Venous Lakes

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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.

Epidemiology

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.

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.


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Venous lake on the helix of the ear.


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Venous lake on the lower lip.


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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.

Laboratory Studies

Imaging Studies

Other Tests

Procedures

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.

Medical Care

Surgical Care

Consultations

Diet

Medication Summary

Further Inpatient Care

Prognosis

Author

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

Disclosure: Nothing to disclose.

Specialty 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; Editor-in-Chief, Journal of Cutaneous Pathology

Disclosure: Apsara Consulting fee Independent contractor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD, Herman Beerman Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Ackerman Academy of Dermatopathology, New York

Disclosure: Nothing to disclose.

Additional Contributors

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

References

  1. Bean WB, Walsh JR. Venous lakes. AMA Arch Derm. Nov 1956;74(5):459-63. [View Abstract]
  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. [View Abstract]
  3. Colver GB, Hunter JA. Venous lakes: treatment by infrared coagulation. Br J Plast Surg. Sep 1987;40(5):451-3. [View Abstract]
  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. [View Abstract]
  5. Suhonen R, Kuflik EG. Venous lakes treated by liquid nitrogen cryosurgery. Br J Dermatol. Dec 1997;137(6):1018-9. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]
  10. Ross BS, Levine VJ, Ashinoff R. Laser treatment of acquired vascular lesions. Dermatol Clin. Jul 1997;15(3):385-96. [View Abstract]
  11. Roncero M, Canueto J, Blanco S, Unamuno P, Boixeda P. Multiwavelength Laser Treatment of Venous Lakes. Dermatol Surg. Nov 3 2009;[View Abstract]
  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. [View Abstract]
  13. Bencini PL, Tourlaki A, De Giorgi V, Galimberti M. Laser use for cutaneous vascular alterations of cosmetic interest. Dermatol Ther. Jul-Aug 2012;25(4):340-51. [View Abstract]
  14. Jay H, Borek C. Treatment of a venous-lake angioma with intense pulsed light. Lancet. Jan 10 1998;351(9096):112. [View Abstract]
  15. 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. [View Abstract]
  16. 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. [View Abstract]

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.

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.

Venous lake becomes inconspicuous during diascopy with a glass slide.