Spider angioma: Difference between revisions

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==Overview==
==Overview==
[[File:Spider nevus.jpg|thumb|left|180px|By Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14900/latest/, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=5038545]]
Spider angioma or spider naevus is a benign, painless [[Vascular malformations|vascular malformation]] in the skin, formed due to [[Vasodilation|vasodilatory effects]] of various [[Metabolism|metabolic]] and [[Hormone|hormonal]] disturbances. These are small [[Blanching|blanchable]] red [[Papule|papules]] with [[Capillaries anomalies|capillaries]] extending radially. They are present mostly on the face, arms and trunk. While multiple, extensive lesions point towards an underlying etiology they can occur solitary without an underlying cause. They are mostly seen in [[Cirrhosis|cirrhotic]] ([[alcoholism]], [[viral hepatitis]]) or [[Hyperestrogenism|hyperestrogenic]] ([[pregnancy]], [[oral contraceptive pills]]) patients. Treating the underlying cause is the mainstay of treatment. Facial lesions can be [[Cauterization|cauterized]] for cosmetic purposes.


==Historical Perspective==
==Historical Perspective==


*Spider angioma was first discovered by Dr. Erasmus Wilson, an English Surgeon, in his practice of modern-day dermatology.
*Spider angioma was first discovered by Dr. Erasmus Wilson, an English Surgeon, in his practice of modern-day [[dermatology]].
*In 1842, he described spider angioma in his book 'A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treatment of Diseases of the Skin' <ref> Wilson E. A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treatment of Diseases of the Skin, arranged according to a Natural System of Classification. The American Journal of the Medical Sciences. 1843 Jul;6(11):170-1. </ref>.
*In 1842, he described spider angioma in his book 'A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treatment of Diseases of the Skin' <ref> Wilson E. A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treatment of Diseases of the Skin, arranged according to a Natural System of Classification. The American Journal of the Medical Sciences. 1843 Jul;6(11):170-1. </ref>.
*In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
*In 1959, Dr. William Bennett Bean described the lesion in detail in his book 'Vascular Spiders and Related Lesions of the Skin' <ref> Bean, W. B. (1959). Vascular spiders and related lesions of the skin. Blackwell Scientific Publications.  </ref>.
   
   
==Classification==
==Classification==
Spider angioma may be classified into two groups:


*Spider angioma may be classified into two groups:
*a. [[Solitary]] [[Vascular malformations|vascular malformation]] without any underlying conditions.
**Benign solitary vascular malformation without any underlying conditions
*b. Multiple [[vascular malformations]] secondary to [[Cirrhosis|liver cirrhosis]] or [[Hormone|hormonal imbalances]].
**Multiple vascular malformations secondary to liver cirrhosis or hormonal imbalances.
 
*Classification based on videodermoscopy<ref name="pmid28960458">{{cite journal| author=Alegre-Sánchez A, Bernárdez C, Fonda-Pascual P, Moreno-Arrones OM, López-Gutiérrez JC, Jaén-Olasolo P | display-authors=etal| title=Videodermoscopy and doppler-ultrasound in spider naevi: towards a new classification? | journal=J Eur Acad Dermatol Venereol | year= 2018 | volume= 32 | issue= 1 | pages= 156-159 | pmid=28960458 | doi=10.1111/jdv.14602 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28960458  }}</ref>:
Classification based on video [[dermoscopy]]<ref name="pmid28960458">{{cite journal| author=Alegre-Sánchez A, Bernárdez C, Fonda-Pascual P, Moreno-Arrones OM, López-Gutiérrez JC, Jaén-Olasolo P | display-authors=etal| title=Videodermoscopy and doppler-ultrasound in spider naevi: towards a new classification? | journal=J Eur Acad Dermatol Venereol | year= 2018 | volume= 32 | issue= 1 | pages= 156-159 | pmid=28960458 | doi=10.1111/jdv.14602 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28960458  }}</ref>:
**Network pattern
 
**Looping pattern
*a. Network pattern
**Star pattern
 
*b. Looping pattern
*c. Star pattern


==Pathophysiology==
==Pathophysiology==


*The hypothesized pathogenesis of spider angioma is arteriolar vasodilatory effects of alcohol, substance P, hyperestrogenism, and inadequate hepatic metabolism of steroid hormones<ref name="pmid12571391" />.
*The hypothesized pathogenesis of spider angioma is arteriolar [[Vasodilator|vasodilatory]] effects of [[alcohol]], [[substance P]], [[hyperestrogenism]], and inadequate hepatic metabolism of [[steroid hormones]]<ref name="pmid12571391" />.
*The Mutation in endoglin (ENG) and activin-receptor-like kinase (ALK1) has been associated with the development of Hereditary hemorrhagic telangiectasia, which is associated with increased spider angiomas.
*In a study of patients with cirrhosis, a higher [[estradiol]]/[[testosterone]] ratio was found. It is hypothesized that relative estrogen excess mediates vasodilatation and results in the lesions<ref name="pmid10423070" />.
*The Mutation in [[endoglin]] (ENG) and activin-receptor-like kinase (ALK1) has been associated with the development of [[Hereditary hemorrhagic telangiectasia]], which is associated with increased spider angiomas<ref name="pmid167032492">{{cite journal| author=Sadick H, Sadick M, Götte K, Naim R, Riedel F, Bran G | display-authors=etal| title=Hereditary hemorrhagic telangiectasia: an update on clinical manifestations and diagnostic measures. | journal=Wien Klin Wochenschr | year= 2006 | volume= 118 | issue= 3-4 | pages= 72-80 | pmid=16703249 | doi=10.1007/s00508-006-0561-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16703249  }}</ref>.


==Causes==
==Causes==


*Common causes of spider angioma include liver cirrhosis, hyperestrogenism, and thyrotoxicosis.
*Common causes of spider angioma include [[Cirrhosis|liver cirrhosis]], [[hyperestrogenism]], and [[thyrotoxicosis]].


==Differentiating spider angioma from other Diseases==
==Differentiating spider angioma from other Diseases==
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*Spider angioma must be differentiated from other diseases that present with similar presentation such as:
*Spider angioma must be differentiated from other diseases that present with similar presentation such as:
**Angioma Serpiginosum
**Angioma Serpiginosum
**Basal Cell Carcinoma
**[[Basal Cell Carcinoma]]
**Cherry Hemangioma
**[[Hemangioma|Cherry Hemangioma]]
**Insect Bites
**[[Insect Bites]]
**Unilateral Nevoid Telangiectasia
**Unilateral Nevoid [[Telangiectasia]]


==Epidemiology and Demographics==
==Epidemiology and Demographics==
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*According to a study, in children without liver involvement, 38% had at least one lesion. 8 of 10 children with cirrhosis had at least one lesion, only 4 of 34 children with chronic liver disease had five or more spiders present. There was an increasing trend with the age<ref name="pmid16595646">{{cite journal| author=Finn SM, Rowland M, Lawlor F, Kinsella W, Chan L, Byrne O | display-authors=etal| title=The significance of cutaneous spider naevi in children. | journal=Arch Dis Child | year= 2006 | volume= 91 | issue= 7 | pages= 604-5 | pmid=16595646 | doi=10.1136/adc.2005.086512 | pmc=2082833 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16595646  }}</ref>.
*According to a study, in children without liver involvement, 38% had at least one lesion. 8 of 10 children with cirrhosis had at least one lesion, only 4 of 34 children with chronic liver disease had five or more spiders present. There was an increasing trend with the age<ref name="pmid16595646">{{cite journal| author=Finn SM, Rowland M, Lawlor F, Kinsella W, Chan L, Byrne O | display-authors=etal| title=The significance of cutaneous spider naevi in children. | journal=Arch Dis Child | year= 2006 | volume= 91 | issue= 7 | pages= 604-5 | pmid=16595646 | doi=10.1136/adc.2005.086512 | pmc=2082833 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16595646  }}</ref>.
*A study reported around 22% prevalence in normal male children and 30% in normal female children<ref name="pmid14117378">{{cite journal| author=WENZL JE, BURGERT EO| title=THE SPIDER NEVUS IN INFANCY AND CHILDHOOD. | journal=Pediatrics | year= 1964 | volume= 33 | issue=  | pages= 227-32 | pmid=14117378 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14117378  }}</ref>.
*A study reported around 22% prevalence in normal male children and 30% in normal female children<ref name="pmid14117378">{{cite journal| author=WENZL JE, BURGERT EO| title=THE SPIDER NEVUS IN INFANCY AND CHILDHOOD. | journal=Pediatrics | year= 1964 | volume= 33 | issue=  | pages= 227-32 | pmid=14117378 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14117378  }}</ref>.
*About 33% of the patients with advanced liver cirrhosis have spider angioma<ref name="pmid10423070">{{cite journal| author=Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH | display-authors=etal| title=Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function. | journal=Scand J Gastroenterol | year= 1999 | volume= 34 | issue= 5 | pages= 520-3 | pmid=10423070 | doi=10.1080/003655299750026272 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10423070  }}</ref>.
*About 33% of the patients with advanced [[Cirrhosis|liver cirrhosis]] have spider angioma<ref name="pmid10423070">{{cite journal| author=Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH | display-authors=etal| title=Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function. | journal=Scand J Gastroenterol | year= 1999 | volume= 34 | issue= 5 | pages= 520-3 | pmid=10423070 | doi=10.1080/003655299750026272 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10423070  }}</ref>.
*A study of 60 pregnant women reported the presence of spider angioma in 32 of them<ref name="pmid7832550">{{cite journal| author=Estève E, Saudeau L, Pierre F, Barruet K, Vaillant L, Lorette G| title=[Physiological cutaneous signs in normal pregnancy: a study of 60 pregnant women]. | journal=Ann Dermatol Venereol | year= 1994 | volume= 121 | issue= 3 | pages= 227-31 | pmid=7832550 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7832550  }}</ref>.
*A study of 60 pregnant women reported the presence of spider angioma in 32 of them<ref name="pmid7832550">{{cite journal| author=Estève E, Saudeau L, Pierre F, Barruet K, Vaillant L, Lorette G| title=[Physiological cutaneous signs in normal pregnancy: a study of 60 pregnant women]. | journal=Ann Dermatol Venereol | year= 1994 | volume= 121 | issue= 3 | pages= 227-31 | pmid=7832550 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7832550  }}</ref>.


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===Gender===
===Gender===


*There is no documented study showing gender predilection for Spider Angioma in otherwise healthy population.
*There is no documented study showing gender predilection for spider angioma in an otherwise healthy population.
*However there is an increased incidence in pregnant women, which is attributed to hyperestrogenic states.
*However there is an increased incidence in pregnant women, which is attributed to [[Hyperestrogenism|hyperestrogenic]] states.
   
   
===Race===
===Race===


*There is no racial predilection for Spider Angiomas, but are more visibile in light skinned people.
*There is no racial predilection for spider angiomas, but are more visible in light-skinned people.


