Definition. – New growths and hypertrophies composed chiefly of the vascular elements of the corium and subcutaneous tissues.
Symptoms. – Numerous and often unnecessary forms of angiomata are described but for the sake of simplicity the four mentioned below will suffice.
Nevus vasculosus (angioma simplex) includes those vascular growths which are congenital or develop shortly after birth and appear as discolorations varying from a light pink or red to a deep blue or purple. The color may disappear on firm pressure but returns immediately after compression is removed. Because of their appearance and their relation to the various items of prenatal influence they have been called port-wine marks, mother’s marks, birth-marks, claret- stains and nevus flammeus. While most frequently observed on the head and neck, they are often multiple and may occur anywhere. They are small or extensive in area, flat or raised above the surrounding surface and may be studded with small, soft, erectile, compressible nodules. These latter may lie deep in the skin and slowly enlarge to the size of hazel nuts, while the overlying skin may be normal in color or of any degree of redness. Even the nodular growths are compressible like the simple form first described. They have been considered true angiomata as distinguished from nevi but the division is of no importance. They are sometimes classified as capillary angiomata when composed of newly formed capillaries, or as cavernous angiomata when composed of large, cavernous blood spaces. These two varieties are usually single, benign and painless, though pressure may excite neuralgic pains and a certain degree of pulsation and murmur.
Telangiectasis is a term applied to a new-growth or enlargement of capillaries, developing after the infantile period. Telangiectases are acquired while nevi are congenital formations. The lesions may be large or small, diffuse or circumscribed but the latter are more common and are usually seen in the form of the spider nevus (nevus araneus) which consists of a minute central red point from which slender red capillaries radiate in all directions. Capillary hypertrophy is often found upon scars, on malignant growths, in connection with scleroderma or other condensations of the skin, after X-ray treatment and is commonly noticed on the nose and cheeks of those affected with rosacea. A condition usually assigned to the domain of surgery, varicose veins, may be included in this group but has little interest for the dermatologist except in the production of the well-known leg ulcer and the accompanying eczematous dermatitis.
Fig. 122- Nevus vasculosus (angioma simplex, port-wine mark) presenting a dark- red discoloration, studded with small compressible nodules. Removed by solidified carbon dioxid.
Angioma serpiginosum (infective angioma; nevus lupus) is a rare and peculiar form, usually found in young children, often starting from nevi. It appears in the form of minute red specks resembling “grains of Cayenne pepper” arranged to form circles or gyrate lines where several circles have coalesced. These groups enlarge peripherally as the center clears up, after the manner of ringworm, by the appearance of new spots at the borders. The disease is slow in its course, the lesions are multiple and may appear on the extremities, head or trunk.
Angiokeratoma is a rare condition characterized by small, translucent, reddish or bluish, warty or horny papules or nodules. They are apt to develop in association with chilblains,in fact the early lesions are almost identical with that condition, and are usually pin-head in size, and seen on the fingers, palms, soles, scrotum and ears. The condition usually begins in childhood and represents a capillary dilation with a thickening of the overlying epidermis.
Etiology and Pathology. – The cause of congenital angiomata or nevi is not known beyond the suggestions of maternal influences and intrauterine pressure. All that can be said is that they are the result of congenital malformations. Telangiectases may arise from long-continued or frequently repeated hyperemia of the skin, due to general or local conditions or from such a slight injury as a pin prick or insect bite. No cause is known for the few cases so far reported of serpiginous angioma but the microscopic findings indicate that these growths are angiosarcomatous. Angiokeratoma has been attributed to cold and has been thought to be allied to chilblains but the disease occurring on the scrotum proves that cold is not the only exciting factor. Anatomically the angiomata are due to dilatation and new formation of the venous and arterial capillaries in the upper portion of the derma, associated with a new formation of connective tissue which constitutes the framework of the new-growth.
Fig. 123. – Nevus vasculous of the nodular type with an elevation of 1/4 inch above the surface. Deep or purplish-red color which partially disappeared on pressure.
