See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/230582142

Erythrophobia - Problems of Diagnostics and Treatment

Article  in  Polish Journal of Surgery · June 2012

DOI: 10.2478/v10035-012-0054-8 · Source: PubMed

CITATIONS READS

0 1,420

1 author:

Tomasz Stefaniak
Medical University of Gdansk
107 PUBLICATIONS   1,030 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Gravimetry as a standard tool in PHH Assessment View project

Polish validation for positive psychology tools View project

All content following this page was uploaded by Tomasz Stefaniak on 15 May 2014.

The user has requested enhancement of the downloaded file.

POLSKI
PRZEGLĄD CHIRURGICZNY 10.2478/v10035-012-0054-8
2012, 84, 6, 322–327
R E V I E W
Erythrophobia – problems of diagnostics and
treatment
Tomasz J. Stefaniak
Department of General, Endocrine and Transplant Surgery, Medical University in Gdańsk
Kierownik: prof. dr hab. Z. Śledziński
Humans are social creatures and therefore
reactions of their surrounding are especially
important for their functioning, in particular
in the period of high importance of interper-
sonal relations for education and professional
career. Pronounced and persisting fear of being
embarrassed or humiliated in social situations
is a principal mental symptom of social phobia.
Anticipatory anxiety and avoidance of public
situations appear when a patient is observed
during a public performance or speech, during
a common meal or exam (1). This problem af-
fects as many as 7-13% of the population (2).
Other problems related to social phobia include
hand tremor, cognitive difficulties (memory,
attention, association), difficulties in communi-
cating with others and fear of reaction of other
persons to these symptoms (3). Some patients
were found to be uncertain in their childhood,
however these observations are inconsistent. In
majority of patients these symptoms appear
between the age of 10 and 20 years (3).
Consequences of untreated social phobia
include social isolation, reduced educational
achievements and career development, depres-
sion and alcohol abuse (2). As studies demon-
strate, symptoms of erythrophobia are closely
associated with social support and fear of los-
ing that support (social cost) (4). Furthermore,
social phobia becomes “a self-fulfilling proph-
ecy”, results from impaired social relations,
not only as a reaction of the environment to
blushing, but also from high focus on their own
symptoms (self-focus) and higher level of
negative feelings that are characteristic for
patients suffering from social phobia (5). More-
P A P E R S
over, psychological features that stimulate the
symptoms include: distorted assessment of
blushing in themselves and others and nega-
tive conditioning of blushing (patients who
suffer from blushing that are free from symp-
toms, wait for them and somewhat “are happy
with” and – stimulate – the fact of appearance
of this symptom (6).
Blushing is the most spectacular symptom
of social phobia and fear of clear signs of ner-
vousness being noticed by the society is a key
factor of behavioral-cognitive models of this
disorder. Physiological role of blushing re-
mains unknown. It is believed that its aim is
to stimulate compassion in the other person
and to obtain help or trust despite unsuccess-
ful interaction (7). Dijk et al. conducted an
experiment during which its participant par-
ticipated in an internet game which key was
to realize tasks assigned to parties. A virtual
associate made a mistake resulting in loss of
all resources and failure of the team at one of
the stages. Then the study subjects were
showed an image of the virtual associate,
blushing or without blushing. This study
showed that the study subjects were willing to
give more resources for further realization of
tasks to a blushing person, they claimed they
had higher trust in this person as well as as-
sessed that probability of this person making
the same mistake in the future is lower than
by a person without blushing (7).
Similarly, association between psychologi-
cal (cognitive) and pathophysiological (behav-
ioral) of blushing remains unknown. Gerlach
et al. analyzed volume of blood inflowing to the
 Erythrophobia – problems of diagnostics and treatment
face and heart rate in patients who complained
of social phobia and in subjects who did not
suffer from this disorder. All study subjects
were subjected to challenges involving watch-
ing, together with a stranger, a movie with a
performance of the study subjects, talking and
performing in front of a group of people. What
was interesting, blushing was found more often
in subjects suffering from erythrophobia only
during watching a movie, but not in the other
stressful situations. During the study patients
with erythrophobia had higher heart rate that
subjects without this disorder (8). It indicates
highly subjective nature of this disorder and
its association with activity of the sympa-
thetic system. Other study of the same authors
rejected a hypothesis of participation of the
parasympathetic system in co-pathogenesis of
blushing – increased parasympathetic tone
was not found in similarly designed experi-
ment, while measures of sympathetic system
stimulation (heart rate and skin conductivity)
were increased (9).
Importance of serotonin metabolism disor-
ders is also emphasized in the origin of social
phobia and erythrophobia. Cortisol response
to phenfluramine, a serotonin receptor agonist,
is enhanced in patients with erythrophobia.
Efficacy of drugs that affect metabolism or
pharmacokinetics of serotonin, such as selec-
tive serotonin reuptake inhibitors, clonazepam
(that potentiates serotonin activity and syn-
thesis), monoamine oxidase inhibitors (that
block oxidative deamination of serotonin) and
beta blockers (that control synthesis of mela-
tonin from serotonin) in the treatment of blush-
ing further support this concept (10). Less active
gene 5-HTTLPR (a variant of the gene for a
serotonin transporter) was associated with
more pronounced erythrophobia in a group of
patients with variable disease activity (11).
Diagnostic tests in erythrophobia
Qualification to surgical treatment of blush-
ing involves three components. First, a struc-
tural interview is collected from the patient to
identify potential diseases that may involve
blushing as a symptom – evaluation of pheo-
chromocytoma and carcinoid tumor is most
important here. Therefore tests required for
qualification include, among others, ultra-
sound imaging of abdominal cavity with as-
323
sessment of adrenal fields and a series of 10
measurements of blood pressure. Furthermore,
in selected cases when there is an appropriate
history (sudden rises of blood pressure, head-
ache), measurements of urine methoxycate-
cholamines or (diarrhea) hydroxyindoleacetic
acid in 24-hour urine are required.
A second group of tests involve assessment of
subjective intensity and frequency of blushing.
This data is entered by the patient in self-assess-
ment diary. Furthermore, patient photographs
taken during the occurrence of the symptom
are required (fig. 1). Perceived burdensome
nature of required tests is related to highly
subjective perception of the disease intensity and
lack of possibility to use an objective method of
assessment of this symptom that is difficult to
induce in control conditions. While some au-
thors suggest a method of social challenge in-
volving watching, together with a stranger, a
video recording of the patient signing a com-
monly known song (e.g. „Happy birthday“) (12),
however, first, this method seems laborious and
second, its specificity is inadequate – the symp-
tom may appear also in subjects who do not
suffer from erythrophobia. Challenge tests used
in the diagnosis of carcinoid need to be consid-
ered – in particular an adrenalin challenge test,
however this type of test requires hospitaliza-
tion. Alternatively a vasodilator, niacin, can be
used that seems to induce increase of facial
blood flow and indirectly also blushing and even
social phobia (13).
Fig. 1. Blushing subjectively evalauted by the patient
at the level of 9 out of 10
324 T. J. Stefaniak
Patients with erythrophobia and subjects
without erythrophobia received 100 mg niacin
or placebo in a study by Drummond and La-
zaroo. Increased facial blood flow was found in
a group of patients with erythrophobia who
received niacin. This phenomenon was not
observed in the other study groups (including
in patients with erythrophobia and placebo).
Unfortunately, niacin was found to have no
effect on blushing, heart rate, anxiety or tem-
perature of the facial skin. As authors stated,
niacin challenge could potentially be of diag-
nostic use even in the setting of low social
anxiety and embarrassment (13). This test
could be particularly valuable to assess effi-