==Risk Factors==
==Risk Factors==


*Common risk factors in the development of spider angioma are those causing hyperestrogenic state (pregnancy, oral contraceptive pills) and liver cirrhosis (Alcohol, Viral hepatitis).
*Common risk factors in the development of spider angioma are those causing [[Hyperestrogenism|hyperestrogenic state]] ([[pregnancy]], [[oral contraceptive pills]]) and [[liver cirrhosis]] ([[Alcohol]], [[Viral hepatitis]]).
*Higher number of angiomas are seen in patients with Hereditary Hemorraghic Telangectasia<ref name="pmid16703249">{{cite journal| author=Sadick H, Sadick M, Götte K, Naim R, Riedel F, Bran G | display-authors=etal| title=Hereditary hemorrhagic telangiectasia: an update on clinical manifestations and diagnostic measures. | journal=Wien Klin Wochenschr | year= 2006 | volume= 118 | issue= 3-4 | pages= 72-80 | pmid=16703249 | doi=10.1007/s00508-006-0561-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16703249  }}</ref>
*Higher number of angiomas are seen in patients with [[Hereditary hemorrhagic telangiectasia]]<ref name="pmid167032492" />.


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
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*The majority of healthy children and adults with spider angioma remain asymptomatic.
*The majority of healthy children and adults with spider angioma remain asymptomatic.
*Common complications of cutaneous spider angioma include bleeding secondary to manipulation.
*Common complications of cutaneous spider angioma include bleeding secondary to manipulation.
*There could be relapsing gastrointestinal bleeding in those with internal lesion<ref name="pmid24714144">{{cite journal| author=Katsanos KH, Sigounas DE, Christodoulou DK, Tsianos EV| title=Bleeding colonic spider angioma. | journal=Ann Gastroenterol | year= 2012 | volume= 25 | issue= 3 | pages= 259 | pmid=24714144 | doi= | pmc=3959367 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24714144  }}</ref>.
*There could be relapsing [[gastrointestinal bleeding]] in those with internal lesion<ref name="pmid24714144">{{cite journal| author=Katsanos KH, Sigounas DE, Christodoulou DK, Tsianos EV| title=Bleeding colonic spider angioma. | journal=Ann Gastroenterol | year= 2012 | volume= 25 | issue= 3 | pages= 259 | pmid=24714144 | doi= | pmc=3959367 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24714144  }}</ref>.
*Prognosis is generally excellent in those with resolution of underlying etiology.
*[[Prognosis]] is generally excellent in those with the resolution of underlying etiology.
*Physiological spider angiomas in younger adults usually increase till puberty and then disappear as the age advances<ref name="pmid14117378" />.
*Physiological spider angiomas in younger adults usually increase till [[puberty]] and then disappear as the age advances<ref name="pmid14117378" />.
*In women developing lesion during pregnancy may resolve post pregnancy.
*In women developing lesions during pregnancy may resolve post-pregnancy.
*In women who take oral contraceptives and present with lesions, they may resolve after the patient discontinues the hormonal preparations.
*In women who take oral contraceptives and present with lesions, they may resolve after the patient discontinues the hormonal preparations.


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===History and Symptoms===
===History and Symptoms===
[[File:Skin spider.jpg|right|200px|thumb]]


*Spider angioma, when not extensive, can be benign.
*Spider angioma, when not extensive, can be benign.
*When present extensively it could be due to an underlying cause.
*When present extensively it could be due to an underlying cause.
*Alcoholism and higher bilirubin levels were proven to have correlation for development of Spider angiomas<ref name="pmid10423070" />.
*[[Alcoholism]] and [[Bilirubin|higher bilirubin]] levels were proven to have a correlation for the development of spider angiomas<ref name="pmid10423070" />.
*Hyperestrogenic states like pregnancy, oral contraceptive pills etc could be the underlying cause in young females with no hepatic etiology<ref name="pmid23121469" />.
*Hyperestrogenic states like pregnancy, oral contraceptive pills, etc could be the underlying cause in young females with no hepatic etiology<ref name="pmid23121469" />.


===Physical Examination===
===Physical Examination===
[[File:Spider nevus face.jpg|150px|thumb|By Michael Sand, Daniel Sand, Christina Thrandorf, Volker Paech, Peter Altmeyer, Falk G Bechara - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903548/, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=74055892]]


