Spider Angioma

Etiology

Spider angiomas are usually benign but often can be suggestive of an underlying systemic disease such as cirrhosis, rheumatoid arthritis, or thyrotoxicosis. Solitary spider angiomas are seen in 15% of young adults who usually have fewer than 3 lesions. The lesions also can appear in other physiologic conditions like pregnancy or severe malnutrition. Multiple spider angiomas are characteristic of chronic liver disease with a specificity of 95%.[4]

Epidemiology

Prevalence of spider angiomas is highest among patients with cirrhosis, alcoholic hepatitis, and hepatopulmonary syndrome. Spider nevi correspond with a higher risk of mortality among patients with the alcoholic liver disease. They also suggest a high likelihood of esophageal varices and are indicative of the extent of hepatic fibrosis. The reported prevalence of spider angiomas in cirrhosis is 33%. In one study, 38% of healthy children had at least single spider telangiectasia. They are also visible in about 60% of pregnant women. Physiological spider angiomas in younger adults usually disappear as the age advances, although in few, it may take several years to disappear completely. In women who take oral contraceptives and present with lesions, they may resolve after the patient discontinues the hormonal preparations. If spider angiomas are associated with pregnancy, they will disappear after delivery of the baby. There is no racial predilection for spider angiomas, but lesions are more apparent in light-skinned patients. Spider angiomas are more common in women than in men, and this is thought to be due to the role of steroid hormones in their formation.

Pathophysiology

Spider naevus is dilation of preexisting central arterioles from which numerous thin-walled capillary branches radiate like spider legs, carrying away freely flowing blood. They form due to the failure of the sphincteric muscle surrounding a cutaneous arteriole leading to dilatation of central arteriole. The exact cause of spider angioma is not known. For decades, there have been many hypotheses of possible mechanisms that lead to the arteriolar vasodilation. Important among those are direct vasodilatory effects of alcohol, substance P, hyperestrogenism, and inadequate hepatic metabolism of steroid hormones. Angiogenesis as a possible mechanism in the pathogenesis of spider nevi has been proposed due to elevated serum vascular growth factors, such as vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) levels in patients with liver cirrhosis. Sex hormone imbalance predominantly hyperestrogenism has also been implicated for the development spider naevi. This is also suggested by the occurrence of spider angioma in individuals with a hyperestrogenic state, like pregnancy.[5][6]

History and Physical

Spider angiomas are characteristically found on the face, neck, upper chest, and arms in adults, corresponding to the distribution of superior vena cava. In children, lesions are common on the upper extremities. They may also be present on the backs of the hands and fingers. However, it must be emphasized that spider angiomas can also be seen in locations other than the skin, such as the mucosa of the oral cavity and gastrointestinal (GI) tract. Its characteristic appearance diagnoses spider angioma. Large spider angiomas may be pulsatile with blood flow toward the periphery secondary to the local increase in arterial blood supply. Bleeding from these lesions is unusual unless picked or scratched. Skin temperature over a spider nevus is higher than surrounding skin. The blood pressure measures 50 to 70 mm Hg in these small arterioles.

The direction of blood flow can be illustrated by applying pressure over the body of spiders with a glass slide (diascopy), leading to pallor with refilling following the release of pressure. No other angiomas show this phenomenon. Due to the varying sizes of spider angioma and for the ease of description, they can be graded from grade 1+ (readily recognizable containing a body, legs, and surrounding erythema) to grade 4+ (visible pulsations with a hand lens, and raised central punctum with many obvious “spider legs” radiating from it). Pregnant patients may present with numerous spider nevi which are harmless and usually resolve after childbirth. Patients with the chronic liver disease will typically have symptoms like jaundice, fluid retention, confusion, and on examination, shifting dullness, icterus, findings related to cause of cirrhosis, and stigmata of liver cell failure.

Evaluation

Solitary spider nevus in otherwise healthy individuals or pregnant women does not warrant further workup. A detailed history and focused physical exam can help to attribute multiple spider angioma to liver disease. As a general rule, number and size of spider angioma correlate with the severity of liver disease. In some occasions, history and exam might not point towards nevi and can lead to concerns of skin malignancy, such as basal cell carcinoma. A skin biopsy will be useful in these situations to exclude skin cancer or other conditions.[7][8][9][10]

Treatment / Management

Treatment of spider nevi is dependant on the cause of intra-arteriolar vasodilation. Patients with an underlying systemic disease like cirrhosis should be managed as the standard of care. However, when spider nevi are present, these patients may already have advanced liver disease.

Rarely, fine-needle electrocautery, 585 nm pulsed, dye laser, 532 nm KTP (potassium-titanyl-phosphate) laser, or electro desiccation have been used to clear spider angioma for cosmetic concerns. The results of the procedure are generally good except for the small risk of the scar. Spider angiomas can recur after treatment. Spider nevi in healthy individuals usually disappear in a few years, in pregnancy following childbirth and those related to oral contraceptive pills after discontinuation of medication. Cirrhotic patients note the disappearance of nevi following liver transplantation.

Differential Diagnosis

• Acneiform Eruptions

• Basal Cell Carcinoma

• Cherry Hemangioma

• Coastal Fringe

• Essential telangiectasia

• Fabry disease

• Hereditary hemorrhagic telangiectasia

• Insect Bites

• Lobular capillary hemangioma

• Osler-Weber-Rendu Syndrome

• Rosacea

• Scleroderma

• Unilateral Nevoid Telangiectasia