cacy of symptom inhibition (including indi-
rectly blushing) resulting from thoracic sym-
pathectomy. The problem of an early assess-
ment of treatment efficacy remains unsolved.
It is not uncommon to see blushing persisting
on the patient’s face even immediately after
the surgical procedure. However this symptom
has no prognostic significance (14).
A third component of the qualification process
involves assessment of intensity of the trunk
sweating. It is related to a side effect that occurs
after the surgery, manifesting as so called com-
pensatory hyperhidrosis or reflex hyperhidrosis
(fig. 2). This symptom involves marked increase
of the trunk sweating as a result of damage of
higher levels of the sympathetic trunk. Patho-
genesis of this symptoms remains unknown
despite multiple attempts to understand
pathophysiology of this problem (15).
Psychometric assessment is an important
component of assessment of patients in whom
surgical treatment of blushing is considered.
Except for standard studies of quality of life
(such as Functional Assessment of Chronic
Illness Therapy – FACIT and Dermatology
Quality of Life Index – DQLI), also dedicated
tools can be used to assess severity of social
phobia, such as Liebowitz Social Anxiety Scale
(LSAS) that provides a comprehensive mea-
sure of this disorder and enables determina-
tion of patient need for therapy and monitor
effects of therapy (2).
The problem of effective cure of erythropho-
bia is highly related to the nature of this dis-
order, which, as already mentioned in the in-
troduction, is an anxiety disorder. Therefore
selective blockade of sympathetic stimulation
of the skin of the face and head does not solve
the problem of fear of sudden blushing despite
surgical treatment. Furthermore this fear is
intensified by phantom blushing involving
feeling of facial burning identical with that
experienced before the surgical treatment.
Therefore patients who underwent surgical
treatment were advised to have a mirror avail-
able for the first month after the operation. If
a patient feels like blushing, he/she verifies
his/her experiences by looking in the mirror
and examining his/her face and therefore
verifies effects of the surgical treatment.
Physiological context of this disorder is also
reflected by recommended physiological work-
shops that are offered to patients who con-
sider surgical treatment and especially those
who assess degree of treatment efficacy as
inadequate. During these workshops patient’s
self-esteem is strengthened, range of stress
management techniques is expanded and body
self-confidence is stimulated, also in social
situations.
Drummond et al. conducted a series of in-
teresting studies. They analyzed pathophysiol-
ogy of facial blood flow in patients suffering
from erythrophobia and in a control group.
They demonstrated that facial blood flow in-
creased only in a group of subjects suffering
from erythrophobia, but only after hearing
information of experienced blushing (no matter
whether it really occurred) (12). Furthermore,
time to reconstruction of blood vessels in pa-
tients with erythrophobia was longer than in
a control group, which resulted in longer per-
sistence of this adverse symptom (16). More-
over, high scores on Blushing Propensity Scale
Fig. 2. Significant reflex hyperhidrosis in a patient
after sympatectomy for erytrophobia
 Erythrophobia – problems of diagnostics and treatment
and Social Interaction Anxiety Scale were
demonstrated to be related to higher facial
blood flow in patients with erythrophobia than
in a control group, which was affected by fear
of blushing as well as perception of increased
facial temperature synonymous with blushing
(17).
Treatment of facial blushing and
erythrophobia
However, treatment of facial blushing and
erythrophobia, i.e. fear of facial blushing in
social situations, needs to be clearly differenti-
ated. Treatment of facial blushing should start
from preparations that inhibit sympathetic
activity, such as beta blockers. Treatment with
these drugs is sometimes referred to as phar-
macological sympathectomy. Unfortunately,
therapeutic doses for facial blushing as well
as primary hyperhidrosis, are associated with
numerous side effects.
Sedatives and anxiolytics can be used in the
treatment of erythrophobia, however high dos-
ages of these drugs are required to achieve
satisfactory symptomatic control, which are
associated with side effects.
Psychotherapeutic help provided by various
centers in various form, is also worth consid-
eration. Short-term, intensive approach was
reported by a study team from Dresden who
presented efficacy of three-day psychothera-
peutic workshop with regard to erythrophobia.
Interaction involved a combination of attention
training and behavioral therapy and included
31 patients with erythrophobia. Assessment
of fear of facial blushing and social phobia was
done before the start of therapy, 6 weeks after
the completion of therapy and at a follow-up
visit 6 months later. Both study variables were
significantly reduced and these changes proved
stable over time in almost 2/3 of patients (18).
Similar study of interaction of behavioral-
cognitive therapy was conducted by Scholing
et al. Therapeutic interaction involved expo-
sure in vivo and behavioral therapy with sub-
sequent cognitive therapy. Similarly as in the
study by Chaker et al., this study also demon-
strated a significant improvement of patient
functioning that persisted during a follow-up
period, up to 18 months (19). Slightly different
regimen of behavioral-cognitive intervention
was suggested by Dijk et al. It involved 6
325
weekly therapeutic meetings and one mainte-
nance session 3 months after completion of
therapy. What interesting, authors abandoned
standard nomenclature “patient” and “thera-
pist” for “students” and “a teacher”. Detailed
assessment of treatment results immediately
after its completion and 12 months later dem-
onstrated over 40% reduction of fear of facial
blushing and incidence of this symptoms, as
measured on Blushing, Trembling and Sweat-
ing Questionnaire (20).
As results of studies with various form of
psychotherapy demonstrate, it is possible to
alleviate symptoms and sometimes even com-
pletely control them, using methods of psycho-
logical intervention, as measured on LSAS
scale (2). This therapy is successful in as many
as 50 – 66% of patients. However, there are no
randomized studies and criteria of success are
not clearly defined.
Thoracic sympathectomy is the last treat-
ment method (21). Most commonly used surgi-
cal approaches include anterior approach in
which a patient is in a semi-sitting position
and trocars are inserted in the anterior axillary
line, in the 2nd intercostals space and in the
posterior axillary line, in the 4th intercostals
space (22) as well as posterior approach in
which a patient lies horizontally on his/her
abdomen and trocars are inserted 2 cm medi-
ally from the angle of the scapula and in the
3rd or 4th intercostals space, in the posterior
axillary line (23). It is possible to use a con-
trolled lung deflation (22) or carbon dioxide
pneumothorax (23). Finally, three principal
methods of sympathetic trunk injury are avail-
able: destruction of ganglia using electrocau-
tery, transsection of connections between them
or clipping of these connections (24). Bilateral
videothoracoscopic simultaneous thoracic sym-
patheticotomy from posterior approach, using
a clipping method is conducted at a Gdansk
site, using methods previously reported in the
treatment of primary hyperhidrosis (23). The
difference lies in clips application that in the
treatment of facial blushing should be placed
above and below the second thoracic ganglion
(T2). Dissection of sympathetic trunk in this
region requires particular attention and subtle
technique, since careless use of diathermy may
result in temporary or permanent injury of the
stellate ganglion and as a consequence, com-
plete or partial Horner’s syndrome. Alternative
methods of the thoracic trunk injury, as for
326 T. J. Stefaniak
example percutaneous thermoablation of
nerves, have proven inadequately successful
in the treatment of erythrophobia (25).
Results of surgical treatment of erythropho-
bia are satisfactory, although far from ideal.
The largest published material is from the
Swedish site and includes 1314 patients who
underwent surgical treatment for erythropho-
bia (26, 27) who were followed-up for 29
months. A statistically significant reduction of
blushing from 8.8 to 2.5 points on a 10-point
VAS scale was found in this group. Compensa-
tory hyperhidrosis occurred in 83% of patients,
while 85% of patients declared complete sat-
isfaction with treatment results.
In a follow-up study of these patients, after
almost 15 years of follow-up, very good treat-
ment results were obtained in 72.8% patients
who underwent surgical treatment for eryth-
rophobia, while 73.5% of patients declared very
high degree of satisfaction with treatment
results which probably indicated annoyance
with compensatory hyperhidrosis increasing
over time (27). Inadequate treatment efficacy
was observed in 15% of patients, while 2% of
them clearly regretted that they underwent
the procedure (28). We believe that clips should
have been removed in this group of patients.
Unfortunately, the Swedish team used a
method of irreversible injury of the sympa-
thetic ganglia. Sciuchetti (29) demonstrated
3-year results of sympathectomy using clipping
and emphasized high success rate and patient
satisfaction with the treatment results. Simi-
larly, success rate around 75% of patients were
observed in Danish investigators from Odense
and Aarhus (22). What is interesting, compen-
satory hyperhidrosis occurred in 88% of pa-
tients which indicates that 12% of them did
not experience resolution of facial blushing but
did experience compensatory hyperhidrosis.
We believe that this group of patients should
undergo more detailed screening for carcinoid.
Furthermore, as many as 10% of patients from
the Danish group regretted that they under-
went the surgical treatment, due to lack of
efficacy and/or side effects of therapy (29).
Perspectives in the treatment of
erythrophobia
Erythrophobia is an axial symptom of a
syndrome of phobic symptoms related to facial
blushing. In response to a stressful event,
most commonly related to social functioning,
patients react with sudden facial blushing
which is perceived by their surrounding as a
pathologic condition. This, in turn, results in
feeling of alienation and avoidance of social
functioning. Moreover, patients withdraw
from social life, claiming that erythrophobia
is responsible for all their failures. This re-
sults in lower involvement in intellectual
development, in particular in areas that re-
quire public performance or oral examina-
tions.
Objective assessment of social importance
of erythrophobia is very difficult. This disorder
does not seem to significantly impair quality
of life, at least seemingly. However psycho-
logical studies indicate its major impairment
(30). It is unclear whether this disorder affects
exclusively young subjects (in our material
from the Gdansk site, an average age was
27.88 years, age range from 22 to 54 years), or
only young subjects, who have access to inter-
net, are able to access information about pos-
sible surgical treatment. Furthermore, inter-
net is a source of subjective information about
treatment effects, emphasizing patients with
pronounced side effects that markedly and
irreversibly impair postoperative functioning
– not by facial blushing, but by symptoms that
are directly or indirectly related to sympath-
ectomy (loss of hair on the skin of the head,
including brows and eyelashes, excessively dry
skin on hands and head, increased susceptibil-
ity to body overheating and cooling and many
others).
Conclusions
In conclusion, we would like to emphasize
that only adequate qualification to surgical
treatment is a basis for the treatment of facial
blushing, while treatment of erythrophobia
requires additional marked involvement of the
psychological team. It must be emphasized
that surgical treatment is a final treatment
option and decision of its implementation
should be taken only when other therapeutic
options have been exhausted.
Only such therapeutic approach gives an
opportunity to reliably and comprehensively
solve patient’s problems.
 Erythrophobia – problems of diagnostics and treatment
references
1. Greist JH: The diagnosis of social phobia. J Clin
Psychiatry 1995; 56 Suppl 5: 5-12.
2. Ballenger JC: Recognizing the patient with social
anxiety disorder. Int Clin Psychopharmacol 2000;
15 Suppl 1: S1-5.
3. Fahlén T: Core symptom pattern of social phobia.
Depress Anxiety 1996-1997; 4(5): 223-32.
4. Glashouwer KA, de Jong PJ, Dijk C et al.: Indi-
viduals with Fear of Blushing Explicitly and Auto-
matically Associate Blushing with Social Costs. J
Psychopathol Behav Assess 2011; 33(4): 540-46.
5. Voncken MJ, Dijk C, de Jong PJ et al.: Not self-
focused attention but negative beliefs affect poor
social performance in social anxiety: an investiga-
tion of pathways in the social anxiety-social rejec-
tion relationship. Behav Res Ther 2010; 48(10):
984-91.
6. Dijk C, de Jong PJ, Müller E et al.: Blushing-
Fearful Individuals’ Judgmental Biases and Con-
ditional Cognitions: An Internet Inquiry. J Psycho‑
pathol Behav Assess 2010; 32(2): 264-70.
7. Dijk C, Koenig B, Ketelaar T et al.: Saved by the
blush: being trusted despite defecting. Emotion
2011; 11(2): 313-19.
8. Gerlach AL, Wilhelm FH, Gruber K et al.: Blu-
shing and physiological arousability in social pho-
bia. J Abnorm Psychol 2001; 110(2): 247-58.
9. Gerlach AL, Wilhelm FH, Roth WT: Embarras-
sment and social phobia: the role of parasympathetic
activation. J Anxiety Disord 2003; 17(2): 197-210.
10. Jefferson JW: Social phobia: everyone’s disor-
der? J Clin Psychiatry 1996; 57 Suppl 6: 28-32.
11. Domschke K, Stevens S, Beck B et al.: Blushing
propensity in social anxiety disorder: influence of
serotonin transporter gene variation. J Neural
Transm 2009 Jun; 116(6): 663-66.
12. Drummond PD, Camacho L, Formentin N et al.:
The impact of verbal feedback about blushing on
social discomfort and facial blood flow during embar-
rassing tasks. Behav Res Ther 2003; 41(4): 413-25.
13. Drummond PD, Lazaroo D: The effect of niacin
on facial blood flow in people with an elevated fear
of negative evaluation. Eur Neuropsychopharmacol
2012; 22(3): 200-04.
14. Olday J, Currie E, Drummond GB: The inci-
dence of flushing on induction of anaesthesia in
patients who blush easily. Anaesthesia 2003; 58(3):
275-77.
15. Araújo CA, Azevedo IM, Ferreira MA et al.:
Compensatory sweating after thoracoscopic sym-
pathectomy: characteristics, prevalence and influ-
ence on patient satisfaction. J Bras Pneumol 2009;
35(3): 213-20.
16. Drummond PD, Back K, Harrison J et al.: Blu-
shing during social interactions in people with
a  fear of blushing. Behav Res Ther 2007; 45(7):
1601-08.
Received: 20.02.2012 r.
Adress correspondence: 80-210 Gdańsk, ul. Dębinki 7
View publication stats
327
17. Drummond PD, Su D: The relationship betwe-
en blushing propensity, social anxiety and facial
blood flow during embarrassment. Cogn emot 2012;
26(3): 561-67.
18. Chaker S, Hofmann SG, Hoyer J: Can a one-
weekend group therapy reduce fear of blushing?
Results of an open trial. Anxiety Stress Coping 2010;
23(3): 303-18.
19. Scholing A, Emmelkamp PM: Treatment of fear
of blushing, sweating, or trembling. Results at long-
term follow-up. Behav Modif 1996; 20(3): 338-56.
20. Dijk C, Buwalda FM, Jong PJ: Dealing with
Fear of Blushing: A Psychoeducational Group In-
tervention for Fear of Blushing. Clin Psychol Psy-
chother 2011 Jul 12. doi: 10.1002/cpp.764. (Epub
ahead of print).
21. Pohjavaara P, Telaranta T, Väisänen E: The
role of the sympathetic nervous system in anxiety:
Is it possible to relieve anxiety with endoscopic
sympathetic block? Nord J Psychiatry 2003; 57(1):
55-60.
22. Licht PB, Ladegaard L, Pilegaard HK: Thora-
coscopic sympathectomy for isolated facial blu-
shing. Ann Thorac Surg 2006; 81(5): 1863-66.
23. Stefaniak T, Pirski MI, Osęka T et al.: Simul-
taneous bilateral transthoracic sympathectomy
through posterior access in Lin-Telaranta modifi-
cation for primary hyperhidrosis. Videosurgery
2009; 4 (2): 47-52.
24. Rennie JA, Lin CC, Cameron AEP: The techniue
of endoscopic thoracic sympathectomy: resection,
clipping and cautery. Clin Auton Res 2003; 13(Supl
I): I/22: I/25.
25. Garcia Franco CE, Perez-Cajaraville J, Guillen-
Grima F et al.: Prospective study of percutaneous
radiofrequency sympathicolysis in severe hyperhi-
drosis and facial blushing: efficacy and safety fin-
dings. Eur J Cardiothorac Surg 2011; 40(4): e146-
51.
26. Drott C, Claes G, Rex L: Facial blushing treated
by sympathetic denervation--longlasting benefits in
831 patients. J Cosmet Dermatol 2002; 1(3): 115-19.
27. Smidfelt K, Drott C: Late results of endoscopic
thoracic sympathectomy for hyperhidrosis and
facial blushing. Br J Surg 2011; 98(12): 1719-24.
28. Drott C, Claes G, Olsson-Rex L et al.: Successful
treatment of facial blushing by endoscopic trans-
thoracic sympathicotomy. Br J Dermatol 1998;
138(4): 639-43.
29. Sciuchetti JF, Corti F, Ballabio D et al.: Results,
side effects and complications after thoracoscopic
sympathetic block by clamping. The monza clinical
experience. Clin Auton Res 2008; 18(2): 80-83.
30. Kwong KF, Hobbs JL, Cooper LB et al.: Strati-
fied analysis of clinical outcomes in thoracoscopic
sympathicotomy for hyperhidrosis. Ann Thorac
Surg 2008; 85(2): 390-93.