*Patients with benign spider angioma usually appear normal.
*Patients with benign spider angioma usually appear normal.
*Those secondary to underlying cause may have additional symptoms pertaining to the disease.
*Those secondary to underlying cause may have additional symptoms pertaining to the disease.
*A spider angioma has 3 features: a body with small bright red lesions (1mm -10mm) with a central red spot, a leg with radiating thin-walled vessels and surrounding erythema<ref name="pmid29939595">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=29939595 | doi= | pmc= | url= }}</ref>.
*A spider angioma has 3 features: a body with small bright red lesions (1mm -10mm) with a central red spot, a leg with radiating thin-walled vessels and surrounding [[erythema]]<ref name="pmid29939595">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=29939595 | doi= | pmc= | url= }}</ref>.
*Unusually large presentations with visible pulsatile blood flow have also been reported<ref name="pmid23451770">{{cite journal| author=Hane H, Yokota K, Kono M, Muro Y, Akiyama M| title=Extraordinarily large, giant spider angioma in an alcoholic cirrhotic patient. | journal=Int J Dermatol | year= 2014 | volume= 53 | issue= 2 | pages= e119-21 | pmid=23451770 | doi=10.1111/j.1365-4632.2012.05548.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23451770  }}</ref><ref name="pmid25988027">{{cite journal| author=Sharma A, Sharma V| title=Giant spider angiomas. | journal=Oxf Med Case Reports | year= 2014 | volume= 2014 | issue= 3 | pages= 55 | pmid=25988027 | doi=10.1093/omcr/omu023 | pmc=4370005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25988027  }}</ref>.
*Unusually large presentations with visible pulsatile blood flow have also been reported<ref name="pmid23451770">{{cite journal| author=Hane H, Yokota K, Kono M, Muro Y, Akiyama M| title=Extraordinarily large, giant spider angioma in an alcoholic cirrhotic patient. | journal=Int J Dermatol | year= 2014 | volume= 53 | issue= 2 | pages= e119-21 | pmid=23451770 | doi=10.1111/j.1365-4632.2012.05548.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23451770  }}</ref><ref name="pmid25988027">{{cite journal| author=Sharma A, Sharma V| title=Giant spider angiomas. | journal=Oxf Med Case Reports | year= 2014 | volume= 2014 | issue= 3 | pages= 55 | pmid=25988027 | doi=10.1093/omcr/omu023 | pmc=4370005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25988027  }}</ref>.
*The blood pressure measures 50 to 70 mm Hg in these small arterioles<ref name="pmid29939595" />.
*The [[blood pressure]] measures 50 to 70 mm Hg in these small arterioles<ref name="pmid29939595" />.
*Spider angiomas are usually present on face, chest and arms in the distribution of Superior Vena Cava. But unusual presentations with Palpebra<ref name="pmid23121469">{{cite journal| author=Yalcin K, Ekin N, Atay A| title=Unusual presentations of spider angiomas. | journal=Liver Int | year= 2013 | volume= 33 | issue= 3 | pages= 487 | pmid=23121469 | doi=10.1111/liv.12009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121469  }}</ref>, Pluera and subpleura<ref name="pmid2290237">{{cite journal| author=Daimaru N, Okamura T, Nagano H, Shigematsu N, Yasunaga C, Sueishi K| title=[Hypoxemia of liver cirrhosis--an autopsy case study]. | journal=Nihon Kyobu Shikkan Gakkai Zasshi | year= 1990 | volume= 28 | issue= 11 | pages= 1504-10 | pmid=2290237 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2290237  }}</ref>, Esophaghus <ref name="pmid19863641">{{cite journal| author=Nur FA, Clemente C, Serino G, Salerno F, Spina L, Vecchi M| title=Atypical esophageal vascular lesions observed in liver cirrhosis. | journal=Dis Esophagus | year= 2010 | volume= 23 | issue= 1 | pages= E9-E11 | pmid=19863641 | doi=10.1111/j.1442-2050.2009.01018.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19863641  }}</ref>,and Gastrointestinal tracts <ref> Madhira, M.S. and M. Tobi. Isolated gastrointestinal spider nevi:
*Spider angiomas are usually present on face, chest and arms in the distribution of [[Superior vena cava]]. But unusual presentations with [[Palpebrae|Palpebra]]<ref name="pmid23121469">{{cite journal| author=Yalcin K, Ekin N, Atay A| title=Unusual presentations of spider angiomas. | journal=Liver Int | year= 2013 | volume= 33 | issue= 3 | pages= 487 | pmid=23121469 | doi=10.1111/liv.12009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23121469  }}</ref>, [[Pleura]] and subpleura<ref name="pmid2290237">{{cite journal| author=Daimaru N, Okamura T, Nagano H, Shigematsu N, Yasunaga C, Sueishi K| title=[Hypoxemia of liver cirrhosis--an autopsy case study]. | journal=Nihon Kyobu Shikkan Gakkai Zasshi | year= 1990 | volume= 28 | issue= 11 | pages= 1504-10 | pmid=2290237 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2290237  }}</ref>, [[Esophagus]] <ref name="pmid19863641">{{cite journal| author=Nur FA, Clemente C, Serino G, Salerno F, Spina L, Vecchi M| title=Atypical esophageal vascular lesions observed in liver cirrhosis. | journal=Dis Esophagus | year= 2010 | volume= 23 | issue= 1 | pages= E9-E11 | pmid=19863641 | doi=10.1111/j.1442-2050.2009.01018.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19863641  }}</ref>,and Gastrointestinal tracts <ref> Madhira, M.S. and M. Tobi. Isolated gastrointestinal spider nevi:
potential clinical significance. Am J Gastroenterol, 2000; 95(10):
potential clinical significance. Am J Gastroenterol, 2000; 95(10):
3009-3010 </ref> have been reported.
3009-3010 </ref> have been reported.
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===Diascopy===
===Diascopy===


*Diascopy is the procedure of applying pressure using glass slide or paper on the lesion to asses for blanchability.
*[[Diascopy]] is the procedure of applying pressure using a glass slide or paper on the lesion to assess for [[Blanching|blanchability]].
*Pallor upon application of pressure, followed by refilling upon relieving the pressure is characteristic of spider angioma.
*[[Pallor]] upon application of pressure, followed by refilling upon relieving the pressure is characteristic of spider angioma.


