Appearance

Haemangiomata appear as red to purple papules or plaques with a normal epithelial surface. Compression leads to partial emptying and the colour becomes less prominent. They may occur at any age, and remain fixed in site and size. There are various types:^[1]

• Capillary naevus - this is a salmon-pink patch seen on the neck in up to 40% of infants. It may not fade, but is often covered by hair. Facial lesions tend to fade in the first year of life.^[2]
• Port-wine stain - this is a lesion lined with endothelial cells and containing blood vessels. It does not regress with age. It may be associated with Sturge-Weber syndrome (port-wine stain of the face, angiomas of the leptomeninges and choroid, and late glaucoma) and Klippel-Trénaunay syndrome (local overgrowth of soft tissue and bone in an extremity or more extensive area, port-wine stain, varicose veins, cutaneous angiomata and other variable features).^[1][2]
• Vin rose patch - this is a pale pink lesion appearing as a birth mark due to dilatation of the sub-papillary dermal plexus.
• Venous-lake angioma - these are are dark blue papules caused by dilatation of venules. They present in sun-exposed areas of the body, particularly the ears of elderly patients. The average age at presentation is 65 years. They are probably more common in men than women. They are of little clinical significance, except that they can be confused with melanomas and pigmented basal cell carcinomas.^[3] 
• Cavernous haemangioma - this is also known as a strawberry naevus. It tends to regress after the first year of life and normally resolves completely after the age of 4 or 5. Persistent lesions or those causing obstruction of vision may require treatment.^[2]
• Cherry angioma - also known as Campbell de Morgan's spots, they appear on the abdomen and chest and are red, slightly elevated keratoangiomata. They do not fade with pressure.^[4]
• Telangiectasia - these are permanent dilatations of groups of capillaries or venules. They may be inherited or associated with atopy, sun damage, connective tissue disease, raised oestrogen levels or venous hypertension.^[5]

Diagnosis

The compression test is useful, or the lesion can be examined with a dermatoscope (an instrument which assists in close examination of the skin) and the blood filled cavities observed.^[6] Sometimes a haemangioma may be confused with a malignant melanoma, if both are dark in colour and of recent origin. They can be differentiated by excision biopsy. Campbell de Morgan spots (cherry angiomas) are a type of haemangiomata which remain small and increase in number with age. A strawberry mark/naevus is a proliferating haemangioma that occurs in the first year of life and then regresses thereafter.

Venous-lake angiomas are also usually asymptomatic. Women are more likely to present for cosmetic advice or removal. They are soft and compressible. They often have a smooth surface. They are found most often on lips, face, neck and ears.

Actinic skin damage often occurs around venous lakes as they have a shared aetiology.

Primary care management

• Most haemangiomata require no treatment unless the patient is concerned about their appearance.
• Port-wine stains are usually treated by camouflage but may wish to be referred for laser therapy (see below).^[7]
• Cavernous haemangiomata may resolve spontaneously. However if they affect normal development, such as development of binocular vision, or cause bleeding, obstruction of other organs or grow rapidly they may need to be referred for treatment (see below).^[8]

Prognosis

Lesions remain fixed but cause no problems.

When to refer

Referral should be considered if diagnosis is in doubt or excision is required. Patients may require laser therapy for port-wine stains. This can be painful but a new technique called pneumatic skin flattening employed during laser treatment has been shown to reduce the discomfort.^[9] Other treatment options include interferon and surgical excision.^[8]