy, dyslipidemic patients treated continuously with ERN/LRPT experienced less NIF than did patients who had had LRPT withdrawn and had continued with ERN alone. In conclusion, the results of our study support the long-term efficacy of ERN/LRPT in reducing NIF symptoms.

Antitumor effects of somatostatin analogs in neuroendocrine tumors

BACKGROUND

For decades, somatostatin analogs (including octreotide and lanreotide) have been indicated for relief of the symptoms of flushing, diarrhea, and wheezing associated with secretory neuroendocrine tumors (NETs). Recently, it has been suggested that somatostatin analogs may provide direct and indirect antitumor effects in secretory and nonsecretory NETs in addition to symptom control in secretory NETs.

METHODS

A systematic review of MEDLINE was conducted to identify studies that investigated the antitumor effects of octreotide or lanreotide for patients with NETs. Additional studies not published in the peer-reviewed literature were identified by searching online abstracts. Results. In all, 17 octreotide trials and 11 lanreotide trials that included antitumor effects were identified. Partial response rates were between 0% and 31%, and stable disease rates were between 15% and 89%. Octreotide was the only somatostatin analog for which results of a phase III, randomized, placebo-controlled clinical trial that investigated antitumor effects were published. After 6 months of treatment in this randomized phase III trial, stable disease was observed in 67% of patients (hazard ratio for time to disease progression: 0.34; 95% confidence interval: 0.20-0.59; p = .000072).

CONCLUSIONS

In addition to symptom control for NETs, the data support an antitumor effect of somatostatin analogs and suggest that they may slow tumor growth. Long-acting repeatable octreotide has been shown to have an antitumor effect in a randomized phase III trial in midgut NETs, whereas results are pending in a corresponding controlled trial with lanreotide for patients with intestinal and pancreatic primary NETs.

[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.

Topical niacin cream-assisted 595-nm pulsed-dye laser treatment for facial flushing: retrospective analysis of 25 Korean patients

BACKGROUND

Flushing is defined clinically as a transient reddening of the face and other areas. Due to the transient nature of flushing, a patient may not show signs of flushing during laser treatment.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of 595-nm pulsed-dye laser treatment of flushing or erythema after provocation of flushing by topical niacin cream.

METHODS

We retrospectively reviewed a total of 25 Korean patients with facial flushing who were treated with three sessions of 595-nm pulsed-dye laser after the application of topical niacin cream.

RESULTS

Follow-up results revealed that 12 of the 25 patients demonstrated marked (51-75%) clinical improvement of baseline facial erythema. Eight patients had moderate (26-50%) improvement and three demonstrated near total (≥ 75%) improvement. Two patients showed minimal to no (0-25%) improvement. We observed that the reactivity to topical niacin cream was markedly reduced in 64% of our patients after 595-nm pulsed-dye laser treatments. Minimal post-therapy facial oedema was noted in most of the patients, which usually resolved spontaneously within 2 days. Pronounced facial swelling was observed in four patients.

CONCLUSION

We suggest that 595-nm pulsed-dye laser treatment after provocation of flushing by topical niacin cream may provide a new treatment algorithm for facial flushing in Asians.

A 6-month old with total body flushing and a macular-papular lesion

Flushing of the skin of an infant may be a sign of the child's first allergic reaction to food, insect envenomation, or other allergens, a sign of sepsis, or due to dilation of cutaneous vessels caused by a vasodilator substance or neural mechanisms. A rare cause of this condition results in the release of mast cell mediators such as histamine, prostaglandin D2, tryptase, chymase, and leukotrienes. We present a case of a 6-month-old with severe total body flushing and a yellow-tan, raised, well-demarcated lesion on the thigh consistent with a solitary mastocytoma. Erythema was most pronounced adjacent to the lesion, suggesting a positive Darier sign. Subsequent evaluation by a dermatologist confirmed the diagnosis, and the patient underwent no further therapy; however, the family was appropriately counseled on management if the symptoms were to reappear. Appropriate diagnosis and management of this patient and other forms of mastocytosis in children are discussed.

Aspirin reduces cutaneous flushing after administration of an optimized extended-release niacin formulation

OBJECTIVE

Niacin is an effective treatment for dyslipidemia due to its favorable effects on multiple lipid parameters. Clinical utility of niacin is sometimes limited, however, because of cutaneous flushing. A once-daily, extended-release (ER) niacin formulation has been shown to significantly reduce flushing compared to immediate-release niacin. An optimized (reformulated) version of niacin ER has recently been developed and was shown in a previous study to significantly reduce flushing intensity (severity) compared to the non-optimized (commercial) formulation. The current study was designed to evaluate the effect of aspirin on various indices of flushing when administered with the optimized niacin ER formulation.

METHOD

This was a randomized, double-blind, double-dummy, placebo-controlled flush provocation crossover study in healthy males. To increase the probability of flushing, subjects received a single dose of reformulated niacin ER 2,000 mg, which is the upper limit of the approved dosage range. Subjects received 650 mg aspirin orally either 30 minutes before or concomitantly with niacin ER, or placebo with niacin ER, in 3-way crossover fashion. The primary endpoint was the number of subjects who reported at least one flushing event. Secondary endpoints included the perceived intensity and duration of flushing symptoms.

RESULTS

In the 148 men who completed all treatments, aspirin significantly reduced flushing incidence (the primary endpoint) following administration of niacin ER compared with placebo. Among subjects receiving placebo, 77% of subjects reported flushing with niacin ER. Among subjects receiving aspirin, 53-61% of subjects reported flushing (pretreatment and concomitant treatment, respectively, both p < 0.001 compared with placebo) with niacin ER. Aspirin also significantly reduced intensity and duration of flushing (by 30-40%) compared with no aspirin. The two aspirin-containing treatments (i.e. pre- or concomitant treatment) were similar in their effects on flushing incidence, intensity and duration. Median intensity on a 100 mm visual analogue scale (VAS) was reduced from 33 mm with placebo to 19-23 mm with aspirin. Median duration was reduced from approximately 1 hour with placebo to 37-48 minutes with aspirin.

CONCLUSION

Aspirin significantly reduced the incidence, intensity and duration of flushing associated with reformulated niacin ER. These results support the administration of aspirin prophylactically to decrease niacin-induced cutaneous flushing and to improve patient adherence and acceptability of chronic niacin treatment at therapeutic doses.

Sympathomimetic amine therapy may improve refractory gastroparesis similar to its effect on chronic pelvic pain--case report

PURPOSE

To determine if treatment with sympathomimetic amines can effectively treat gastroparesis that was refractory to other medical therapy.

METHODS

After failing a water load test, a 29-year-old female was treated with 20 mg/day of dextroamphetamine sulfate.

RESULTS

After several weeks of therapy she noted that most of her symptoms of gastroparesis subsided and she has remained symptom free for eight months.

CONCLUSIONS

Similar to its beneficial effect on chronic pelvic pain of both bladder and non bladder origin, refractory weight gain, esophageal pain, chronic fatigue syndrome, headaches and vasomotor symptoms, sympathomimetic amine therapy can also effectively treat gastroparesis refractory to other medical therapies at least in some cases.

Symptomatic treatment of idiopathic and rosacea-associated cutaneous flushing with propranolol

Flushing has been associated with medications, rosacea, menopause, carcinoid syndrome, pheochromocytoma, polycythemia, and mastocytosis, although it can occur without known cause. There are no known specific treatments available, but beta-blockers have suppressed flushing reactions in some patients, particularly when associated with anxiety. The medical histories and clinical characteristics of 9 patients with either idiopathic flushing or flushing associated with rosacea were reviewed. Eight patients experienced subjective improvement with propranolol therapy.

Antagonism of the prostaglandin D2 receptor 1 suppresses nicotinic acid-induced vasodilation in mice and humans

Nicotinic acid (NA) is commonly used to treat dyslipidemia, but it elicits an adverse effect, termed flushing, which consists of cutaneous vasodilation with associated discomfort. An animal model of NA-induced flushing has been established in mice. As in humans, NA stimulated vasodilation in a dose-dependent manner, was associated with an increase of the vasodilatory prostaglandin (PG) D2 in plasma and could be blocked by pretreatment with aspirin. Two PGD2 receptors have been identified: PGD2 receptor 1 (DP1, also called DP) and PGD2 receptor 2 (DP2, sometimes termed CRTH2). DP2 does not mediate NA-induced vasodilation; the DP2-specific agonist DK-PGD2 (13,14-dihydro-15-keto-PGD2) did not induce cutaneous vasodilation, and DP2-/- mice had a normal vasodilatory response to NA. By contrast, BW245C, a DP1-selective agonist, induced vasodilation in mice, and MK-0524, a DP1-selective antagonist, blocked both PGD2- and NA-induced vasodilation. NA-induced vasodilation was also studied in DP1+/+, DP1+/-, and DP1-/- mice; although NA-induced vasodilation depended almost completely on DP1 in female mice, it depended only partially on DP1 in male mice. The residual NA-induced vasodilation in male DP-/- mice was aspirin-sensitive. Thus, in the mouse, DP1 appears to be an important component involved in NA-induced vasodilation, but other cyclooxygenase-dependent mechanisms also may be involved. A clinical study in healthy men and women demonstrated that treatment with MK-0524 reduced the symptoms of flushing and the increase in skin perfusion after the administration of NA. These studies suggest that DP1 receptor antagonism may be an effective means to suppress NA-induced flushing in humans.