===Laboratory Findings===
===Laboratory Findings===


*Laboratory work up for hepatic etiology (Liver function tests, Viral markers), pregnancy (urine pregnancy test), hyperestrogenic etiology (Estrogen and FSH levels) and thyrotoxicosis (T3,T4, and TSH)<ref name="pmid12571391">{{cite journal| author=Khasnis A, Gokula RM| title=Spider nevus. | journal=J Postgrad Med | year= 2002 | volume= 48 | issue= 4 | pages= 307-9 | pmid=12571391 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12571391  }}</ref> should be done.
*Laboratory work up for hepatic etiology (Liver function tests, Viral markers), pregnancy ([[Pregnancy test|urine pregnancy test]]), hyperestrogenic etiology (Estrogen and FSH levels) and [[thyrotoxicosis]] (T3,T4, and TSH)<ref name="pmid12571391">{{cite journal| author=Khasnis A, Gokula RM| title=Spider nevus. | journal=J Postgrad Med | year= 2002 | volume= 48 | issue= 4 | pages= 307-9 | pmid=12571391 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12571391  }}</ref> should be done.


===Electrocardiogram===
===Electrocardiogram===


*There are no ECG findings associated with Spider angiomas.
*There are no ECG findings associated with spider angiomas.


===X-ray===
===X-ray===


*There are no x-ray findings associated with Spider angiomas.
*There are no x-ray findings associated with spider angiomas.


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===


*There are no echocardiography/ultrasound findings associated with Spider angiomas as such.
*There are no echocardiography/ultrasound findings associated with spider angiomas as such.
*Ultrasound has a high positive predictive value in identifying the underlying liver cirrhosis<ref name="pmid15671013">{{cite journal| author=Viganò M, Visentin S, Aghemo A, Rumi MG, Ronchi G| title=US features of liver surface nodularity as a predictor of severe fibrosis in chronic hepatitis C. | journal=Radiology | year= 2005 | volume= 234 | issue= 2 | pages= 641; author reply 641 | pmid=15671013 | doi=10.1148/radiol.2342041267 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15671013  }}</ref>.
*[[Ultrasound]] has a high positive predictive value in identifying the underlying liver cirrhosis<ref name="pmid15671013">{{cite journal| author=Viganò M, Visentin S, Aghemo A, Rumi MG, Ronchi G| title=US features of liver surface nodularity as a predictor of severe fibrosis in chronic hepatitis C. | journal=Radiology | year= 2005 | volume= 234 | issue= 2 | pages= 641; author reply 641 | pmid=15671013 | doi=10.1148/radiol.2342041267 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15671013  }}</ref>.
*Ultrasound may be useful in identifying underlying ovarian tumors<ref name="pmid20093591">{{cite journal| author=Twickler DM, Moschos E| title=Ultrasound and assessment of ovarian cancer risk. | journal=AJR Am J Roentgenol | year= 2010 | volume= 194 | issue= 2 | pages= 322-9 | pmid=20093591 | doi=10.2214/AJR.09.3562 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20093591  }}</ref>.
*Ultrasound may be useful in identifying underlying [[Ovarian tumor|ovarian tumors]]<ref name="pmid20093591">{{cite journal| author=Twickler DM, Moschos E| title=Ultrasound and assessment of ovarian cancer risk. | journal=AJR Am J Roentgenol | year= 2010 | volume= 194 | issue= 2 | pages= 322-9 | pmid=20093591 | doi=10.2214/AJR.09.3562 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20093591  }}</ref>.


===CT scan===
===CT scan===


*There are no CT scan findings associated with Spider angiomas.
*There are no CT scan findings associated with spider angiomas.
*CT scan is the most sensitive imaging modality for identifying the underlying liver cirrhosis<ref name="pmid18544944">{{cite journal| author=Kudo M, Zheng RQ, Kim SR, Okabe Y, Osaki Y, Iijima H | display-authors=etal| title=Diagnostic accuracy of imaging for liver cirrhosis compared to histologically proven liver cirrhosis. A multicenter collaborative study. | journal=Intervirology | year= 2008 | volume= 51 Suppl 1 | issue=  | pages= 17-26 | pmid=18544944 | doi=10.1159/000122595 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18544944  }}</ref>.
*CT scan is the most sensitive imaging modality for identifying the underlying liver cirrhosis<ref name="pmid18544944">{{cite journal| author=Kudo M, Zheng RQ, Kim SR, Okabe Y, Osaki Y, Iijima H | display-authors=etal| title=Diagnostic accuracy of imaging for liver cirrhosis compared to histologically proven liver cirrhosis. A multicenter collaborative study. | journal=Intervirology | year= 2008 | volume= 51 Suppl 1 | issue=  | pages= 17-26 | pmid=18544944 | doi=10.1159/000122595 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18544944  }}</ref>.
*Ct scan can reveal underlying ovarian tumors<ref name="pmid12432104">{{cite journal| author=Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST| title=CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. | journal=Radiographics | year= 2002 | volume= 22 | issue= 6 | pages= 1305-25 | pmid=12432104 | doi=10.1148/rg.226025033 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432104  }}</ref>.
*Ct scan can reveal underlying [[Ovarian tumor|ovarian tumors]]<ref name="pmid12432104">{{cite journal| author=Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST| title=CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. | journal=Radiographics | year= 2002 | volume= 22 | issue= 6 | pages= 1305-25 | pmid=12432104 | doi=10.1148/rg.226025033 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432104  }}</ref>.


