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Vascular lesions

These are skin blemishes caused by abnormalities of vessels that are located just beneath the skin surface. It gives reddish appearance to the skin. The different types of vascular lesions of skin are hemangiomas, spider veins, port-wine stains and cherry angiomas. No satisfactory mode of treatment was available for management of these conditions prior to the advent of innovative laser surgeries.

Some vascular lesions are acquired during the lifetime of an individual, especially those that are caused by infections. Some vascular lesions are present at birth like vascular birthmarks. Vascular birthmarks are of different types, including vascular tumors and vascular malformation. Infantile hemangiomas are commonly occurring vascular tumors. Malformed vascular lesions are usually congenital and tend to remain for the lifetime of the individual. Vascular birthmarks affect only the skin of the patient and do not have any damaging effect on the central nervous system.

Infantile Hemangiomas
These are common types of vascular lesions that are reddish or purplish in color. They are raised above the skin surface. These are hyperplasic lesions. Infantile Hemangiomas that involute spontaneously and obstruct airways, vision or other organs in the body, need to be treated.

Oral corticosteroids are a good option for the management of these lesions. Surgical therapies are not very useful in these types of vascular lesions. Infantile hemangiomas are the most commonly occurring tumors in infants and affect 10-12% of infants. It can be present at birth or occurs within a few weeks after birth. The vascularity and size of lesions increase rapidly over a period of time and reaches its peak by the age of 12 months. Infantile Hemangiomas can be categorized based on its general appearance or based on some descriptive terms. It can be noticed as superficial, cavernous or deep lesions. However, the pathophysiology of all types of these lesions is common.
Signs and Symptoms of Infantile Hemangiomas:
The superficial infantile hemangiomas are red in color while the deep ones are blue in color. There can be bleeding or ulceration from the lesions due to slightest trauma. The ulcers are painful. Based on the locations, these lesions can cause pressure symptoms and can interfere with the functioning of some organs. If they are present on face or on oropharynx, they can affect eyesight or obstruct airways. Those situated near the anus or urethral meatus can affect the elimination process.

Infants suffering from periocular hemangiomas need to be treated immediately, as it can cause permanent loss of vision. These lesions start involuting at the age of 12-18 months leading to reduction in their vascularity and size. The maximum involution of the lesions is achieved at the age of 10 years. The lesions that are involuted are yellowish color and are telangiectatic. They are fibro-fatty with lax texture and are wrinkled. These changes are proportional to the maximum vascularity and size of the lesions. The diagnosis of the condition is based upon clinical signs and symptoms. However, MRI may be needed to know the extent of the lesions to see their encroachment on vital organs. Treatment of these lesions includes laser therapy and systemic corticosteroids. Use of intra-lesional corticosteroids is also beneficial for treating these vascular lesions.

Ulcerated Wounds: General Care of Wound
Treatment of ulcerated lesions is controversial. Several clinicians are of opinion that these lesions need to be treated early for preventing their enlargement and for making them less visible. Some believe that the lesions should be treated only if they pose a risk of loss of normal functions of body due to their location. The choice of treatment depends upon the location of lesions, their size, rate of growth and extent. Systemic or intra-lesional corticosteroids can be helpful in effective treatment of this condition. Laser therapy can also be administered for treating these conditions.

Systemic corticosteroids treatment can be given by using 1-3 mg/ Kg body weight of Prednisolone given 2-3 times in a day. The treatment needs to be continued for more than 2 weeks to see the results. Once the resolution of lesion begins to fade, dose of Prednisolone can be tapered slowly. If there is no improvement in the lesions, intake of Prednisolone can be stopped. Proper care of wound with topical creams and dressings is also needed. Bleeding and scarring of the lesions should be prevented by avoiding further injuries to the wound. Use of topical Metronidazole or mupirocin, barrier dressings and compresses can be helpful in fast healing of the wound.

Surgical interventions for excision of the lesions or other invasive techniques should be avoided unless the lesion interferes with normal functions of the body. These procedures can interfere with the normal involution process of lesion and can lead to scarring. Review of history of the case with the help of photographic evidence can be helpful in relieving the anxiety of parents of the patient and to assure them about the benefits of non-intervention. Careful and sympathetic listening to the parents, along with counseling is needed to allay their anxiety about the condition.

Port Wine Stains and Nevus Flammeus: 
These are vascular malformations occurring in capillaries and are present at birth. They appear as pink or red colored flat lesions. Some of the lesions may be purplish in color. Nevi flammei commonly occur at the glabella, nape or eyelids. They are flat pink lesions. Those formed around eyelids tend to disappear within few months, while the lesions over nape tend to disappear early in childhood. But, they can reoccur at middle age.

Port wine stains can appear on any part of the body. They are flat and red or purple in color. They may become darker over time. They are palpable and often become hyperplasic by the age of 40-50 years. The lateral extent of these lesions increases in proportion to natural growth of patient. Port wine stains over trigeminal area are common in Sturge-Weer syndrome and similar lesions appear in underlying cerebral cortex and meninges in this, with associated attacks of convulsions. The diagnosis of the lesions is based on clinical signs and symptoms.

The lesions need to be treated in their early phase for getting excellent results. Vascular lasers help in producing very good results in these cases. Patients can also use opaque creams that are specially prepared to match exactly with the skin color of patients, for hiding the lesions.

Nevus Araneus:
These are bright red lesions and are faintly pulsatile. They consist of central arteriole and slender projections that resemble legs of spider. Hence, the lesions are also called spider nevus. They are also referred to as vascular spider or spider angioma due to their typical appearance. These lesions are acquired during the lifetime of an individual. Patients may have a single or multiple lesions of spider nevus on the body. It can occur in children or in adults. Spider angiomas are commonly seen in patients suffering from hepatic cirrhosis.

Women taking oral contraceptives are prone to developing these lesions. They are also common in pregnancy. These lesions usually resolve spontaneously once the oral contraceptive pills are stopped or 6-8 months after the delivery. These lesions are commonly seen over the face in children. Temporary obliteration of lesions may occur due to compression of central vessels. Diagnosis of the condition is clinical.

Pyogenic Granuloma:
These are fleshy and crusty lesions and are made up of proliferating capillaries in edematous stroma. They develop rapidly and represent fibrous and vascular response to injuries. These lesions are friable and bleed easily. They tend to become large during pregnancy. They do not blanch on pressure. Diagnosis of this condition can be done based on biopsy of the lesion. It can be treated by curettage or electrodesiccation. Surgical excision of the lesion may also be needed in some cases.

Lymphatic Malformations:
These are vascular malformations resulting in elevated lesions, comprising of dilated lymph vessels. They are usually present at birth; but may also develop within first 2 years after birth. They are yellowish in color and may turn purple or red if the blood vessels are entangled. Diagnosis of these lesions can be done clinically or based on MRI. No treatment is needed for these types of vascular lesions. If these lesions are excised surgically, they tend to reoccur.

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