Erythrophobia: Ever Red-dy To Blush

24. January 2017

"The human is the only creature that is able to blush. It is however also the only one with reason for doing so", Mark Twain already understood. Even today this biological phenomenon puzzles researchers. Medically speaking there are several possible options for intervening.

Embarrassing situations are plentiful. We spill red wine on someone’s shirt when eating at the in-laws. And bang – redness shoots across one’s face. An expensive gift or a compliment received in a large group has similar effects. Within 15 seconds, the colour reached its maximum, together with a temperature increase of up to one degree. Why people ever even turn red with embarrassment is something scientists have not yet understood. Doctors can now help patients who suffer too much cheek glow or from getting a red face. Where medicine stands at present is shown in a current review article.

Showing emotions is social

Blushing is according to current knowledge the body’s only known reaction which only occurs in social situations. Anybody who puts together clumsy poses behind closed doors experiences none of the undesirable colour. This brought psychologists led by Matthew Feinberg of the University of Berkeley to the following controversial thesis: anybody who turns red in face to face company is showing their awareness of rule infraction. To the company present this would be regarded as being social and trustworthy, according to Feinberg’s conclusion from several studies.

The prerequisite for this appeasement signal is light skin. In dark-skinned people, the same effects occur, but can be hardly noticed. Why we also blush when receiving compliments or a birthday song cannot be explained by this thesis. Perhaps it’s however more of a physical warning to the people themselves to recognise socially difficult situations immediately.

Caution – getting close to our fellow humans

For some people this creates a huge problem. A highpoint is reached in the frequency of blushing, unsurprisingly, during puberty. Those affected develop mitigation strategies, in order to not get into situations that could be accompanied by blushing. Erythrophobia (blush anxiety) is not rare among these people. According to Dutch researchers, three to four percent of all people are affected by erythrophobia. Every second patient with social phobias blushes regularly.

Behavioural therapy does not only focus on the causes. Rather, patients learn to concentrate more on their interlocutor during social interactions. In a protected environment, they have the opportunity to try out different situations, such as a conversation with superiors or party guests.

Help via pill

Should psychological interventions not suffice, there remain pharmacotherapeutic and surgical options. In addition, let’s look at the biology involved. Fibres of the sympathetic nervous system control the diameter of small capillaries. Australian researchers explain the blush as a result of reduced blood outflow, and not as an effect of increased blood supply.

The possibility of pre-existing conditions that lead to so-called blushing should be excluded. These include serotonin-producing carcinoids. Vasodilator medications or interactions of some drugs with alcohol lead to the same effect. If these causatory factors do not turn up, doctors then mostly reach for their prescription pad.

Kristian Smidfeld and Christer Drott Gothenburg report about experiences using selective serotonin reuptake inhibitors (SSRI) against blushing and against social phobia. Beta-blockers are also frequently prescribed. Here the scientific data body is, however, meagre, it says in the article. Experiments involving topically applied ibuprofen are promising. Yet here also, no recommendation is stated in the article.

When nerves get on the nerve

If drugs do not show the desired effect, neurosurgeons in severe cases perform an endoscopic transthoracic sympathectomy (ETS).

The process became known as a measure of last resort in cases of hyperhidrosis, but it also helps against unwanted blushing. Individual ganglia of the sympathetic nervous system are interrupted either reversibly or irreversibly.

Smidfeld and Drott advise surgeons to only select appropriate patients for the procedure. Pleural diseases or thoracotomies in a patient’s previous medical history complicate any ETS. At the same time Smidfeld and Drott warn against having unrealistic expectations. In many cases, victims also need postoperative psychological support. Complications are rare with experienced surgeons. Temporary thoracic catheters are mainly worth mentioning here. Following erroneous damage to the stellate ganglion, Horner’s syndrome can occur with miosis, ptosis and enophthalmos.

The potential risks are offset by good results. Based on data from 648 patients, Smidfeld and Drott report that 73.5 percent were satisfied with the results, 11.0 per cent were dissatisfied and 15.5 percent regretted their decision to go under the knife. Their follow-up covered on average a period of 14.6 years. One critical remark remains: according to the National Institute for Health and Care Excellence (NICE), prior to undergoing ETS all other possible options should be exhausted.

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