===MRI===
===MRI===
Line 139: Line 146:
===Other Diagnostic Studies===
===Other Diagnostic Studies===


*Biopsy may be helpful in the diagnosis of Spider angioma when the presentation isn't classical. Findings diagnostic of spider angioma include Cutaneous arterial net, Central spider arteriole, Subepidermal ampulla , Star shaped arrangement of efferent spider vessels, and Capillaries<ref>Graham-Brown RAC and Sarkany I. The hepatobiliary system and the skin. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, et al. Editors. Fitzpatrick’s Dermatology in General Medicine. McGraw Hill 1999. Pp1972</ref>.
*[[Biopsy]] may be helpful in the diagnosis of spider angioma when the presentation isn't classical. Findings diagnostic of spider angioma include [[Cutaneous]] arterial net, Central spider arteriole, Subepidermal ampulla, Star-shaped arrangement of efferent spider vessels, and Capillaries<ref>Graham-Brown RAC and Sarkany I. The hepatobiliary system and the skin. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, et al. Editors. Fitzpatrick’s Dermatology in General Medicine. McGraw Hill 1999. Pp1972</ref>.
 
==Grading==
===Medical Therapy===


*
*


==Treatment==
==Treatment==
*There is no need of treatment for spider angiomas as they cause no imminent harm. Treatment is only directed for cosmetic purposes.
===Medical Therapy===
===Medical Therapy===


*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*Treating the underlying cause such as improvement of hepatic function, removal of the agent causing hyperestrogenic state leads to resolution of spider angiomas.
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
   
   
===Surgery===
===Surgery===


*Surgery is the mainstay of therapy for [disease name].
*Surgery therapy is used on facial angiomas for cosmetic concerns.
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*Fine-needle electrocautery, [[Laser|595 nm pulse-dye laser]] (PDL), 532 nm KTP (potassium-titanyl-phosphate) laser or electro desiccation have been used successfully with only minor scarring.
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
*595 nm PDL showed once-treatment cure rates were 100% in the Small-spot-combined-with-large-spot group and 34.8% in the Large spot-group (for skin lesions with a central spider body diameter ≥1 mm)<ref name="pmid31634243">{{cite journal| author=Zhang C, Ge HS, Yang S, Zhang XJ| title=Clinical efficacy of 595-nm pulsed-dye laser in treatment of childhood facial spider nevi: a retrospective study of 110 patients. | journal=Chin Med J (Engl) | year= 2019 | volume= 132 | issue= 20 | pages= 2417-2422 | pmid=31634243 | doi=10.1097/CM9.0000000000000467 | pmc=6831075 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31634243  }}</ref>.
*In another study usage of 595 nm PDL showed the improvement rate is 89.4% in a single time of treatment, and 91.0% in twice, 88.4% in 3 times of treatment<ref name="pmid26448027">{{cite journal| author=Yang B, Li L, Zhang LX, Sun YJ, Ma L| title=Clinical Characteristics and Treatment Options of Infantile Vascular Anomalies. | journal=Medicine (Baltimore) | year= 2015 | volume= 94 | issue= 40 | pages= e1717 | pmid=26448027 | doi=10.1097/MD.0000000000001717 | pmc=4616746 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26448027  }}</ref>.
   
   
===Prevention===
===Prevention===


*There are no primary preventive measures available for [disease name].
*There are no primary preventive measures available for spider angiomas.
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].


==References==
==References==

Latest revision as of 18:12, 27 September 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ;Associate Editor(s)-In-Chief: Nihas Raja Mateti, M.B.B.S.[2]

Overview

By Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14900/latest/, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=5038545

Spider angioma or spider naevus is a benign, painless vascular malformation in the skin, formed due to vasodilatory effects of various metabolic and hormonal disturbances. These are small blanchable red papules with capillaries extending radially. They are present mostly on the face, arms and trunk. While multiple, extensive lesions point towards an underlying etiology they can occur solitary without an underlying cause. They are mostly seen in cirrhotic (alcoholism, viral hepatitis) or hyperestrogenic (pregnancy, oral contraceptive pills) patients. Treating the underlying cause is the mainstay of treatment. Facial lesions can be cauterized for cosmetic purposes.

Historical Perspective

  • Spider angioma was first discovered by Dr. Erasmus Wilson, an English Surgeon, in his practice of modern-day dermatology.
  • In 1842, he described spider angioma in his book 'A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treatment of Diseases of the Skin' [1].
  • In 1959, Dr. William Bennett Bean described the lesion in detail in his book 'Vascular Spiders and Related Lesions of the Skin' [2].

Classification

Spider angioma may be classified into two groups:

Classification based on video dermoscopy[3]:

  • a. Network pattern
  • b. Looping pattern
  • c. Star pattern

Pathophysiology

Causes

Differentiating spider angioma from other Diseases

Epidemiology and Demographics

  • The prevalence of spider angioma is approximately 10,000-15,000 per 100,000 individuals in healthy adults and young children worldwide[4].
  • According to a study, in children without liver involvement, 38% had at least one lesion. 8 of 10 children with cirrhosis had at least one lesion, only 4 of 34 children with chronic liver disease had five or more spiders present. There was an increasing trend with the age[7].
  • A study reported around 22% prevalence in normal male children and 30% in normal female children[8].
  • About 33% of the patients with advanced liver cirrhosis have spider angioma[5].
  • A study of 60 pregnant women reported the presence of spider angioma in 32 of them[9].

Age

  • The mean age was 39.5 years (range: 10–76 years)[3].
  • Spider angioma is more common in women of childbearing age.

Gender

  • There is no documented study showing gender predilection for spider angioma in an otherwise healthy population.
  • However there is an increased incidence in pregnant women, which is attributed to hyperestrogenic states.

