eMedicine Specialties > Dermatology > Diseases of the Vessels

Venous Lakes

Claudia Hernandez, MD, Assistant Professor, Department of Dermatology, University of Illinois at Chicago College of Medicine

Updated: Nov 20, 2009

Introduction

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 their compressibility and predilection for sun-exposed skin, especially the ears of elderly patients.^{[1 ]}Although benign, venous lakes are important because of their mimicry of malignant lesions, such as melanoma and pigmented basal cell carcinoma.

Pathophysiology

A venous lake is an acquired form of vascular ectasia (vascular dilatation). A capillary aneurysm is considered a precursor or variant of a venous lake.

Frequency

United States

The exact incidence of venous lakes is unknown but they are believed to be common.

International

The worldwide incidence of venous lakes is unknown but is believed to be the same as that in the United States.

Mortality/Morbidity

Mortality from venous lakes has not been reported. Venous lakes are usually asymptomatic, although pain, tenderness, and excessive bleeding may occur if a lesion is traumatized. Venous lakes are considered biologically harmless.

Race

No racial predilection has been documented for venous lakes.

Sex

Bean and Walsh reported that 95% of venous lakes were observed in males.^{[1 ]}Another review of venous lakes confirmed the same sex distribution. The disproportionate 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.

Age

Venous lakes have been reported only in adults and usually occur in patients older than 50 years. The average age of presentation for venous lakes has been reported to be 65 years.

Clinical

History

Venous lakes most commonly occur in adults older than 50 years with a history of long-term sun exposure. The typical presentation is a slow-growing asymptomatic lesion. Patients with venous lakes may report that the papule has been present for several years prior to presentation. Recurrent bleeding after minor trauma may also be reported.

Physical

Physical examination usually reveals a soft, compressible, dark-blue or violaceous papule (slightly elevated lesion), up to 1 cm in diameter. Venous lakes usually are well demarcated, with a smooth surface. Compression often causes a emptying of the blood content. Venous lakes 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, as shown in the image below. Another common site of involvement is the vermilion border of the lower lip, shown below. Sometimes, several lesions are found on the same person, and the surrounding skin reveals actinic damage, as shown below.

Venous lake on the helix of the ear.

Venous lake on the lower lip.

Venous lake of the lip. Note the apparent actinic damage of the surrounding skin. Courtesy of Albert C. Yan, MD.

Causes

Two main theories regarding the development of venous lakes have been proposed. The first involves injury to the vascular adventitia and the dermal elastic tissue due to long-term solar damage permitting dilatation of superficial venous structures. The second theory involves the involvement of vascular thrombosis in the development of venous lakes. Thrombosis is commonly present in lesions of this type; however, whether the thromboses is a primary or a secondary event in the development of these lesions is unclear.

Differential Diagnoses

Workup

Laboratory Studies

• Blood laboratory studies are not usually indicated in the evaluation of venous lakes and other lesions of this type. Pathologic examination can prove useful in confirmation of a clinical diagnosis of venous lakes.

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 causes 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 ensues. Cherry angiomas and neoplasms (ie, basal cell carcinoma or nodular melanoma) do 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 of venous lakes remains in doubt.

Procedures

• Punch or shave biopsy can be used to obtain a specimen from the venous lake for pathologic confirmation of diagnosis.

Histologic Findings

In venous lakes, 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.

Treatment

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 the diagnosis or for venous lake removal. Treatment usually is performed for cosmetic reasons or to alleviate recurrent bleeding.
• Surgical treatment by cryosurgery, electrosurgery, sclerotherapy, and excision have all been reported to be successful forms of therapy for venous lakes.^{[2,3,4,5 ]}Although all of these approaches are economical, multiple treatments may be necessary. Treatment of venous lakes may be complicated by prolonged bleeding, swelling, pain, textural changes in treated areas, and scarring.
• The use of the argon laser and infrared coagulator has required up to 10-14 days for resolution of crusting and eschar formation. A tendency for scar formation with these therapies has been reported in the literature.^{[6 ]}
• 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, minimizing injury to the surrounding healthy skin. Numerous treatments may be necessary with this laser to clear the venous lake. Although scarring does not appear to be common with this laser, bleeding may occur after venous lake treatment.^{[7 ]}
• Other visible-light lasers include the quasicontinuous wave lasers, such as copper vapor, krypton, and potassium-titanyl-phosphate (KTP) lasers.^{[8,9,10,11 ]}These lasers carry a slightly higher risk of scarring compared with the pulsed dye laser.
• One study reported a series of 34 patients responding well to long-pulsed Nd:YAG laser, with 94% of the lesions clearing completely with one treatment and no complications reported.^{[12 ]}The high rate of success is attributed to the deep-penetrating 1064-nm wavelength and the longer pulse widths, which damage larger vascular structures.
• A single case report describes intense pulse light source treatment with a cool thermocoupling gel to protect the epidermis. This approach has been efficacious and, similar to the visible-light lasers, requires no anesthesia. No purpura or crusting and no visible scarring were observed at 1-month follow-up visits.^{[13 ]}Because only one case report has been published, more studies are needed prior to making conclusions about the effectiveness of this modality for venous lakes.
• 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.^{[14 ]}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 with carbon dioxide lasers compared with visible-light lasers.
• An 810-nm diode laser was used on 2 patients in one study.^{[15 ]}Both patients needed 2 treatments for clearance, and no atrophy or scarring was noted after treatments.
• With continuing advances in the technology of new lasers and intense pulsed light sources, 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 of venous lakes.