Photodynamic therapy for the treatment of erythema, papules, pustules, and severe flushing consistent with rosacea

We report a case of a 45-year-old woman who presented with facial erythema, papules, pustules, and severe flushing consistent with rosacea. The patient had failed standard pharmacologic treatments. The patient's flushing was so severe that she had undergone an elective sympathectomy. She received 6 sessions of photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA as Levulan Kerastick, Dusa Pharmaceuticals) given at 2-week intervals. Improvement was evident after the second treatment and was considered "excellent" after the sixth treatment. Improvement continued and no flares were observed 1 month after the final treatment.

Oral therapy for rosacea

This article will examine oral therapies utilized in the treatment of rosacea. Important topics include recognizing which types of rosacea can benefit from oral therapy and concerns regarding the emergence of bacterial resistance.

Improvement of accessory symptoms of hypertension by TSUMURA Orengedokuto Extract, a four herbal drugs containing Kampo-Medicine Granules for ethical use: a double-blind, placebo-controlled study

A double-blind, placebo-controlled study was conducted to evaluate the efficacy, safety, and utility of TSUMURA Orengedokuto Extract Granules for Ethical Use (TJ-15) as a treatment for the accessory symptoms of hypertension. Two capsules of the study drug were administered orally 3 times daily (i.e., before meals) for 8 weeks. Among 265 patients enrolled in the study, 134 were assigned to the TJ-15 group and 131 were assigned to the placebo group, of whom 204 patients (103 in the TJ-15 group and 101 in the placebo group) were included in the efficacy and utility analyze and 251 patients (128 in the TJ-15 group and 123 in the placebo group) were included in the safety analysis. Efficacy was significantly higher in the TJ-15 group based on the total score for the accessory symptoms of hypertensions which was the primary efficacy endpoint (Wilcoxon's rank sum test, p=0.013). When each accessory symptom of hypertension was assessed separately, efficacy was higher for hot flushes and facial suffusion in the TJ-15 group (Wilcoxon's rank sum test, p=0.034, and 0.022, respectively). There were no significant differences between the TJ-15 and the placebo groups with respect to the decrease of blood pressure or the antihypertensive effect. There was also no significant difference between the two groups with regard to the overall safety rating. The utility rating was significantly higher in the TJ-15 group than in the placebo group (Wilcoxon's rank sum test, p=0.016). In conclusion, TJ-15 was superior to placebo with respect to efficacy, safety, and utility for the treatment of accessory symptoms of hypertension.

Efficacy of pulsed estrogen therapy in relatively younger patients with surgically induced menopause

BACKGROUND

Pulsed estrogen therapy is a new approach in estrogen replacement therapy. We carried out a prospective study to evaluate the efficacy of pulsed estrogen therapy in relatively younger patients with surgically induced menopause.

METHODS

Patients (n=138) <45 years old and suffering from severe vasomotor symptoms secondary to surgically induced menopause were included in the study. After the initiation of pulsed estrogen therapy (300 microg/day), the patients were re-evaluated every 4 weeks. The dose was increased at each follow-up, if necessary (to a maximum of 600 microg/day). The patients who preferred another method after the first 12 weeks were prescribed oral conjugated estrogen (0.625 mg/day) and at the end of the second 12 weeks their satisfaction levels were assessed.

RESULTS

At the end of the first 12 weeks, 26 patients were completely satisfied (18.8%) and 47 were moderately satisfied (34.1%), whereas 65 concluded that the pulsed estrogen therapy they received was ineffective (47.1%). At the end of the second 12 weeks, all the patients were completely satisfied.

CONCLUSION

Pulsed estrogen therapy for 12 weeks reduced the frequency of hot flushes in relatively younger patients with surgically induced menopause; however, 81.2% of patients were not completely satisfied at the end of this period.

