Notably, erythema that develops after alcohol intake in a patient taking a topical TCI can mimic the dermatosis being treated—similar to one of our patients (Figure 2) whose flushing was mistaken for a flare of periorificial dermatitis—contact dermatitis or another flushing disorder such as rosacea. Uninformed patients might mistakenly self-diagnose the flushing as an allergic or anaphylactic reaction to foods, drugs, or other exposures contemporaneous with alcohol ingestion. The side effect can be frustrating owing to its appearance and discomfort, which often coincide with social interactions involving alcohol.
FIGURE 2. A woman for whom the topical calcineurin inhibitor pimecrolimus cream 1% had been prescribed for periorificial dermatitis. She noted erythema and a “burning” sensation restricted to areas where pimecrolimus had been applied within 20 minutes after an alcoholic drink.
Techniques to Avoid Flushing
Discontinuing a TCI altogether leads to resolution of associated adverse effects, including flushing, typically within weeks to 1 month.5 Alternatively, oral aspirin (81 mg) might eliminate or attenuate symptoms, as documented in a double-blind, controlled trial in which relief of TCI-induced flushing after consuming wine was investigated.6
Another approach (albeit nontraditional) is for patients who experience this phenomenon to “wet their whistles” with an alcoholic drink before a social engagement. After flushing resolves in 20 to 60 minutes, subsequent drinks do not appear to elicit symptoms again in most patients. That said, we stop short of calling this tip “doctor’s orders.”
Practical Implication
Counseling patients who will be using a TCI—tacrolimus or pimecrolimus—about the potential for these drugs to produce localized flushing after alcohol ingestion as well as techniques for lessening or eliminating this adverse effect are important facets of their dermatologic care.