Skin nonmelanocytic tumor
Vascular tumors
Malformations, ectasias and hamartomas of vascular origin
Venous lake
Editorial Board Member: Bethany R. Rohr, M.D.
Last author update: 17 December 2024
Last staff update: 17 December 2024
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PubMed Search: Venous lake
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Radiology description | Radiology images | Prognostic factors | Case reports | Treatment | Clinical images | Microscopic (histologic) description | Microscopic (histologic) images | Virtual slides | Positive stains | Electron microscopy description | Videos | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Wilham M, Dehner C. Venous lake. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/skintumornonmelanocyticvenouslake.html. Accessed December 21st, 2024.
Definition / general
- Venous ectasia in the superficial dermis or submucosa
- Often found on sun damaged skin or vermillion lip
Essential features
- Dilated blood vessel(s) with single cell layered endothelium
- Benign lesion with no atypia
- May be associated with sun damage or venous thrombi
- Can grow slowly over time
- Bluish purple skin lesion that blanches with pressure
Terminology
- Phlebectasis
Epidemiology
- Older age
- History of prolonged sun exposure
- M > F (J Cutan Aesthet Surg 2023;16:62)
Sites
- Sun damaged skin
- Lips
- Ears
- Cheeks
- Eyelids
- Oral mucosa
- Reference: Dermatol Surg 2007;33:100
Pathophysiology
- Possibly a result of sun damage to venous adventitia or dermal elastin
- Other theories implicate thrombi as the impetus (Dermatol Surg 2007;33:100)
Etiology
- Unknown at this time
Clinical features
- Blanching and compressible with pressure
- Black-blue to violaceous papule (may mimic melanoma)
- 2 - 10 mm diameter
- Slow growth (Lasers Med Sci 2016;31:1511)
Diagnosis
- Typically a clinical diagnosis
- Dermatoscopy may be used
- Shows blue or purple clods (J Cutan Aesthet Surg 2023;16:62)
- Biopsy is rarely needed (Saavedra: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 9th Edition, 2023)
Radiology description
- Hypoechoic venous ectasia
Radiology images
Images hosted on other servers:
Ultrasound
Prognostic factors
- Benign lesion
- Recurrence rates are dependent on treatment modality (Lasers Med Sci 2016;31:1511)
Case reports
- 20 year old man treated with radiofrequency ablation (Int J Dermatol 2019;58:854)
- 40 year old woman with eyelid lesion (J Cutan Aesthet Surg 2023;16:62)
- 54 year old woman and 65 year old man with lip and face lesions (Dermatol Surg 2007;33:100)
Treatment
- No treatment required
- Cryotherapy
- Laser therapy
- 595 nm pulsed dye laser (PDL) or 1064 nm neodymium doped yttrium aluminum garnet (Nd:YAG)
- Argon laser (488 to 514 nm)
- CO2 laser (10,600 nm)
- Pulse duration and frequency have not been standardized
- Infrared coagulation (Lasers Med Sci 2016;31:1511)
- Radioablation (Int J Dermatol 2019;58:854)
- Surgical excision (J Cutan Aesthet Surg 2023;16:62)
Clinical images
Images hosted on other servers:
Lip
Compression effect
Treated with cryotherapy
Eyelid
Microscopic (histologic) description
- Dilated vessel(s)
- Single layer of endothelium
- Typically no elastin or smooth muscle
- With or without thrombus
- Background solar elastosis (due to tendency to arise in sun damaged sites) (J Am Acad Dermatol 1997;37:523)
Microscopic (histologic) images
Contributed by Carina Dehner, M.D., Ph.D.
Superficial vascular dilation
Vessel within solar elastosis
Single layer endothelium
Partially thrombosed lesion
Thrombus and solar elastosis
Tortuous lesion with normal epidermis
Lesion lacking epidermis
Virtual slides
Images hosted on other servers:
Venous lake of a 40 year old man
Positive stains
Electron microscopy description
- Vascular space lined with endothelium with a continuous basement membrane and no muscular layer
- Pinocytic vesicles and bundles of microfilaments within endothelial cells
- Reference: Int J Dermatol 1987;26:645
Videos
Dr. Gardner discusses features and differential diagnosis of venous lakes
Sample pathology report
- Skin lesion, right lower lip, biopsy:
- Venous lake (see comment)
- Comment: Sections show a dilated, thin walled, vascular space within the dermis associated with extensive solar elastosis. No atypia appreciated.
Differential diagnosis
- Cherry hemangioma:
- Proliferation of capillary sized vessels in superficial dermis
- Clinically bright red papule
- Cavernous hemangioma:
- More common in liver
- More common in younger patients
- Proliferation of ectatic vessels
- Pyogenic granuloma (lobular capillary hemangioma):
- Lobules of proliferating blood vessels with interspersed fibrous septa
- Associated with subacute or acute inflammation
- May show evidence of ulceration
- Angiokeratoma:
- Acanthosis and hyperkeratosis with thin walled vessels abutting the epidermis
- Common incidentally in older individuals on scrotum and vulva
- May be associated with genodermatoses (i.e., Fabry disease)
Board review style question #1
A 72 year old man undergoes a biopsy of a 0.5 cm, well circumscribed, blue lesion on his vermillion lower lip. The H&E is shown above. Which of the following is the most likely diagnosis?
- Angiokeratoma
- Basal cell carcinoma
- Cavernous hemangioma
- Pyogenic granuloma
- Venous lake
Board review style answer #1
E. Venous lake. The clinical appearance and location of the lesion both support the diagnosis of venous lake; additionally, the dilated superficial dermal vasculature lined with a single layer of epithelium and the lack of an elastic or smooth muscle layer are features of venous lakes. Answer A is incorrect because an angiokeratoma would have epidermal changes like acanthosis or hyperkeratosis and the vermillion lip would be an unusual location. Answer B is incorrect because basal cell carcinoma (BCC) would not have a vascular space lined by a single endothelial layer. BCC is composed of atypical basaloid islands with clefting artifact and fibromyxoid stroma. Answer C is incorrect because cavernous hemangiomas can have similar histologic appearances but are abnormal proliferations of blood vessels typically with thicker vessel walls or fibrosis. They also clinically present differently, usually in younger patients and with a predilection for the liver. Answer D is incorrect because pyogenic granuloma would appear with a proliferation of small capillary sized vessels separated by fibrous septa on microscopy.
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Reference: Venous lake
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Board review style question #2
A patient with a skin lesion concerning for melanoma is found to instead have a venous lake on biopsy. Which of the following is a characteristic finding of venous lake on microscopy?
- Atypical endothelial cells
- Granulation tissue
- Lymphohistiocytic inflammation
- Parakeratosis
- Solar elastosis in the dermis
Board review style answer #2
E. Solar elastosis in the dermis. While the pathophysiology is still uncertain, solar elastosis is an extremely common finding alongside venous lakes. Answer D is incorrect because venous lakes do not induce nor are they associated with epidermal changes like parakeratosis. Answer A is incorrect because venous lakes lack atypical cells. Answer C is incorrect because venous lakes are not an inflammatory process. Answer B is incorrect because venous lakes are thought to be dilations originating in a single vessel, whereas granulation tissue is more commonly found in other reactive pathologies, such as poor wound healing or ulcerated pyogenic granulomas.
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Reference: Venous lake
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