| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Dermatology > DISEASES OF THE VESSELS
Venous Lakes
Article Last Updated: Feb 28, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Jining Wang, MD, Department of Dermatology, Dean Health System
Jining Wang is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Coauthor(s):
Kim Wang, MD, Staff Physician, Department of Pathology, Northwestern University Medical School
Editors: Timothy McCalmont, MD, Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA; Rosalie Elenitsas, MD, Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
venous-lake angioma, Bean-Walsh angioma, venous varix, senile hemangioma of the lips
Background
Venous lakes manifest as dark blue-to-violaceous compressible papules caused by dilation of venules. They were first described in 1956 by Bean and Walsh, who noted how they can be easily compressed and their tendency to occur on sun-exposed skin, especially the ears of elderly patients. Although venous lakes may be considered clinically insignificant from a biological standpoint, they are important because of their mimicry of more ominous lesions, such as melanoma and pigmented basal cell carcinoma.
Pathophysiology
Vascular anomalies are classified into various groups, including malformations, hamartomas, vascular ectasias, vascular hyperplasias, and benign and malignant neoplasms. Venous lakes represent a form of vascular ectasia (vascular dilatation). This group of diseases also includes spider angiomas and telangiectases. A capillary aneurysm is considered a precursor or variant of a venous lake.
The development of venous lakes is believed to be exacerbated by solar exposure and damage. One theory is that chronic solar damage injures the vascular adventitia and the dermal elastic tissue, permitting dilatation of superficial venous structures.
Vascular thrombosis also may play a role in the development of these lesions because thrombosis is commonly present in lesions of this type. Whether thrombosis is a primary or a secondary event in the development of these lesions is unclear.
Frequency
United States
The incidence of disease in the United States is not believed to differ from the incidence worldwide.
International
Although the exact incidence is unknown, venous lakes are common.
Mortality/Morbidity
Mortality from venous lakes has not been reported. There is very little associated morbidity, and lesions typically are considered biologically harmless. Venous lakes are usually asymptomatic, although pain, tenderness, and excessive bleeding can occur once a lesion has been traumatized.
Race
No racial predilection has been documented.
Sex
Bean and Walsh reported that 95% of venous lakes were observed in males. Another review of venous lakes confirmed the same gender distribution. It has been suggested that the disproportionately male distribution may be related to occupational sun exposure, hair length, and hairstyles. Women comprised the majority of treated patients in a large study of laser therapy for venous lakes; however, this may be related to increased concern among women regarding cosmetic appearance rather than with true incidence (a selection bias).
Age
Venous lakes have been reported only in adults and usually occur in patients older than 50 years. The average age of presentation has been reported to be 65 years.
History
Venous lakes occur most commonly in adults older than 50 years with a history of chronic sun exposure. The typical presentation is as an asymptomatic lesion.
Physical
Physical examination usually reveals a soft, compressible, violaceous papule, up to 1 cm in greatest diameter. The lesions usually are well demarcated with a smooth surface, and compression often causes a transient depression. Lesions typically are distributed on the sun-exposed surfaces of the face and neck, especially on the helix and antihelix of the ear and the posterior aspect of the pinna (see Image 2). Another common site of involvement is the vermilion border of the lower lip (see Image 3). Sometimes, several lesions are found on the same person, and the surrounding skin reveals actinic damage (see Image 1).
Causes
Solar elastosis is believed to contribute to the development of venous lakes via alteration of vascular and dermal elastic fibers.
Angiokeratoma Circumscriptum
Basal Cell Carcinoma
Blue Nevi
Cherry Hemangioma
Kaposi Sarcoma
Lentigo
Malignant Melanoma
Nevi, Melanocytic
Pyogenic Granuloma (Lobular Capillary Hemangioma)
Lab Studies
- Blood laboratory studies are not usually indicated in the evaluation of lesions of this type. Pathologic examination can prove useful in confirmation of the clinical diagnosis.
Imaging Studies
- Imaging studies are not necessary in the evaluation of venous lakes.