Diet

• Diet is not relevant to the development of venous lakes.

Medication

• Drugs cannot be used to ameliorate or remove venous lakes.

Follow-up

Further Inpatient Care

• Inpatient care is not required for venous lakes, which are superficial vascular anomalies.

Prognosis

• The prognosis for venous lakes is excellent. Although venous lakes do not resolve on their own, patients can be reassured that venous lakes do not evolve into something more serious, such as a skin cancer.

Miscellaneous

Medicolegal Pitfalls

• The primary medicolegal pitfall related to venous lakes would be misdiagnosis of a clinical lesion as a melanocytic neoplasm. The careful use of diascopy, dermoscopy, and microscopic examination help avoid this misdiagnosis.

Multimedia

Media file 1: Venous lake on the helix of the ear.

Media file 2: Venous lake on the lower lip.

Media file 3: Venous lake of the lip. Note the apparent actinic damage of the surrounding skin. Courtesy of Albert C. Yan, MD.

Media file 4: Venous lake becomes inconspicuous during diascopy with a glass slide.

References

1. Bean WB, Walsh JR. Venous lakes. AMA Arch Derm. Nov 1956;74(5):459-63. [Medline].

2. 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].

3. Colver GB, Hunter JA. Venous lakes: treatment by infrared coagulation. Br J Plast Surg. Sep 1987;40(5):451-3. [Medline].

4. 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].

5. Suhonen R, Kuflik EG. Venous lakes treated by liquid nitrogen cryosurgery. Br J Dermatol. Dec 1997;137(6):1018-9. [Medline].

6. 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].

7. 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].

8. 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].

9. 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].

10. Ross BS, Levine VJ, Ashinoff R. Laser treatment of acquired vascular lesions. Dermatol Clin. Jul 1997;15(3):385-96. [Medline].

11. Roncero M, Canueto J, Blanco S, Unamuno P, Boixeda P. Multiwavelength Laser Treatment of Venous Lakes. Dermatol Surg. Nov 3 2009;[Medline].

12. 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].

13. Jay H, Borek C. Treatment of a venous-lake angioma with intense pulsed light. Lancet. Jan 10 1998;351(9096):112. [Medline].

14. del Pozo J, Pena C, Garcia Silva J, Goday JJ, Fonseca E. Venous lakes: a report of 32 cases treated by carbon dioxide laser vaporization. Dermatol Surg. Mar 2003;29(3):308-10. [Medline].

15. Wall TL, Grassi AM, Avram MM. Clearance of multiple venous lakes with an 800-nm diode laser: a novel approach. Dermatol Surg. Jan 2007;33(1):100-3. [Medline].

16. Alcalay J, Sandbank M. The ultrastructure of cutaneous venous lakes. Int J Dermatol. Dec 1987;26(10):645-6. [Medline].

17. Goldberg LH, Altman AR. Venous lakes of the ears. Cutis. Dec 1985;36(6):472-5. [Medline].

18. 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].

Keywords

venous lakes, venous lake, venous-lake angioma, Bean-Walsh angioma, venous varix, senile hemangioma of the lips

Contributor Information and Disclosures

Author

Claudia Hernandez, MD, Assistant Professor, Department of Dermatology, University of Illinois at Chicago College of Medicine
Claudia Hernandez, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, Chicago Dermatological Society, Chicago Medical Society, Dermatology Foundation, National Hispanic Medical Association, and Society for Investigative Dermatology
Disclosure: Amgen Honoraria Speaking and teaching; Centocor Honoraria Speaking and teaching

Medical Editor

Timothy McCalmont, MD, Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Editor-in-Chief, Journal of Cutaneous Pathology
Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Apsara Consulting fee Independent contractor

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Rosalie Elenitsas, MD, Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System
Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Jining Wang, MD, and Kim Wang, MD, to the development and writing of this article.

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