Appearance of Vascular Skin Changes
Vascular skin changes present with distinct morphologic features that vary by lesion type, depth of vessel involvement, and underlying pathophysiology—ranging from flat, well-demarcated capillary malformations to raised, proliferative vascular tumors.
Vascular Tumors
Infantile Hemangiomas
- Highly vascular, raised lesions with well-defined borders that are readily distinguished from flat capillary malformations 1
- Appear before 4 weeks of age as red, bright lesions that proliferate rapidly, completing most growth by 5 months 1
- Superficial hemangiomas: bright red, raised, and lobulated appearance 1
- Deep hemangiomas: bluish discoloration with less distinct borders, appearing later than superficial types 1
- Up to 70% leave residual changes including telangiectasia, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, and scarring 1
Pyogenic Granuloma
- Rapidly enlarging, pedunculated lesions with median size of 6.5 mm 1, 2
- Most commonly located on head and neck 1, 2
- Prone to erosion and difficult-to-control bleeding 1, 2
- Frequently misdiagnosed as infantile hemangioma despite being a reactive proliferative vascular lesion, not a true hemangioma 1, 2
Congenital Hemangiomas
- Fully formed at birth, distinguishing them from infantile hemangiomas 1
- RICH (rapidly involuting): present at birth and involute during first year of life 1
- NICH (noninvoluting): remain stable without growth or involution 1
Vascular Malformations
Capillary Malformations
- Flat lesions in contrast to most infantile hemangiomas 1
- Port wine stains (PWS): flat, darker red-purple lesions with well-defined borders that darken with time 1
- Nevus flammeus simplex (NFS/"salmon patch"): flat, pink or red lesions with ill-defined borders 1
- Present in up to 43% of general population 1
- Nonmidline lesions on glabella, lip ("angel kiss"), or nape of neck ("stork bite") are benign 1
- Midline or juxta-midline lumbosacral lesions may indicate underlying spinal dysraphism 1
Venous Malformations
- Historically misnamed as "cavernous hemangiomas" or "venous hemangiomas" 1
- Bluish, compressible lesions that may expand with dependent positioning 1
- Do not involute and grow proportionally with the patient 1
Lymphatic Malformations
- Subdivided into microcystic and macrocystic based on lacuna size 1
- May appear hemorrhagic when bleeding occurs into surface vesicles 1
- Previously misnamed as "cystic hygromas" or "lymphangiomas" 1
Varicose Veins and Chronic Venous Disease
Clinical Appearance
- Elongated, tortuous, dilated veins most commonly on lower extremities 1
- Telangiectasias occur in 43% of men and 55% of women 1
- Varicose veins occur in 16% of men and 29% of women 1
Advanced Changes
- Skin pigmentation changes (hemosiderin deposition) 1
- Eczema and dermatitis in affected areas 1
- Lipodermatosclerosis: hardening and decreased lower leg circumference from chronic inflammation, fibrosis, and skin/subcutaneous tissue contraction 1
- Venous ulceration in severe cases 1
Vasculitis-Related Changes
Small Vessel Involvement
- Palpable purpura: slightly raised, non-blanching purplish lesions 3
- Urticarial plaques: relatively persistent, unlike typical urticaria 3
- Papules and petechiae 3
Deeper Vessel Involvement
- Nodules when dermohypodermic junction or hypodermis affected 3
- Livedo pattern: reticular, net-like discoloration 3
- Ulcers in severe cases 3
Special Vascular Lesions
Angiokeratomas (Fabry Disease)
- Small, slightly raised, purplish-red, non-blanching angiectases 1
- Initially appear between 5-13 years of age 1
- Progressive increase in number and size with age 1
- Commonly affect hips, back, thighs, buttocks, penis, scrotum, oral mucosa, and conjunctiva 1
- Large genital lesions particularly susceptible to thrombosis and bleeding 1
Key Diagnostic Distinctions
Critical pitfall: The term "hemangioma" has been historically misused for various vascular lesions 1. Proper classification requires distinguishing: