Venous lake

What is a venous lake

A venous lake is a small blood vessel (vein) in the skin, which over time has become enlarged and wider (or dilated). Venous lake is a common bluish soft macule or papule due to vascular dilatation. Venous lake is most often seen on the lower lip. Venous lakes manifest as dark blue-to-violaceous compressible papules caused by dilation of venules. Venous lakes 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). Venous lakes most commonly occur in adults older than 50 years with a history of long-term sun exposure. Although benign, venous lakes are important because of their mimicry of malignant lesions, such as melanoma and pigmented basal cell carcinoma. A venous lake is most often diagnosed in middle-aged or older men and women of any race. The average age of presentation for venous lakes has been reported to be 65 years. 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 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.

Can a venous lake be cured?

No treatment is required, unless the venous lake causes bleeding or soreness. Treatment may be desired for cosmetic reasons, but often leaves a permanent scar so one blemish is exchanged for another.

Are venous lakes hereditary?

Venous lakes are common and may affect more than one member of a family, but they are not inherited (passed on from one generation to another).

They are not contagious or ‘catching’. They are benign (harmless) and are not cancerous.

What causes venous lake?

It is thought that long-term sun exposure can cause venous lakes and possibly smoking, although the cause is unknown 2). They are usually seen in people older than 50 and are more common in men than in women. 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. 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.

What are the symptoms of a venous lake?

Usually, venous lakes despite being visible do not cause any other symptoms. However, if they have been knocked or caught, they may become painful or bleed.

A venous lake is a usually a small soft blue lump, up to 1cm wide, which may be flat or slightly dome-shaped. It usually affects sun-exposed areas of skin, most commonly on the lower lip or the rim of the ear. When compressed (pressure is applied to it), the blood may drain out of it causing it to flatten and almost disappear, the blood then returns once the pressure is removed.

Most affected persons just have one venous lake, but some people can have more than one.

What are the clinical features of a venous lake?

A venous lake is a soft, squashable, blue or purple macule or papule, that is 0.2–1 cm in diameter. Although they may arise anywhere, most venous lakes are diagnosed on the lower lip (on the vermilion margin or mucosal surface), on an earlobe, or elsewhere on the face, neck, or upper trunk.

How is a venous lake diagnosed?

A venous lake is usually easy to diagnose clinically by its appearance. The color disappears on compression of the macule or papule due to the clearance of blood from the dilated venule. This is most easily seen using a glass slide or the lens of a contact dermatoscope. A venous lake has a structureless blue or purple appearance on dermoscopy. A biopsy is rarely necessary and shows a dilated venule.

Venous lake treatment

A venous lake is harmless and does not require treatment. Many people choose to manage a venous lake by using a cosmetic camouflage cream to conceal the discoloured area of skin. This is a special form of make-up, used for medical purposes, that is water-resistant and available in a range of shades to match different skin tones.

A venous lake that is unsightly can be removed by destroying the lesion. This causes a temporary scab, and the procedure may result in a scar. Treatments to remove a venous lake include:

  • Cryotherapy: (the application of a freezing agent such as liquid nitrogen to skin cells with the aim of removing them) this means freezing the venous lake with liquid nitrogen (a procedure performed in clinic); the treated site feels very cold and sore during the procedure. This is usually followed by swelling, blistering and crusting that can last about 10-14 days). It usually leaves a pale scar.
  • Electrocautery
  • Sclerotherapy
  • Intense pulsed light
  • Vascular laser. the pulsed dye laser or other ‘vascular lasers’ are commonly used. These target the blood in the enlarged vein, heating it up and causing the vessel to shrink.

Surgical excision is rarely necessary and inevitably leaves a scar.

Venous lake removal

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 3). 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 4).

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 5).

Other visible-light lasers include the quasicontinuous wave lasers, such as copper vapor, krypton, and potassium-titanyl-phosphate (KTP) lasers 6). 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 7). The high rate of success is attributed to the deep-penetrating 1064-nm wavelength and the longer pulse widths, which damage larger vascular structures. Authors of a recent review article stated in their experience between pulsed dye laser, intense pulsed light, and Nd:YAG, the long-pulsed Nd:YAG laser was “superior to achieve fast and safe results” 8).

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 9). 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 10). 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 two patients in one study 11). Both patients needed two treatments for clearance, and no atrophy or scarring was noted after treatments.

Multiwavelength laser therapy (595-nm pulsed-dye and 1064-nm Nd:YAG) have been tried with some success since the combination of lasers helps reduce pulse duration and fluence 12). However, the studies have been small and more are needed.

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.

Venous lake 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 13). 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.

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