Rosacea ETS Comments and Warnings

Written by on January 6, 2009 with 0 Comments

Date:  Thu Apr 12, 2001  6:29 pm
Subject:  more comments and warnings on ETS

Attached below is the publication I referred to earlier by Peter Drummond concerning the ETS procedure. BTW, I have corresponded with Peter concerning sns-mediated flushing (he has been very generous with his time – I’m truly indebted to him). One comment he made is that sns-mediated flushing is closely linked to sweating, ie if you don’t exhibit heavy sweating, then it is unlikely that your blushing/flushing is sns-mediated. (My corrollary: in this case, it is unlikely that ETS will mitigate flushing symptoms). Here is exact text of his private comments to me:

I’d be surprised if you had a problem with sympathetic nerves in your face.  Sympathetic vasodilators make the face flush when you need to lose body heat (e.g., after exercise) and during certain types of emotion (e.g., embarrassment and anger). There is a close link between sweating and flushing, so if your face isn’t sweating as well as flushing it is unlikely to be a sympathetic nerve problem. Has anyone checked your blood levels of epinephrine when your face flushes? Epinephrine is secreted from the adrenal medulla into the bloodstream during sympathetic nervous system arousal and can induce facial flushing. Occasionally the cells proliferate and start to over secrete.

I should add that others (possibly including Geoffrey) would disagree with this connection. Just goes to show how complex these issues are in that there is no consensus among experts. (BTW, much of what little I know about sns-mediated flushing I learned from Jen Sandwell on this board, who understands these issues much better than I …)

My net on ETS is that it is a mini-labotomy to your sympathetic nervous system, and easily is the most radical and controversial procedure for treatment of facial blushing. Another useful discussion, already mentioned in some recent posts, is whether ETS is only for social blushers or for people (like me) who flush for no real apparent reason.


CORRESPONDENCE: A caution about surgical treatment for facial blushing

British Journal of Dermatology, 142, 194-195, 2000


The fear of blushing can become so problematic that it limits the range of activities in which the blusher is willing to participate, and occasionally develops into full-blown social phobia.

Recently, endoscopic transthoracic sympathicotomy has appeared in this journal’ and elsewhere as a solution for chronic blushing. Short-term results from this procedure were positive, and few distressing side-effects were encountered.

However, the benefits of surgery must be balanced against the risk of developing postsurgical complications, primarily compensatory sweating and pathological gustatory sweating and flushing. These conditions seem almost to be the rule rather than the exception.

For example, gustatory sweating was reported by 47% of 352 patients who were followed up by questionnaire or clinical examination a median period of 16 years after endoscopic transthoracic sympathectomy for palmar hyperhidrosis. In this series, patient satisfaction declined from 95.5% initially to 66.7% when patients were questioned many years after the operation.s In fact, compensatory and gustatory sweating were the most frequently stated reasons for dissatisfaction with the surgical outcome. The incidence of gustatory sweating was lower (12 of 72 patients) in another series, but all patients except one suffered from compensatory sweating elsewhere in the body. Physiological assessment of gustatory sweating would probably have revealed a higher incidence than selfreporting in this study.

Gustatory sweating takes time to develop: a patient who initially is satisfied with the surgical outcome may later regret having the operation when autonomic disturbances appear.

Pathological gustatory sweating and flushing can develop after injury to preganglionic cervicothoracie sympathetic fibres, an unavoidable consequence of resecting that part of the sympathetic chain. The mechanism of this abnormal response is uncertain; conceivably, though, regeneration of injured salivatory fibres or collateral sprouting from nearby intact fibres creates aberrant connections between salivatory fibres and denervated vasomotor and sudomotor neurons in the superior cervical ganglion. Commands to salivate would then be translated into commands to sweat and flush in the distribution of sympathetic denervation.

Cross-innervation lower down in the stellate ganglion can also produce unusual and potentially distressing autonomic disturbances in the sympathetically denervated arm (e.g.  piloerection while cating). Interrupting the sympathetic pathway to the face destroys the neural circuitry which controls flushing to heat and blushing to emotional events,  and may therefore alleviate anxiety about blushing.  However, as inappropriate facial sweating and flushing while eating can be just as distressing as anxiety about blushing, most patients who opt for the surgical procedure may be little better off in the long term.

At present there is very little evidence to show that those most likely to pursue surgical treatment for blushing actually blush more readily or intensely than other people. In fact, changes in facial blood flow during acute embarrassment seem to be unrelated to ratings of the self-reported frequency of blushing.10.11 On the other hand, self-consciousness and fear of blushing correlate well with subjective estimates of blushing frequency and intensity. ”

In this respect blushing differs from palmar hyperhidrosis, the usual indication for endoscopic transthoracic sympathectomy; sweaty palms are far easier for the patient to detect than blushing, which often is just a worrying suspicion not substantiated by fact.  If the source of the patient’s problem is anxiety about blushing rather than blushing per se, anxiety would be a more appropriate target for treatment than permanently eliminating the normal regulation of facial blood flow and sweating.

Cognitive-behavioural and drug therapies help patients with social phobia to control anxiety, 12 and should thus be considered the treatments of choice for patients with a fear of blushing.

School of Psychology, Murdoch University,
South Street, Murdoch,
Western Australia 6150

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About the Author: David Pascoe started the Rosacea Support Group in October 1998. .

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