Fig. 124. – Showing the result of four applications of solidified carbon dioxid, at three month intervals. Pressure, moderate. Length of each application, 30 seconds.
Diagnosis. – Vascular nevi can be recognized without difficulty. They may be distinguished from the acquired form, telangiectasis, by their congenital history and the lack of visible capillaries except at the margin. Dilated capillaries, single, interlaced or formed into tubercles, are pathognomonic of telangiectasis. Angiomatous tumors are usually free from pain or sensitiveness, disappear on pressure, but quickly refill as pressure is removed and sometimes pulsate. A cavernous angioma with a firm and dense capsule may be difficult to distinguish from a fibroma but the latter is much more likely to be multiple. The extremely rare serpiginous angioma can always be recognized by its peculiar clinical course. Angiokeratoma is distinguished by its minute red or purplish warty elevations, from which the color partly disappears on pressure, by its frequent association with chilblains, and its persistency if not treated.
Fig. 125 – Congenital angioma of the cavernous variety, protruding 3/4 of an inch and presenting marked pulsation. Partially removed by solidified carbon dioxid; still under treatment.
Prognosis of the angiomata is uncertain. Some congenital growths remain stationary, some diminish or disappear with age, others may pursue an opposite course and increase steadily in size or change from a flat birth-mark to tumor- like growths. The pulsating or cavernous angioma may be accidentally ruptured or ulcerate and alarming or fatal hemorrhage result. Telangiectases can be cured only by a removal of the causal conditions. Serpiginous angioma is persistent and progressive even under treatment. Angiokeratoma is persistent and shows no tendency toward involution.
Treatment. – Various local methods are employed to remove these blemishes especially if they are noticeably located or disfiguring in character. There is no disease for which a more careful selection should be made of the remedial agents because the result is enduring and, if the treatment is improper or meddlesome, it may be as disfiguring as the original lesions. My experience in the treatment of nearly three hundred angiomata would lead me to select the following methods. For small superficial nevi the daily application of collodion, adrenalin chlorid (1:1000), or liquor plumbi subacetatis should suffice. If the growth
Fig. 126. – Nevus vasculosus, presenting at birth a dark brown, nearly black, area which covered the lumbar and sacral regions and both nates. A number of smaller spots of a dark red color, can be noted on other parts of the surface. General health of the baby was good but all the spots increased in size after birth.
Fig. 127. – Front view of Fig. 126 showing a few small circular spots. These photographs were taken at eight months of age and present the climax of the process.
is elevated or situated over a bone, a compress of cork or other substance may be placed over the lesions and held in position with an elastic bandage. For a great majority of angiomata, solidified carbon dioxid is the most convenient, most effectual, least painful and the most exact method. The resulting scars should be fine, neat and, if the nevi be superficial, hardly visible. The details of procedure consist of the amount of pressure necessary, which must vary according to the depth of the lesions, and the length of time required for the application. Light or moderate pressure for from 10 to 30 seconds will suffice for superficial growths, while the deeper lesions call for firm or heavy pressure from 30 to 90 seconds. Only careful observation and ripened experience can make this method uniformly successful, for its technic depends entirely upon the operator and cannot be set forth in words. The bleb, appearing a few hours after the freezing, ruptures in a day or two leaving a clean-cut ulcer. This should be treated antiseptically and dressed with boric-acid powder, solution or ointment.
Before the advent of refrigeration, electrolysis was the most popular and satisfactory method and it still remains the best in the treatment of some of the nodular and cavernous angiomata. Phototherapy, galvano-cauterization, vaccination and multiple scarification have all been successfully employed. The high-frequency current spark, mild fulguration and radium have given good results and my personal experience has been that in certain cases they are better suited than any other methods. Excision may be performed when the growths are large or projecting, or ligation and other surgical procedure may be needed in a few instances. Ordinary caustics such as carbolic acid or sodium ethylate, employed locally or as injections, should never be recommended. It is my custom when the symptoms call for it to prescribe remedies that have a pronounced capillary and vascular action, such as Aconite, Belladonna, Calcarea fluor., Condurango, Fluoric acid and Lycopodium.