Other Tests
- Diascopy is useful for differentiating venous lakes from other lesions. Direct pressure created by a glass microscope slide will cause a vascular lesion such as a venous lake to blanch as its contents are emptied. Sometimes, blood may not be completely emptied with diascopy, but a color change will ensue. Cherry angiomas and neoplasms like a basal cell carcinoma or a nodular melanoma will not change color with diascopy.
- Epiluminescence techniques such as dermoscopy also can be used to differentiate vascular lesions (eg, venous lake) from melanocytic neoplasms. A venous lake observed under the dermatoscope has a homogenous reddish-blue to reddish-black color and no pigment network structures.
- A biopsy is indicated if the diagnosis remains in doubt.
Procedures
- Punch or shave biopsy can be used to obtain a specimen for pathologic confirmation of diagnosis.
Histologic Findings
A single large dilated space or several interconnecting dilated spaces characteristically are observed in the superficial dermis. The dilated channels have very thin walls that are lined by a single layer of flattened endothelium and supported by a thin layer of fibrous connective tissue.
Usually, no smooth muscle or elastic tissue is found in the vessel wall. In rare cases, a thin and noncircumferential area suggestive of smooth muscle can be found instead of the fibrous tissue. Solar elastosis and other evidence of sun damage usually are found in the adjacent dermis.
Medical Care
Venous lakes are nonproliferative vascular lesions that are not treatable via medical means.
Surgical Care
- Surgical biopsy or excision can be useful for confirmation of diagnosis or for lesion removal. Treatment usually is performed for cosmetic reasons or to alleviate recurrent bleeding.
- Surgical treatment by cryosurgery, electrosurgery, sclerotherapy, or excision can be successful. All of these approaches are economical modalities. Occasionally, treatment has been complicated by prolonged bleeding, swelling, pain, or scarring.
- In the past, the use of the argon laser and infrared coagulator required up to 10-14 days for resolution of crusting and eschar formation. There was a marked tendency toward scar formation.
- Using the theory of selective photothermolysis, dermatologic laser surgeons have effectively used visible-light lasers such as the flashlamp pulsed dye laser at carefully chosen wavelengths, pulse durations, and doses to selectively destroy blood vessels without injuring surrounding normal skin. However, the pulsed dye laser produces such explosive destruction of blood vessels that purpura and postinflammatory hyperpigmentation may last for several weeks after treatment. Some pulse dye lasers now have an attached dynamic cooling function, which reduces pain and protects the epidermis from injury.
- Other visible-light lasers include the quasi-continuous wave lasers, such as copper vapor, krypton, and potassium-titanyl-phosphate (KTP) laser. These lasers carry a slightly higher risk of scarring than the pulsed dye laser. However, these lasers have proven to be more effective in ameliorating larger-caliber vessels, similar to those found in venous lakes and other vascular ectasias, without causing the postoperative purpura of the pulsed dye laser. In addition, less crusting and eschar formation occurs than with the argon laser.
- One study reported a series of 34 cases responding well to long-pulsed Nd:Yag laser, with 94% of the lesions clearing completely with one treatment and no complications reported (Bekhor, 2006). The high rate of success is attributed to the deep penetrating 1064-nm wavelength and the longer pulse widths, which damage larger vascular structures.
- Intense pulse light source has been used with a cool thermocoupling gel to protect the epidermis. This approach has been efficacious and, like the visible-light lasers, requires no anesthesia. No purpura or crusting and no visible scarring were observed at 1-month follow-up visits (Jay, 1998). A larger number of cases treated with intense pulsed light sources are needed to evaluate the safety and effectiveness of this approach.
- Vaporization with infrared lasers (eg, carbon dioxide laser) has been effective. One study reported that, on average, only one session was needed to treat venous lakes, and the postoperative crusting resolved after 7-10 days (del Pozo, 2003). Unlike visible-light lasers, local anesthesia is needed when venous lakes are treated with a carbon dioxide laser. Scarring, including pigmentary and textural changes, is thought to be more likely compared with visible-light lasers; however, excellent results have been reported in the literature.
- With continuing advances in technology of new lasers and the intense pulsed light source, excellent results with reduced costs, minimal pain, minimal postoperative care, and scarring will be available to an increasing patient population.
Consultations
Consultation with a dermatologist is usually appropriate for confirmation of the clinical diagnosis.
Diet
Diet is completely unrelated to the development of these lesions.
Drugs cannot be used to ameliorate or remove venous lakes.
Further Inpatient Care
- Inpatient care is not required for these superficial and biologically trivial vascular anomalies.
Prognosis
- Prognosis is excellent. Although the lesions will not resolve on their own, patients can be reassured that venous lakes will never evolve into something more serious such as a skin cancer.
Medical/Legal Pitfalls
- The primary medicolegal pitfall would be misdiagnosis of a clinical lesion as a melanocytic neoplasm. The careful use of diascopy, dermoscopy, and microscopic examination would contribute to the avoidance of this misdiagnosis.
| Media file 1:
Venous lake of the lip. Note the apparent actinic damage of the surrounding skin. Courtesy of Albert C. Yan, MD. |
 |  View Full Size Image | |
Media type: Photo
|
| Media file 4:
Venous lake becomes inconspicuous during diascopy with a glass slide. |
 | View Full Size Image | |
Media type: Photo
|
- Ah-Weng A, Natarajan S, Velangi S, Langtry JA. Venous lakes of the vermillion lip treated by infrared coagulation. Br J Oral Maxillofac Surg. Jun 2004;42(3):251-3. [Medline].
- Alcalay J, Sandbank M. The ultrastructure of cutaneous venous lakes. Int J Dermatol. Dec 1987;26(10):645-6. [Medline].
- Bean WB, Walsh JR. Venous lakes. AMA Arch Derm. Nov 1956;74(5):459-63. [Medline].
- Bekhor PS. Long-pulsed Nd:YAG laser treatment of venous lakes: report of a series of 34 cases. Dermatol Surg. Sep 2006;32(9):1151-4. [Medline].
- Boffa MJ. Pulsed dye laser treatment of thick/raised vascular lesions using compression with clear plastic. J Am Acad Dermatol. Nov 2003;49(5):879-81. [Medline].
- Colver GB, Hunter JA. Venous lakes: treatment by infrared coagulation. Br J Plast Surg. Sep 1987;40(5):451-3. [Medline].
- Goldberg LH, Altman AR. Venous lakes of the ears. Cutis. Dec 1985;36(6):472-5. [Medline].
- Jay H, Borek C. Treatment of a venous-lake angioma with intense pulsed light. Lancet. Jan 10 1998;351(9096):112. [Medline].
- Kuo HW, Yang CH. Venous lake of the lip treated with a sclerosing agent: report of two cases. Dermatol Surg. Apr 2003;29(4):425-8. [Medline].
- Landthaler M, Haina D, Waidelich W, Braun-Falco O. Laser therapy of venous lakes (Bean-Walsh) and telangiectasias. Plast Reconstr Surg. Jan 1984;73(1):78-83. [Medline].
- Neumann RA, Knobler RM. Venous lakes (Bean-Walsh) of the lips--treatment experience with the argon laser and 18 months follow-up. Clin Exp Dermatol. Mar 1990;15(2):115-8. [Medline].
- Polla LL, Tan OT, Garden JM, Parrish JA. Tunable pulsed dye laser for the treatment of benign cutaneous vascular ectasia. Dermatologica. 1987;174(1):11-7. [Medline].
- Requena L, Sangueza OP. Cutaneous vascular anomalies. Part I. Hamartomas, malformations, and dilation of preexisting vessels. J Am Acad Dermatol. Oct 1997;37(4):523-49; quiz 549-52. [Medline].
- Ross BS, Levine VJ, Ashinoff R. Laser treatment of acquired vascular lesions. Dermatol Clin. Jul 1997;15(3):385-96. [Medline].
- Suhonen R, Kuflik EG. Venous lakes treated by liquid nitrogen cryosurgery. Br J Dermatol. Dec 1997;137(6):1018-9. [Medline].
- del Pozo J, Pena C, Garcia Silva J, et al. Venous lakes: a report of 32 cases treated by carbon dioxide laser vaporization. Dermatol Surg. Mar 2003;29(3):308-10. [Medline].
Venous Lakes excerpt Article Last Updated: Feb 28, 2007
|