Rapid and sustained relief from the symptoms of carcinoid syndrome: results from an open 6-month study of the 28-day prolonged-release formulation of lanreotide

This 6-month, open, non-controlled, multicenter, dose-titration study evaluated the efficacy and safety of 28-day prolonged-release (PR) lanreotide in the treatment of carcinoid syndrome. Eligible patients had a carcinoid tumor with > or =3 stools/day and/or > or =1 moderate/severe flushing episodes/day. Six treatments of 28-day PR lanreotide were administered by deep subcutaneous injection. The dose for the first two injections was 90 mg. Subsequent doses could be titrated (60, 90, 120 mg) according to symptom response. Seventy-one patients were treated. Flushing decreased from a mean of 3.0 at baseline to 2.3 on day 1, and 2.0 on day 2, with a daily mean of 2.1 for the first week post-treatment (p < 0.05). Diarrhea decreased from a mean of 5.0 at baseline to 4.3 on day 1 (p < 0.05), and 4.5 on day 2, with a daily mean of 4.4 for the first week post-treatment (p < 0.001). Symptom frequency decreased further after the second and third injections, and reached a plateau after the fourth injection. By month 6, flushing and diarrhea had significantly decreased from baseline by a mean of 1.3 and 1.1 episodes/day, respectively (both p < or = 0.001); 65% of patients with flushing as the target symptom and 18% of diarrhea-target patients achieved > or =50% reduction from baseline. Median urinary 5-hydroxyindoleacetic acid and chromogranin A levels decreased by 24 and 38%, respectively. Treatment was well tolerated. 28-day PR lanreotide was effective in reducing the symptoms and biochemical markers associated with carcinoid syndrome.

Botulinum Toxin for the Treatment of Facial Flushing

BACKGROUND

Facial flushing is a common problem that is encountered by fair-skinned patients of Celtic and Northern European descent. Although usually transient in nature, some patients display a persistent reddened skin tone, with periods of increased erythema. Treatment of this condition is limited.

OBJECTIVE

To describe a novel method for the treatment of persistent facial flushing.

METHOD

We report a case of persistent facial flushing that was resistant to multiple pulsed dye laser treatments and was successfully treated with botulinum toxin A.

RESULTS

The posttreatment appearance was dramatic, and the patient was highly satisfied with the cosmetic outcome.

CONCLUSION

Botulinum toxin A can be used in small quantities to decrease persistent facial flushing temporarily.

Successful use of Botulinum toxin-A for the treatment of neck and anterior chest wall flushing

Neck and anterior chest wall flushing can be a social handicap to the sufferer and current treatment options are often unsatisfactory. We report the case of a 48-year-old woman with severe flushing of the anterior neck and anterior chest wall which resolved after three treatments of intracutaneous botulinum toxin A injections. We believe that this treatment method for skin flushing is simple, effective and free of significant side effects at these sites. Further studies are needed to evaluate the duration of the therapeutic effect.

The management of rosacea

Rosacea is a multiphasic disease which is associated with flushing, erythrosis, papulopustular rosacea and phymas; each phase is likely to have its own treatment. Flushing is better prevented rather than treated, and its etiology investigated. Beta-blockers, atenolol in particular, are worthy of prophylactic trials examining their efficacy in treating the flushing associated with rosacea. Currently, clonidine is the only drug available for the treatment of flushing. Treatment for erythrosis includes topical and systemic therapies. Metronidazole 1% cream and azelaic acid 20% cream have been reported to reduce the severity score of erythema. The systemic treatment of erythrosis is based on the association of Helicobacter pylori with rosacea. However, this role is still being debated. Eradication of H. pylori can be achieved using a triple therapy regimen lasting 1 to 2 weeks [omeprazole and a combination of two antibacterials (a choice from clarithromycin, metronidazole or amoxicillin)]. Both the flashlamp-pumped long-pulse dye laser and the potassium-titanyl-phosphate laser may be used in the treatment of facial telangiectases. Both systemic and topical remedies may be used to treat the papulopustules of rosacea. Systemic treatment includes metronidazole, doxycycline, minocycline, clarithromycin and isotretinoin, while topical treatment is based on metronidazole cream and gel. The presence of Demodex folliculorum is important in the inflammatory reaction, whether it is pathogenetic or not. Crotamiton 10% cream or permethrin 5% cream may be useful medications for papulopustular rosacea, although they are rarely successful in eradicating D. folliculorum. Oral or topical ivermectin may also be useful in such cases. Ocular involvement is common in patients with cutaneous rosacea and can be treated with orally administered or topical antibacterials. Once rhinophyma starts to be evident, the only way to correct it is by aggressive dermatosurgical procedures. Decortication and various types of lasers can also be used. Associated conditions, such as seborrheic dermatitis and possible contact sensitizations, deserve attention.

