Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analysis
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter To Editor
doi: 10.4103/0378-6323.42921
PMID: 18797075

Spider nevi: A presenting feature of chronic liver disease

Maya Vedamurthy, Amar Vedamurthy
 Department of Dermatology, Apollo Hospitals, Chennai, India

Correspondence Address:
Maya Vedamurthy
AB-76, I street, Annanagar, Chennai-600 040
How to cite this article:
Vedamurthy M, Vedamurthy A. Spider nevi: A presenting feature of chronic liver disease. Indian J Dermatol Venereol Leprol 2008;74:397-398
Copyright: (C)2008 Indian Journal of Dermatology, Venereology, and Leprology


The vascular spider, arterial spider or spider angioma is the most classical vascular lesion that is sometimes a presenting sign of chronic liver disease. Spider telangietasia occur in up to 15% of normal individuals and may also be seen in pregnant women. The main vessel of the spider is an arteriole represented by a red point from which numerous, small, twisted vessels radiate. Application of pressure on the central arteriole with the head of a pin or a match stick causes blanching of the whole lesion. We report here a case with profusion of spider nevi predating the onset of liver disease.

A 36 year-old, non-alcoholic man presented to the Dermatology OPD for evaluation of multiple, eight months old, erythematous, asymptomatic macules distributed mainly over the front of the chest, with a few on the upper arm and back [Figure - 1]. The rash was earlier diagnosed as an allergic reaction and was treated with antihistamines by a general physician. Six months after the patient presented to us, he developed jaundice and was investigated and found to have chronic liver disease.

Dermatological examination showed hundreds of erythematous macules 2-5 mm in size, mainly over the front of the chest, upper abdomen and a few on the upper arm and back [Figure - 1]. The central body and the vessels radiating from it, could be seen clearly in a few lesions; mucous membranes were spared. There was no other dermatological evidence of chronic liver disease.

Hematological investigations revealed thrombocytopenia: 1,25,000 (Normal = 1,50,000-4,50,000); prothrombin time = 17 s (control: 13 s ) and activated partial thromboplastin time = 36 s (control: 26 s) were prolonged. Viral markers for hepatitis were all absent. Total estrogen level was 85.7 pg/mL (normal < 56 pg/mL) and the total testosterone level was 218 mg/dL (normal: 245-1836 mg/dL). Tests for antinuclear antibody and alpha fetoprotein were also negative. Liver function tests showed elevated bilirubin (total 4.3 mg/dL) and elevated enzyme levels (ALT: 93 IU/L, ALP: 328 IU/L) (expand abbreviations). Blood sugar and renal parameters were normal. An ultrasound of the whole abdomen showed a shrunken liver with a coarse and nodular echo texture, suggestive of chronic liver disease, splenomegaly and ascites. A liver biopsy was not done as the patient was unwilling to have it done. Based on the above findings, a diagnosis of cryptogenic cirrhosis was made.

Spider angioma or nevus araenus is a dilatation of preexisting vessels under several circumstatnces. [1] Common causes of spider nevi are listed in [Table - 1].

Spider nevi are commonly distributed over the face, necklace area, forearms, hands and the upper part of chest, i.e., mainly over the region drained by the superior vena cava. [2] Vascular spiders have been attributed to excessive levels of estrogen because estrogens cause blood vessels to enlarge and dilate. [3] Serum estradiol and total testosterone levels are altered particularly in male patients with cirrhosis and spiders. Serum estradiol levels are increased and the total free testosterone level is reduced, thus leading to high estradiol/free testosterone ratios in male patients with spiders. Regression of spiders in patients with liver disease is possible with an improvement in the underlying condition although persistence of these spiders is more likely. [4]

Morphological studies and reconstruction methods demonstrated that spiders represent an arteriole and an organ with five separate parts:

  1. A cutaneous arterial net,
  2. A central spider arteriole,
  3. A subepidermal ampulla
  4. A star-shaped arrangement of afferent spider vessels, and
  5. Capillaries [5]

Awareness of the association of spider nevi with systemic illnesses is essential to determine the underlying pathology. This case is presented for two reasons: 1. As spider nevi can precede liver diseases, it would be advisable to screen the patients with spider nevi for liver disease as early detection could prove to be beneficial to the patient, 2. The presence of spider nevi is also considered to be one of the physical findings predicting the presence of esophageal or gastric varices in patients with advanced liver disease. [6] It could therefore be cost-effective to screen and identify a group of patients who would most benefit from endoscopic screening for varices.

Robin AC Graham-Browne, Rathbone B, Marks J. The skin and disorders of the alimentary tract. In: Freedberg IM, Eisen AZ, Austen KF, Goldsmith LA, Katz SI et al, editors. Dermatology in internal medicine. 5 th ed. New York: McGrowHill; 1999. p. 1909-29.
[Google Scholar]
Champion RH. Disorders of blood vessels. In: Champion RH, Burton JL, Ebling FJ, editors. Rook / Wilkinson / Ebling Textbook of Dermatology. 5 th ed. Oxford: Blackwell science Publishers; 1992. p. 1827-49.
[Google Scholar]
Akiyama M, Inamoto N. Arteriovenous haemangioma in chronic liver disease - clinical and hisopathologic features of four cases. Br J Dermatol 2001;144:604-9.
[Google Scholar]
Whiting DA, Kallmeyer JC, Simson IW. Widespread arterial spiders in a case of latent hepatitis with resolution after therapy. Br J Dermatol 1970;82:32-6.
[Google Scholar]
Requena L, Sangueza OP. Cutaneous vascular anomalies Part I, Hamartomas, malformation and dilation of preexisting vessels. J Am Acad Dermatol 1997;37:523-49.
[Google Scholar]
Zaman A, Hapke R, Flora K, Rosen HR. Bennerk in Factors predicting the presences of esophageal or gastric varices in patients with advanced liver disease. Am J Gasteroenterol 1999;95:3292-6.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections