Effects of Alcohol on the Skin

Alcohol and Sweating

Sweat glands are innervated by the sympathetic nerves ^[1]. Acute alcohol ingestion stimulates sympathetic activity ^[2], so it can trigger sweating.

Causes of alcohol-related sweating:

• Drinking alcohol by itself may stimulate sweating in some individuals ^[3].
• Hangover ^[4]
• Delirium tremens during alcohol withdrawal ^[5]. Some individuals may sweat excessively for several weeks after alcohol withdrawal, possibly due to anxiety ^[41].
• Chronic alcoholics may experience constant excessive sweating of the palms and soles (palmoplantar hyperhidrosis) ^[6,7].
• Sweating, nausea and abdominal pain occur in acute pancreatitis, which is common in chronic alcoholics ^[9].
• Sweating may be due to interaction between alcohol and drugs, such as analgesics (phenacetin, phenylbutazone), antibiotics (cefamandole, chloramphenicol, griseofulvin, metronidazole, nitrofurantion, nitromidazole, sulfamethoxazole, tolbutamide), antifungals (ketokonazole), antidiabetics (chlorpropramide, tolbutamide) or nitrates (isosorbide dinitrate, nitroglycerine).
• A combination of alcohol and disulfiram triggers sweating, flushing and nausea within minutes of use ^[10].

Alcohol and Facial Flushing

In both healthy individuals and chronic alcoholics, flushing may be due to dilation of skin arteries triggered by histamine, which is released from certain body cells in response to increased blood levels of acetaldehyde (a breakdown product of alcohol) ^[12]. Flushing may appear within few minutes of starting drinking and may last for an hour or more.

Alcohol may aggravate hot flashes in menopause ^[13].

Combining fermented beverages, like beer, wine or sherry, which contain tyramine or histamine, with MAO inhibitors (a type of antidepressants, including isocarboxazid, phenelzine, selegiline and tranylcypromine) may trigger facial flushing.

Flushing may occur within minutes of combining alcohol and certain drugs ^[15]:

• Analgesics: phenacetin, phenylbutazone
• Antibiotics: cefamandole, chloramphenicol, griseofulvin, isoniazid, metronidazole, nitrofurantion, nitromidazole, sulfamethoxazole, tolbutamide
• Antidiabetics: chlorpropramide, tolbutamide
• Antifungals: ketokonazole, clotrimazole
• Antihypertensives: phentolamine
• Antimalarics: quinacrine
• Chemotherapeutic (anti-cancer drug): procarbazine.
• Sedatives: chloral hydrate
• Vasodilators: nitrates, such as isosorbide dinitrate and nitroglycerine
• Vitamin B3 (niacin)
• Medications to help with abstinence: calcium carbamide, disulfiram

Alcohol drunk after exposure to industrial solvents, such as N-butyraldoxime and thiuran derivatives used in printing and rubber industry, dimethylformamide (DMF) or trichlorethylene vapor may cause flushing ^[11,15].

Asian Flush Reaction (ALDH2 Deficiency)

About 30-50% of Japanese, Han Chinese, Taiwanese, Koreans and, rarely, some Caucasians, have a low activity of the enzyme aldehyde dehydrogenase (ALDH2) ^[16].

In these people, acetaldehyde cannot be effectively converted to acetate, so acetaldehyde start to accumulates in their blood within few minutes after drinking even small amounts of alcohol and causes what is known as Asian flush reaction, Asian blush, Asian glow or oriental flushing syndrome. Symptoms include bright redness or patchy rash on the face, neck and upper chest, rapid heart beat, nausea, headache, itchiness, blocked nose, difficult breathing, drowsiness and low blood pressure ^[8,16]. Symptoms may last from few to more than 24 hours.

Antibiotics metronidazole and antifungal griseofulvin may aggravate the symptoms.

Diagnosis can be made from the history of flushing after drinking alcohol, or by an “ethanol patch test” ^[16,17].

Acetaldehyde stimulates the synthesis of prostaglandins (prostacyclines) and histamine, which are probably responsible for vasodilation and flushing ^[15]. There are a lot of reports on the internet forums how antihistamines (H2 blockers), such as gastric acid-lowering drugs famotidine or ranitidine, if taken within an hour before drinking, decrease flushing and other symptoms, but there is lack of studies that would confirm that. Ranitidine inhibits the enzyme alcohol dehydrogenase (ADH) and thus slows down alcohol degradation to acetaldehyde (but also increases the blood alcohol concentration after the same amount of alcohol drunk) ^[22]. Other drugs that may decrease flushing include H1 antihistamines (diphenhydramine), H2 antihistamines (cimetidine) ^[18,19], prostacycline inhibitors (aspirin) ^[20] and opioid antagonists (nalmefene) ^[21]. Note that alcohol taken along with aspirin may increase the risk of bleeding, and alcohol taken along with H1 antihistamines may increase drowsiness.

Cancer, Alcohol and Flushing

Flushng may be triggered by drinking alcohol in certain cancers:

• In individuals with carcinoid (a rare type of cancer), alcohol or tyramine from certain wines and beers may trigger facial flushing episodes, difficulty breathing and increased heart that last few minutes, and diarrhea (carcinoid syndrome) ^[46].
• In individuals with urticaria pigmentosa (a type of mastocytosis – a cancerous overgrowth of the mast cells, with itchy brown skin lesions), alcohol may trigger flushing that may last for 20 minutes ^[15,23].
• Other cancers in which alcohol may trigger flushing include small-cell carcinoma of the lungs, islet carcinoma of the pancreas and medullary carcinoma of the thyroid
• In certain cases, flushing may be reduced by aspirin or antihistamines H1 (diphenhydramine) or H2 (cimetidine).
• Reference: ^[15]

Fish Poisoning, Alcohol and Flushing

Scombroid fish poisoning is poisoning with histamine that builds up in large fish (tuna, mackerel) or improperly preserved fish. Flushing, hives (urticaria), itching, vomiting, diarrhea, headache, dizziness and rapid heart beat may occur within 30 minutes of fish consumption and may last for few hours; alcohol may aggravate symptoms ^[25]. Antihistamines H1 (diphenhydramine) or H2 (cimetidine) may help to relieve symptoms ^[15].

In ciguatera fish poisoning, ciguatoxin from tropic fish, such as barracuda or grouper, may cause vomiting, tingling and numbness in and around the mouth and in limbs 1-24 hours after ingestion; symptoms may last for few days to several months. In some individuals symptoms may return after drinking alcohol ^[24].

Other Causes of Alcohol-Related Flushing

• Alcohol may trigger flushing in patients with hypereosonophilic syndromes ^[26], Hodgkin’s lymphomas ^[27] or polycythemia vera ^[15].
• Severe headache on one side of the head and flushing within one hour of consumption alcohol may be symptoms of cluster headache ^[28].
• Alcohol may induce flushing and nausea (disulfiram-like reaction) when drunk within 72 hours after eating a mushroom Alcohol inky (Coprinus atramentarius), because coprine from a mushroom inhibits the conversion of acetaldehyde (a breakdown product of ethanol) to acetate, so acetaldehyde builds up in the blood ^[29].

Alcohol and Itch

Alcohol dilates the skin arteries and thus warms the skin, which may trigger itch.

Itchy nose after drinking alcohol may speak for allergic rhinitis ^[30].

Generalized itch after drinking may occur in individuals with histamine intolerance ^[44], allergic reaction, chronic urticaria ^[31], cholinergic urticaria ^[32], Hodgkin lymphoma ^[33], alcohol related exercise-induced anaphylaxis ^[34] or those who take vitamin B3 (niacin) supplements.

Itchy legs at night in individuals with restless leg syndrome may become worse after drinking alcohol ^[35]. Nerve damage in chronic heavy drinkers (alcoholic neuropathy) may result in restless leg syndrome ^[36,37].

Persistent itch may be due to advanced liver cirrhosis ^[38].

Alcohol and Skin Conditions

Excessive drinking increases the risk of psoriasis, discoid eczema (nummular dermatitis), adult acne, seborrheic dermatitis, pellagra (scaly skin, inflamed mucous membranes), strep, staph and fungal skin infections ^{[12,39,40-p.396]}.

A chronic alcoholic can have a strong breath and body odor (reek) that does not go away after showering, but only after few weeks of abstaining (1960). Persistent facial redness due to enlarged small skin vessels ^[12] and bloodshot eyes are also characteristic.

Alcohol may trigger flushing in individuals with rosacea (chronic facial rash in adults); alcohol does not cause rosacea, though ^[41]. Alcohol also does not cause a large, red, bulb-shaped nose (rhinophyma) ^[42,43].