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Birthmarks, including angiomas and vascular malformations, are benign (noncancerous) skin growths composed of rapidly growing or poorly formed blood vessels or lymph vessels. Found at birth (congenital) or developing later in life (acquired) anywhere on the body, they range from faint spots to dark swellings covering wide areas.
Skin angiomas, also called vascular (pertaining to vessel) nevi (marks), are composed of blood vessels (hemangiomas) or lymph vessels (lymphangiomas), that lie beneath the skin's surface. Hemangiomas, composed of clusters of cells that line the capillaries, the body's smallest blood vessels, are found on the face and neck (60%), trunk (25%), or the arms and legs (15%). Congenital hemangiomas, 90% of which appear at birth or within the first month of life, grow quickly, and disappear over time. They are found in 1-10% of full-term infants, and 25% of premature infants. About 65% are capillary hemangiomas (strawberry marks), 15% are cavernous (deep) hemangiomas, and the rest are mixtures. Hemangiomas are three times more common in girls. Usually, only one hemangioma is found, in 20% two are found, while fewer than 5% have three or more. Lymphangiomas are skin bumps caused by enlarged lymph vessels anywhere on the body.
Vascular malformations are poorly formed blood or lymph vessels that appear at birth or later in life. One type, the salmon patch (nevus simplex), a pink mark composed of dilated capillaries, is found on the back of the neck (also called a stork bite) in 40% of newborns, and on the forehead and eyelids (also called an angel's kiss) in 20%. Stork bites are found in 70% of white and 60% of black newborns.
Found in fewer than 1% of newborns, port-wine stains (nevus flammeus), are vascular malformations composed of dilated capillaries in the upper and lower layers of the skin of the face, neck, arms, and legs. Often permanent, these flat pink to red marks develop into dark purple bumpy areas in later life; 85% appear on only one side of the body.
Acquired hemangiomas include spider angiomas (nevus araneus), commonly known as spider veins, and cherry angiomas (senile angiomas or Campbell de Morgan spots). Found around the eyes, cheekbones, arms, and legs, spider angiomas are red marks formed from dilated blood vessels. They occur during pregnancy in 70% of white women and 10% of black women, in alcoholics and liver disease patients, and in 50% of children. Cherry angiomas, dilated capillaries found mainly on the trunk, appear in the 30s, and multiply with aging.
Causes and symptoms
There are no known causes for congenital skin angiomas; they may be related to an inherited weakness of vessel walls. Exposure to estrogen causes spider angiomas in pregnant women or those taking oral contraceptives. Spider angiomas tend to run in families, and may be associated with liver disease, sun exposure, and trauma.
Hemangiomas first appear as single or multiple, white or pale pink marks, ranging from 2-20 cm (average 2-5 cm) in size. Some are symptomless while others cause pain or bleeding, or interfere with normal functioning when they are numerous, enlarged, infected, or ulcerated. Vision is affected by large marks on the eyelids. Spider and cherry angiomas are unsightly but symptomless.
Angioma — A benign skin tumor composed of rapidly growing, small blood or lymph vessels.
Capillaries — The smallest blood vessels, they connect the arteries and veins.
Corticosteroids — Drugs that fight inflammation.
Hemangioma — A benign skin tumor composed of abnormal blood vessels.
Lymph vessels — Part of the lymphatic system, these vessels connect lymph capillaries with the lymph nodes; they carry lymph, a thin, watery fluid resembling blood plasma and containing white blood cells.
Lymphangioma — A benign skin tumor composed of abnormal lymph vessels.
Nevus — A mark on the skin.
Ulcer — A red, shallow sore on the skin.
Vascular malformation — A poorly formed blood or lymph vessels.
Each type of hemangioma has a characteristic appearance:
- Capillary hemangiomas (strawberry marks). These round, raised marks are bright red and bumpy like a strawberry, and become white or gray when fading.
- Cavernous hemangiomas. These slightly raised, dome-shaped, blue or purple swellings are sometimes associated with lymphangiomas or involve the soft tissues, bone, or digestive tract.
- Spider angiomas. These are symptomless, reddish blue marks formed from blood-filled capillaries radiating around a central arteriole (small artery) in the shape of a spider web.
- Cherry angiomas. These harmless, dilated capillaries appear as tiny, bright red-to-violet colored bumps.
- Lymphangiomas. These dilated lymph vessels form light pink or yellow cysts (fluid- filled sacs) or swellings.
These are faint, flat, pink stains that grow as the child grows into larger dark red or purple marks. Some are symptomless but others bleed if enlarged or injured. Disfiguring port-wine stains can cause emotional and social problems. About 5% of port-wine stains on the forehead and eyelids increase eye pressure due to involvement of the eye and surrounding nerves. Abnormalities of the spinal cord, soft tissues, or bone may be associated with severe port-wine stains.
Each type has a characteristic appearance:
- Salmon patches. These symptomless, light red-to-pink marks usually fade with time.
- Port-wine stains. These flat, pink marks progress to raised, dark red-to-purple grape-like lumps distorting the facial features, arms, or legs.
Patients are treated by pediatricians (doctors who specialize in the care of children), dermatologists (skin disease specialists), plastic surgeons (doctors who specialize in correcting abnormalities of the appearance), and ophthalmologists (eye disease specialists).
Angiomas and vascular malformations are not difficult to diagnose. The doctor takes a complete medical history and performs a physical examination including inspection and palpation of the marks. The skin is examined for discoloration, scarring, bleeding, infection, or ulceration. The type, location, size, number, and severity of the marks are recorded. The doctor may empty the mark of blood by gentle pressure. Biopsies or specialized x rays or scans of the abnormal vessels and their surrounding areas may be performed. Patients with port-wine stains near the eye may require skull x rays, computed tomography scans, and vision and central nervous system tests. Most insurance plans pay for diagnosis and treatment of these conditions.
Treatment choices for skin angiomas and vascular malformations depend on their type, location, and severity, and whether they cause symptoms, pain, or disfigurement.
No treatment is given, but the mark is regularly examined. This continues until the mark disappears, or requires treatment. This approach is particularly appropriate for the treatment of hemangiomas, which often do not require treatment, since they eventually shrink by themselves.
CORTICOSTEROIDS. Daily doses of the anti-inflammatory drugs prednisone or prednisolone are given for up to 2 months with gradual reduction of the dose. The marks begin to subside within 7-10 days, but may take up to 2 months to fully disappear. If no response is seen in 2 weeks, the drug is discontinued. Treatment may be repeated. Side effects include growth retardation, increased blood pressure and blood sugar, cataracts, glandular disorders, and infection. The corticosteroids triamcinolone acetate and betamethasone sodium phosphate or acetate are injected directly into the marks with a response usually achieved within a week; additional injections are given in 4-6 weeks. Side effects include tissue damage at the injection site.
INTERFERON ALPHA-2A. This drug reduces cell growth, and is used for vascular marks that affect vision, and that are unresponsive to corticosteroids. Given in daily injections under the skin, a response rate of 50% is achieved after about 7 months. Side effects include fever, chills, muscle and joint pain, vision disorders, low white and red blood cell counts, fatigue, elevated liver enzymes, nausea, blood clotting problems, and nerve damage.
LASER SURGERY. Lasers create intense heat that destroys abnormal blood vessels beneath the skin, without damaging normal skin. Two types of lasers are used: the flashlamp-pulsed dye laser (FPDL) and the neodymium:YAG (Nd:YAG) laser. The FPDL, used mainly for strawberry marks and port-wine stains, penetrates to a depth of 1.8 mm and causes little scarring, while the Nd:YAG laser penetrates to a depth of 6 mm, and is used to treat deep hemangiomas. Laser surgery is not usually painful, but can be uncomfortable. Anesthetic cream is used for FPDL treatment. Treatment with the Nd:YAG laser requires local or general anesthesia. Children are usually sedated or anesthetized. Healing occurs within 2 weeks. Side effects include bruising, skin discoloration, swelling, crusting, and minor bleeding.
SURGICAL EXCISION. Under local or general anesthesia, the skin is cut with a surgical instrument, and vascular marks or their scars are removed. The cut is repaired with stitches or skin clips.
CRYOSURGERY. Vascular marks are frozen with an extremely cold substance sprayed onto the skin. Wounds heal with minimal scarring.
ELECTRODESICCATION. Affected vessels are destroyed with the current from an electric needle.
- Sclerotherapy. Injection of a special solution causes blood clotting and shrinkage with little scarring. Side effects include stinging, swelling, bruising, scarring, muscle cramping, and allergic reactions. This treatment is used most commonly for spider angiomas.
- Embolization. Material injected into the vessel blocks blood flow which helps control blood loss during or reduces the size of inoperable growths. A serious side effect, stroke, can occur if a major blood vessel becomes blocked.
- Make-up. Special brands are designed to cover birthmarks (Covermark or Dermablend).
- Cleaning and compression. Bleeding marks are cleaned with soap and water or hydrogen peroxide, and compressed with a sterile bandage for 5-10 minutes.
Alternative treatments for strengthening weak blood vessels include eating high-fiber foods and those containing bioflavonoids, including citrus fruit, blueberries, and cherries, supplementing the diet with vitamin C, and taking the herbs, ginkgo (Ginkgo biloba) and bilberry (Vaccinium myrtillus.)
The various types of birthmarks have different prognoses:
- Capillary hemangiomas. Fewer than 10% require treatment. Without treatment, 50% disappear by age 5, 70% by age 7, and 90% by age 9. No skin changes are found in half while others have some discoloration, scarring, or wrinkling. From 30-90% respond to oral corticosteroids, and 45% respond to injected corticosteroids; 50% respond to interferon Alpha-2a. About 60% improve after laser surgery.
- Cavernous hemangiomas. Some do not disappear and some are complicated by ulceration or infection. About 75% respond to Nd:YAG laser surgery but have scarring. Severe marks respond to oral corticosteroids, but some require excision.
- Spider angiomas. These fade following childbirth and in children, but may recur. About 90% respond to sclerotherapy, electrodesiccation, or laser therapy.
- Cherry angiomas. These are easily removed by electrodesiccation.
- Lymphangiomas. These require surgery.
- Salmon patches. Eyelid marks disappear by 6-12 months of age, and forehead marks fade by age 6; however, 50% of stork bites on the neck persist into adulthood.
- Port-wine stains. Some flat birthmarks are easily covered with make-up. Treatment during infancy or childhood improves results. About 95% of the stains respond to FPDL surgery with minimal scarring; 25% will completely and 70% will partially disappear. For unknown reasons, 5% show no improvement.
Congenital hemangiomas or vascular malformations cannot be prevented, but spider angiomas may be prevented by exercise, weight control, and a high-fiber diet, as well as avoidance of sun exposure, alcohol drinking, or wearing tight hosiery.
American Academy of Dermatology. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-0230. Fax: (847) 330-0050. http://www.aad.org.
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000. http://www.aap.org.
Congenital Nevus Support Group. 1400 South Joyce St., Number C-1201, Arlington, VA 22202. (703) 920-3249.
National Congenital Port Wine Stain Foundation. 123 East 63rd St., New York, NY 10021. (516) 867-5137.