Race

  • There is no racial predilection for spider angiomas, but are more visible in light-skinned people.

Risk Factors

Natural History, Complications and Prognosis

  • The majority of healthy children and adults with spider angioma remain asymptomatic.
  • Common complications of cutaneous spider angioma include bleeding secondary to manipulation.
  • There could be relapsing gastrointestinal bleeding in those with internal lesion[10].
  • Prognosis is generally excellent in those with the resolution of underlying etiology.
  • Physiological spider angiomas in younger adults usually increase till puberty and then disappear as the age advances[8].
  • In women developing lesions during pregnancy may resolve post-pregnancy.
  • In women who take oral contraceptives and present with lesions, they may resolve after the patient discontinues the hormonal preparations.

Diagnosis

Diagnostic Criteria

  • There is no diagnostic criteria for Spider angioma.

History and Symptoms

  • Spider angioma, when not extensive, can be benign.
  • When present extensively it could be due to an underlying cause.
  • Alcoholism and higher bilirubin levels were proven to have a correlation for the development of spider angiomas[5].
  • Hyperestrogenic states like pregnancy, oral contraceptive pills, etc could be the underlying cause in young females with no hepatic etiology[11].

Physical Examination

By Michael Sand, Daniel Sand, Christina Thrandorf, Volker Paech, Peter Altmeyer, Falk G Bechara - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903548/, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=74055892
  • Patients with benign spider angioma usually appear normal.
  • Those secondary to underlying cause may have additional symptoms pertaining to the disease.
  • A spider angioma has 3 features: a body with small bright red lesions (1mm -10mm) with a central red spot, a leg with radiating thin-walled vessels and surrounding erythema[12].
  • Unusually large presentations with visible pulsatile blood flow have also been reported[13][14].
  • The blood pressure measures 50 to 70 mm Hg in these small arterioles[12].
  • Spider angiomas are usually present on face, chest and arms in the distribution of Superior vena cava. But unusual presentations with Palpebra[11], Pleura and subpleura[15], Esophagus [16],and Gastrointestinal tracts [17] have been reported.

Diascopy

  • Diascopy is the procedure of applying pressure using a glass slide or paper on the lesion to assess for blanchability.
  • Pallor upon application of pressure, followed by refilling upon relieving the pressure is characteristic of spider angioma.

Laboratory Findings

  • Laboratory work up for hepatic etiology (Liver function tests, Viral markers), pregnancy (urine pregnancy test), hyperestrogenic etiology (Estrogen and FSH levels) and thyrotoxicosis (T3,T4, and TSH)[4] should be done.

Electrocardiogram

  • There are no ECG findings associated with spider angiomas.

X-ray

  • There are no x-ray findings associated with spider angiomas.

Echocardiography or Ultrasound

  • There are no echocardiography/ultrasound findings associated with spider angiomas as such.
  • Ultrasound has a high positive predictive value in identifying the underlying liver cirrhosis[18].
  • Ultrasound may be useful in identifying underlying ovarian tumors[19].

CT scan

  • There are no CT scan findings associated with spider angiomas.
  • CT scan is the most sensitive imaging modality for identifying the underlying liver cirrhosis[20].
  • Ct scan can reveal underlying ovarian tumors[21].

MRI

  • There are no MRI findings associated with Spider angiomas.

Other Imaging Findings

  • There are no other imaging findings associated with Spider angiomas.

Other Diagnostic Studies

  • Biopsy may be helpful in the diagnosis of spider angioma when the presentation isn't classical. Findings diagnostic of spider angioma include Cutaneous arterial net, Central spider arteriole, Subepidermal ampulla, Star-shaped arrangement of efferent spider vessels, and Capillaries[22].

Treatment

  • There is no need of treatment for spider angiomas as they cause no imminent harm. Treatment is only directed for cosmetic purposes.

Medical Therapy

  • Treating the underlying cause such as improvement of hepatic function, removal of the agent causing hyperestrogenic state leads to resolution of spider angiomas.

Surgery

  • Surgery therapy is used on facial angiomas for cosmetic concerns.
  • Fine-needle electrocautery, 595 nm pulse-dye laser (PDL), 532 nm KTP (potassium-titanyl-phosphate) laser or electro desiccation have been used successfully with only minor scarring.
  • 595 nm PDL showed once-treatment cure rates were 100% in the Small-spot-combined-with-large-spot group and 34.8% in the Large spot-group (for skin lesions with a central spider body diameter ≥1 mm)[23].
  • In another study usage of 595 nm PDL showed the improvement rate is 89.4% in a single time of treatment, and 91.0% in twice, 88.4% in 3 times of treatment[24].

Prevention

  • There are no primary preventive measures available for spider angiomas.

