Are easily visible blueish veins in the hands a sign of Hereditary Hemorrhagic Telangiectasia (HHT)?

Easily Visible Blueish Veins in Hands Are NOT a Sign of HHT

Visible blueish veins in the hands are normal superficial venous anatomy and are not a diagnostic feature of Hereditary Hemorrhagic Telangiectasia (HHT). HHT is characterized by specific vascular lesions—telangiectasias and arteriovenous malformations—not prominent normal veins.

What HHT Actually Looks Like

The diagnosis of HHT requires clinical recognition of telangiectasias, which are distinctly different from visible veins 1:

• Telangiectasias appear as small red spots on characteristic sites including lips, oral cavity (tongue and inner mouth), fingers, and nose—not as blue linear veins 1
• These lesions are mucocutaneous vascular malformations that represent abnormal direct connections between arteries and veins, lacking normal capillary beds 2
• Telangiectasias typically develop over time with age-dependent penetrance, usually appearing after epistaxis begins (mean age 11 years for nosebleeds) 3

The Curaçao Diagnostic Criteria

The American College of Physicians recommends applying the Curaçao criteria, which requires 3 of 4 clinical features for definite diagnosis 1:

1. Spontaneous and recurrent epistaxis (nosebleeds)—present in >90% of adults with HHT 1, 4
2. Multiple telangiectasias at characteristic sites (lips, oral cavity, fingers, nose)—these are red spots, not blue veins 1
3. Visceral arteriovenous malformations (pulmonary, cerebral, hepatic, or GI) 1
4. First-degree relative with HHT 1

Why Visible Veins Are Not Part of HHT

• Normal superficial veins appear blue through the skin due to light absorption properties—this is standard anatomy, not pathology
• HHT vascular lesions are arteriovenous connections that appear red due to arterial blood flow directly shunting to venous circulation 2, 5
• The characteristic skin findings in HHT are described as "red spots" on fingers, not prominent blue veins 6, 7

What You Should Actually Look For

If concerned about HHT, assess for these specific features 1:

• Recurrent nosebleeds starting in childhood or adolescence
• Small red spots (1-3mm) on the lips, tongue, fingertips, or face
• Family history of similar bleeding or vascular problems
• Unexplained anemia from chronic bleeding

Critical Clinical Pitfall

Do not confuse normal venous anatomy with pathologic vascular malformations. Telangiectasias are red, not blue, and occur at specific mucocutaneous sites 1, 6. Visible hand veins are a common normal variant influenced by skin thickness, body fat percentage, hydration status, and genetics—none of which relate to HHT pathophysiology 2.