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Symptomatic Treatment of Idiopathic and Rosacea- Associated Cutaneous flushing with Propranolol

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Symptomatic Treatment of Idiopathic and Rosacea- Associated Cutaneous flushing with Propranolol JAM ACAD DERMATOL Brief reports 881 VOLUME 53, NUMBER 5 Symptomatic treatment of idiopathic and rosacea- associated cutaneous flushing with propranolol Helen Craige, MD, and Jack B. Cohen, DO Dallas, Texas Flushing has been associated with medications, rosacea, menopause, carcinoid syndrome, pheochromo- cytoma, polycythemia, and mastocytosis, although it can occur without known cause. There are no known specific treatments available, but b-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. ( J Am Acad Dermatol 2005;53:881-4.) lushing, a periodic exaggeration of the normal and had symptom duration between 1 and 10 years. blush response, has been associated with Facial erythema or blushing on examination was F rosacea, menopause, alcohol or nicotinic acid noted in 8 patients. Heat was the most common ingestion, and with rare conditions, such as carcinoid aggravating factor, but sunlight induced flushing in 4 syndrome, pheochromocytoma, polycythemia, and patients. One patient reported that fluorescent lights mastocytosis.1,2 Flushing also occurs in the absence made her flushing worse. Eight patients had eryth- of any known cause. Despite its benign nature, ematotelangiectatic or papular rosacea and one had some patients find their symptoms disabling. The b- idiopathic flushing. Four patients with rosacea had blockers nadolol3 and propranolol1,4 have suppressed associated symptoms that occurred with each epi- flushing reactions in some patients, particularly when sode: 3 with a burning sensation, and one with associated with anxiety. We present our findings of stinging. Medical histories revealed one patient with 9 patients with flushing treated with propranolol. hypertension, 4 with allergic rhinitis or sinus aller- gies, 3 with headaches (2 migraine), and 3 patients METHOD had fibromyalgia. Medical records of patients with flushing treated Eight of the 9 patients reported diminished symp- with propranolol were reviewed retrospectively to toms and fewer flushing episodes while taking compare age, sex, duration, distribution, aggravating propranolol. None had sufficient relief from the factors, symptomatology, and co-occurring illnesses. initial dosage of propranolol, 10 mg taken 3 times a All but one patient was treated initially with pro- day. This dosage was then increased and individu- pranolol, 10 mg, by mouth 3 times daily, with doses alized. The dose of propranolol needed to achieve increased as tolerated until symptoms improved. symptomatic control of flushing varied between Success was measured by each patient’s perception 20 and 40 mg taken twice daily to 3 times a day of improvement, based on decreasing flushing (Table II). For patient 2, long-acting propranolol, 80 episodes, decreasing symptoms, and quality of life mg daily, was substituted for a calcium channel (Tables I and II). blocker that controlled her hypertension without affecting her flushing. This propranolol formulation RESULTS controlled her blood pressure and decreased her All but one patient were female and all were flushing symptoms. Caucasian. They ranged in age from 31 to 69 years Patient 3, the only male patient in the study, did not have his flushing improve with propranolol. However, he only received 10 mg of propranolol 3 From the Department of Dermatology, University of Texas Southwestern Medical School. times a day for 1 month without side effects and then Funding sources: None. elected to discontinue propranolol altogether. Conflicts of interest: None identified. Two patients experienced adverse side effects that Reprint requests: Jack B. Cohen, DO, Department of Dermatology, necessitated discontinuation of propranolol. Patient UT Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, 1 had significant improvement of her flushing, but TX 75390-9190. E-mail: [email protected]. 0190-9622/$30.00 her pulse rate decreased and she experienced some ª 2005 by the American Academy of Dermatology, Inc. dizziness. Patient 8 had mild improvement, but doi:10.1016/j.jaad.2005.07.021 dizziness and a sensation of balance loss developed 882 Brief reports JAM ACAD DERMATOL NOVEMBER 2005 Table I. Summary of case presentations Ethnic Duration Distribution Presence Patient Age origin/ of of Aggravating of blush Other no. (y) Sex symptoms (y) flushing factors on exam symptoms 1 42 Caucasian/F 3 Nose, cheeks, chin, Cold or hot weather, Yes None ears, anterior neck alcohol ingestion, stress 2 53 Hispanic/F 10 Malar cheeks and Sun and heat exposure Yes None nose 3 31 Caucasian/M 1 Nose, cheeks, chin, Heat, alcohol ingestion No None lower forehead 4 35 Caucasian/F 2 Diffuse background Anger, heat, Yes None erythema on face nervousness, sun, wind, or cold exposure 5 52 Caucasian/F 2 Forehead, Heat, stress, Yes Burning medial cheeks, sun exposure sensation chin, nose 6 31 Caucasian/F 2 Cheeks, chin, nose Mowing the lawn Yes None 7 69 Caucasian/F 10 Face and anterior Heat, stress Yes Burning neck sensation 8 43 Caucasian/F 2 Face, neck, ears, Heat, fluorescent lights, Yes; Burning chest, scalp; stress, and sun preferred sensation left side more exposure to sit in a than right dark room 9 35 Caucasian/F 1 Cheeks, chin Exercise; sometimes Yes Stinging flushing wakes her at night when her propranolol dose reached 40 mg 3 times for an underlying systemic cause. Once systemic a day. Patient 4 attributed her mild weight gain to diseases and medications are excluded, flushing is propranolol, but she continued it because propran- most commonly associated with rosacea and meno- olol was effective in treating her flushing and head- pause, although it may also be idiopathic. Flushing aches. The two patients with known histories of that accompanies menopause is usually amenable to migraine headache also experienced the positive estrogen replacement therapy. On the other hand, side effect of decreased severity of headaches while flushing associated with rosacea commonly fails to taking propranolol. respond to standard therapies for rosacea. Idiopathic flushing tends to occur in women and the symptoms DISCUSSION persist for a long duration.2 Flushing of the face, chest, and neck occurs most Treatment of flushing is difficult primarily because commonly in individuals with fair complexion, par- it has been associated with multiple etiologies. ticularly those of Celtic or northern European ances- Improvement in transient flushing is also difficult to try. The redness is often transient, but it may become quantitate, although attempts to provoke flushing persistent, and telangiectasia can occur. Patients are and to measure the responses to medications have not only distressed by the visual redness; many also been performed. Even so, only small series and case complain of symptoms such as burning, stinging, reports are found in the literature. Friedman et al2 and heat associated with each episode. These symp- described 10 patients with idiopathic flushing. These toms even caused several patients to carry handheld patients failed to respond to one or more therapies or battery-operated fans and spray bottles with cold including H1 and H2 antihistamines, aspirin and water for relief. Patient 5, whose symptoms were nonsteroidal anti-inflammatory drugs, systemic aggravated by light, preferred to remain in a dark- steroids, calcium channel blockers, danazol, and ened room. cromolyn sodium. In another report, clonidine re- Flushing that is accompanied by other symptoms, duced malar temperature in patients with erythema- including abdominal pain, dyspnea, palpitations, totelangiectatic rosacea, despite the failure to reduce and frequent stools, should prompt further work-up redness after provocative maneuvers.5 Although JAM ACAD DERMATOL Brief reports 883 VOLUME 53, NUMBER 5 Table II. Diagnoses, treatment, and side effects Patient Other medical no. diagnoses Systemic medications b Blocker dose* Side effects 1 Rosacea, fibromyalgia None Propranolol, 10 mg, Decreased heart rate, 20 mg q afternoon fatigue, dizziness and 10 g qhs 2 Rosacea, contact dermatitis, Estrogen Propranolol Controlled migraine migraines, depression, Sertraline LA 80 mg qd headaches sinus allergies, hypertension Rabeprazole Fexofenadine 3 Psoriasis, rosacea, hypertension, Tetracycline Propranolol 10 mg None peptic ulcer disease Valsartan tid for 1 mo gave no relief of symptoms; patient discontinued drug 4 Allergic rhinitis, seborrheic Fexofenidine Propranolol 20 mg tid Weight gain, less dermatitis, headaches Aspirin 81 mg headaches Cetirizine 5 Rosacea, atopic dermatitis Aspirin 81 mg Propranolol 40 mg tid None 6 Fibromyalgia, atopic dermatitis, Cetirizine Propranolol 40 mg bid Less migraine rosacea, migraine headaches Tetracycline headaches Oral contraceptive pills 7 Rosacea Aspirin 81 mg Propranolol 20 mg bid None 8 Fibromyalgia, chronic pain Morphine Propranolol 40 mg tid Transient dizziness syndrome, allergic rhinitis, Alprazolam and sense rosacea Lorazepam of balance loss Cyclobenzaprine Lansoprazole Gabapentin Amitriptyline Oral contraceptive pills 9 Hypothyroidism, rhinitis, rosacea Levothyroxine Propranolol 20 mg tid None bid, Twice daily; q, every; qd, daily; qhs, at bed time; LA, long-acting; tid, 3 times a day. *The dose required for subjective relief of symptoms. b-blockers have also not demonstrated objective lab- can occur in up to 3% of patients,
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