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What is Causing This Rash?

Volume 55 - Issue 7 - July 2015

A 55-year-old male presented with complaints of a persistent nonitchy rash (Figures 1 and 2). 

History

His past medical history is significant for hepatitis C, complicated by cirrhosis and depression. His skin condition had been present for the last 2 years and he had been prescribed multiple topical ointments including steroid, antifungal creams, and moisturizers with no resolution of symptoms. 

nonitchy rash

Physical Examination

On examination, the skin lesions were located on his chest, back, and upper extremities. They were nonpruritic,
nonraised, and blanched when pressure was applied. 

(Answer and discussion on next page)

Answer: Spider Angiomatas

Diagnosis

Given the patient’s history, these lesions are highly suspicious for spider angiomatas related to his decompensated liver disease.

Discussion

Nevus araneus, also known as spider angiomata or spider telangiectasias, are vascular lesions made up of a central arteriole surrounded by several smaller radiating vessels.1,2 These lesions are most commonly found on the trunk, face, and upper limbs. They are often seen in patients with cirrhosis, but can also be seen during pregnancy, thyrotoxicosis, oral contraceptive use, and severe malnutrition. Interestingly, spider angiomata are more common in alcohol-related cirrhosis.3

The pathogenesis remains elusive, but believed to be related to either an elevation in serum estradiollevels or due to neovascularization from elevated vascular endothelial growth factor levels.4

Presentation

Spider angiomas have certain characteristics that can help with their identification in a patient. If the central arteriole is compressed with a glass slide or one’s finger, the rash blanches and the lesion temporarily disappears. Once pressure is lifted off the central vessel, there is a rapid return of blood flow and the characteristic spider appearance returns.

Often, the number and size of angiomas found can be correlated with the severity of fibrosis and damage to hepatic cells.5 Solitary lesions are sometimes treated with electro or laser surgery.1

Outcome of the Case

The patient was asked to stop all the inappropriate creams he was using for his rash. He was referred to the hepatology department for continued care for his cirrhosis.

Dr Aduba discusses the case in this short podcast:

References:

  1. Fitzpatrick TB, Johnson RA, Wolff K, et al. Color Atlas and Synopsis of Clinical Dermatology. 3rd ed. New York, NY: McGraw-Hill; 1996:158.
  2. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia, PA: Mosby; 2004: 830-831.
    1.  Hane H, Yokota K, Kono M, Akiyama M. Extraordinarily large, giant spider angiomas in an alcoholic cirrhotic patient. Inter J of Derm. 2014,53:e119-e120.
    2.  Li CP, Lee FY, Hwang SJ, et al. Spider angiomas in patients with lover cirrhosis: role of vascular endothelial growth factor and basic fibroblast factor. World J Gastroenterol. 2003;9(12):2832-2835.
    3. Foutch PG, Sullivan JA, Gaines JA, Sanowski RA. Cutaneous vascular spiders in cirrhotic patients: correlation with hemorrhage from esophageal varices. Am J Gastroenterol. 1988;83(7):723-726.