The role of gustatory flushing in Frey's syndrome and its treatment with botulinum toxin type A

After parotid surgery, gustatory sweating and flushing occur more frequently, the former reportedly in 15-100% of cases, while no reliable data are available for the latter. Although botulinum toxin (BoNT) is effective in controlling sweating, little is known about its effect on flushing. In 17 patients suffering from Frey's syndrome after parotid surgery, we studied the gustatory flushing phenomenon as compared to gustatory sweating, analyzing their frequency, area, type of stimulus and response to BoNT administration. Cutaneous blood flow (CBF) was monitored by laser Doppler flowmetry (LDF) on affected and unaffected areas of the cheek in basal conditions and after meals, before and then 1 month after starting the BoNT injections. The Minor test was used to identify the sweating area. Flushing was observed in 7 of 17 patients after masticatory activity, spicy meals or citrus fruits. No clinical data correlated with any presence of flushing. Flushing regressed completely after BoNT administration and CBF reached similar values in the affected and unaffected sites. No adverse effects were observed. BoNT administration proved an effective and safe treatment for gustatory sweating and flushing in patients with Frey's syndrome.

Treatment of systemic mast cell disorders

The heterogeneous nature of disease manifestations in mastocytosis requires the individualization of therapy to each patient's clinical presentation and prognosis. The mainstay of treatment for most categories of mastocytosis are H1 and H2 antihistamines with the addition of corticosteroids for more severe symptoms. This article presents a summary of treatment strategies for indolent and aggressive forms of mastocytosis along with a discussion of future therapeutic directions.

Treatment of an acute flush reaction caused by subcutaneous r-hirudin with pegylated hirudin

We report a patient who was treated with recombinant (r)-hirudin for heparin-induced thrombocytopenia and developed a flush reaction twice upon re-exposure to 25 mg of subcutaneous r-hirudin. Antihirudin IgG antibodies developed. The patient received 50 mg of PEG-hirudin subcutaneously over 2 days. No side-effects occurred. The level of IgG antihirudin antibodies increased. Ecarin clotting time and thrombin inhibition S2238 assay were not influenced by the patient's IgG antihirudin antibody. PEG-hirudin may be used in patients with intolerance to r-hirudin because of a dissociation of the allergenic and immunogenic properties of the pegylated drug.

Octreotide inhibition of flushing and colonic motor dysfunction in carcinoid syndrome

OBJECTIVES

Previous studies showed increased plasma motilin and substance P concentrations and accelerated motor function in the small bowel and colon in patients with carcinoid diarrhea. Octreotide is beneficial in patients with carcinoid syndrome. Our hypothesis was that octreotide inhibits accelerated motility and gut neuropeptides in carcinoid syndrome.

METHODS

In 12 patients with metastatic carcinoid syndrome, we investigated the effect of octreotide 50 microg s.c. t.i.d (n = 6) or placebo (n = 6) on postprandial symptoms, GI transit, colonic motility, and circulating levels of selected circulating peptides and amines.

RESULTS

Octreotide reduced postprandial flushing (p = 0.03) but not pain. Octreotide significantly retarded overall colonic transit and proximal colonic emptying (p < 0.05); it tended to prolong small bowel transit time (p = 0.13) and to reduce postprandial colonic tone (p = 0.08) compared with placebo. Octreotide also reduced circulating levels of peptide YY, neurotensin, vasoactive intestinal polypeptide, and substance P but had no effect on plasma motilin, neuropeptide Y, calcitonin gene-related peptide, or histamine after meal ingestion.

CONCLUSION

Octreotide ameliorates gut motor dysfunctions that characterize carcinoid diarrhea; the potential role of specific antagonism of serotonin, substance P, and vasoactive intestinal polypeptide alone or in combination with agents that inhibit their release in carcinoid diarrhea deserves further study.

Determinants of self rated menopause status

This study, based on a population survey, examines the self ratings of progress through the menopausal transition of women in natural menopause, women using hormone therapy and women who have undergone hysterectomy. The latter two groups are usually excluded from discussions of menopausal transition, since the accepted menstrually defined criteria do not apply to them. Hysterectomised women do not differ in their self rating profile from non-hysterectomised women, after hormone therapy status is taken into account. This is surprising, since they may have been expected to see themselves as in the main postmenopausal. Use of hormone therapy is tantamount to self perception as at least perimenopausal. Among women in natural menopause there is 29% disagreement between self ratings and menstrually defined categories. On the basis of these observations it is hypothesised that experience of symptoms associated with menopause is important in determining self ratings. The good fit of logistic regression predictions of self ratings from hysterectomy status, hormone therapy status and experience of hot flushes is consistent with this hypothesis. This research indicates that it is important to take women's subjective evaluations into account in assessing progress through the menopausal transition.