References

  1. ↑ Wilson E. A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treatment of Diseases of the Skin, arranged according to a Natural System of Classification. The American Journal of the Medical Sciences. 1843 Jul;6(11):170-1.
  2. ↑ Bean, W. B. (1959). Vascular spiders and related lesions of the skin. Blackwell Scientific Publications.
  3. ↑ 3.0 3.1 Alegre-Sánchez A, Bernárdez C, Fonda-Pascual P, Moreno-Arrones OM, López-Gutiérrez JC, Jaén-Olasolo P; et al. (2018). "Videodermoscopy and doppler-ultrasound in spider naevi: towards a new classification?". J Eur Acad Dermatol Venereol. 32 (1): 156–159. doi:10.1111/jdv.14602. PMID 28960458.
  4. ↑ 4.0 4.1 4.2 Khasnis A, Gokula RM (2002). "Spider nevus". J Postgrad Med. 48 (4): 307–9. PMID 12571391.
  5. ↑ 5.0 5.1 5.2 Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH; et al. (1999). "Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function". Scand J Gastroenterol. 34 (5): 520–3. doi:10.1080/003655299750026272. PMID 10423070.
  6. ↑ 6.0 6.1 Sadick H, Sadick M, Götte K, Naim R, Riedel F, Bran G; et al. (2006). "Hereditary hemorrhagic telangiectasia: an update on clinical manifestations and diagnostic measures". Wien Klin Wochenschr. 118 (3–4): 72–80. doi:10.1007/s00508-006-0561-x. PMID 16703249.
  7. ↑ Finn SM, Rowland M, Lawlor F, Kinsella W, Chan L, Byrne O; et al. (2006). "The significance of cutaneous spider naevi in children". Arch Dis Child. 91 (7): 604–5. doi:10.1136/adc.2005.086512. PMC 2082833. PMID 16595646.
  8. ↑ 8.0 8.1 WENZL JE, BURGERT EO (1964). "THE SPIDER NEVUS IN INFANCY AND CHILDHOOD". Pediatrics. 33: 227–32. PMID 14117378.
  9. ↑ Estève E, Saudeau L, Pierre F, Barruet K, Vaillant L, Lorette G (1994). "[Physiological cutaneous signs in normal pregnancy: a study of 60 pregnant women]". Ann Dermatol Venereol. 121 (3): 227–31. PMID 7832550.
  10. ↑ Katsanos KH, Sigounas DE, Christodoulou DK, Tsianos EV (2012). "Bleeding colonic spider angioma". Ann Gastroenterol. 25 (3): 259. PMC 3959367. PMID 24714144.
  11. ↑ 11.0 11.1 Yalcin K, Ekin N, Atay A (2013). "Unusual presentations of spider angiomas". Liver Int. 33 (3): 487. doi:10.1111/liv.12009. PMID 23121469.
  12. ↑ 12.0 12.1 "StatPearls". 2021. PMID 29939595.
  13. ↑ Hane H, Yokota K, Kono M, Muro Y, Akiyama M (2014). "Extraordinarily large, giant spider angioma in an alcoholic cirrhotic patient". Int J Dermatol. 53 (2): e119–21. doi:10.1111/j.1365-4632.2012.05548.x. PMID 23451770.
  14. ↑ Sharma A, Sharma V (2014). "Giant spider angiomas". Oxf Med Case Reports. 2014 (3): 55. doi:10.1093/omcr/omu023. PMC 4370005. PMID 25988027.
  15. ↑ Daimaru N, Okamura T, Nagano H, Shigematsu N, Yasunaga C, Sueishi K (1990). "[Hypoxemia of liver cirrhosis--an autopsy case study]". Nihon Kyobu Shikkan Gakkai Zasshi. 28 (11): 1504–10. PMID 2290237.
  16. ↑ Nur FA, Clemente C, Serino G, Salerno F, Spina L, Vecchi M (2010). "Atypical esophageal vascular lesions observed in liver cirrhosis". Dis Esophagus. 23 (1): E9–E11. doi:10.1111/j.1442-2050.2009.01018.x. PMID 19863641.
  17. ↑ Madhira, M.S. and M. Tobi. Isolated gastrointestinal spider nevi: potential clinical significance. Am J Gastroenterol, 2000; 95(10): 3009-3010
  18. ↑ Viganò M, Visentin S, Aghemo A, Rumi MG, Ronchi G (2005). "US features of liver surface nodularity as a predictor of severe fibrosis in chronic hepatitis C." Radiology. 234 (2): 641, author reply 641. doi:10.1148/radiol.2342041267. PMID 15671013.
  19. ↑ Twickler DM, Moschos E (2010). "Ultrasound and assessment of ovarian cancer risk". AJR Am J Roentgenol. 194 (2): 322–9. doi:10.2214/AJR.09.3562. PMID 20093591.
  20. ↑ Kudo M, Zheng RQ, Kim SR, Okabe Y, Osaki Y, Iijima H; et al. (2008). "Diagnostic accuracy of imaging for liver cirrhosis compared to histologically proven liver cirrhosis. A multicenter collaborative study". Intervirology. 51 Suppl 1: 17–26. doi:10.1159/000122595. PMID 18544944.
  21. ↑ Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST (2002). "CT and MR imaging of ovarian tumors with emphasis on differential diagnosis". Radiographics. 22 (6): 1305–25. doi:10.1148/rg.226025033. PMID 12432104.
  22. ↑ Graham-Brown RAC and Sarkany I. The hepatobiliary system and the skin. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, et al. Editors. Fitzpatrick’s Dermatology in General Medicine. McGraw Hill 1999. Pp1972
  23. ↑ Zhang C, Ge HS, Yang S, Zhang XJ (2019). "Clinical efficacy of 595-nm pulsed-dye laser in treatment of childhood facial spider nevi: a retrospective study of 110 patients". Chin Med J (Engl). 132 (20): 2417–2422. doi:10.1097/CM9.0000000000000467. PMC 6831075 Check |pmc= value (help). PMID 31634243.
  24. ↑ Yang B, Li L, Zhang LX, Sun YJ, Ma L (2015). "Clinical Characteristics and Treatment Options of Infantile Vascular Anomalies". Medicine (Baltimore). 94 (40): e1717. doi:10.1097/MD.0000000000001717. PMC 4616746. PMID 26448027.

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