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Here is a full clinical explanation of the image and the exam-style questions:

What is seen in this picture?

Spider Angioma (also called spider nevus, vascular spider, or nevus araneus)
The image shows a classic spider angioma on the skin of a chronic alcoholic patient presenting with abdominal distension. You can see:
  • A central red arteriole ("body" of the spider)
  • Multiple fine radiating vessels spreading outward like the legs of a spider
This is the textbook appearance. Here is a reference image from Harrison's showing the same finding in a cirrhosis patient:
Spider angioma from Harrison's - central arteriole with radiating vessels
A bedside diagnostic trick: press on the center - the lesion blanches completely, and when you release, blood refills from the center outward.

Pathophysiology (Why does this happen?)

In chronic alcohol-related liver disease / cirrhosis:
  1. The damaged liver fails to metabolize estrogen, leading to hyperestrogenism
  2. Elevated estrogens + increased circulating angiogenic factors (VEGF, basic FGF) drive dilation of the central arteriole and formation of the radiating vessels
  3. Spider angiomas appear predominantly in the distribution of the superior vena cava - face, neck, upper chest, upper arms
About one-third of patients with chronic liver disease will develop spider nevi, and their frequency increases with worsening liver fibrosis. - Yamada's Textbook of Gastroenterology, 7e

Differential Diagnosis

ConditionHow to distinguish
Simple telangiectasiaLinear fine vessels, no central arteriole, no pulsation
Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu)Multiple telangiectasias on lips, tongue, fingertips; family history; recurrent epistaxis
Cherry angiomaDome-shaped red papule, does NOT radiate legs, does not blanch from center
Unilateral nevoid telangiectasiaFollows a dermatomal distribution
Venous lakeDark blue, compressible, on sun-exposed areas (ear, lips)
Basal cell carcinomaPearly rolled edge, associated ulceration, telangiectasias are over the tumor
The key distinguishing feature of spider angioma is the pulsatile central arteriole and centrifugal blanching on pressure. - Andrews' Diseases of the Skin, Clinical Dermatology

Treatment

1. Treat the underlying liver disease (primary)

  • Alcohol cessation - most important; spider angiomas can involute with disease improvement
  • Nutritional support (thiamine, folate, multivitamins)
  • Management of portal hypertension and ascites:
    • Dietary sodium restriction
    • Diuretics: spironolactone (first-line) +/- furosemide
    • Large-volume paracentesis for tense ascites
  • Evaluate for liver transplantation in advanced disease
  • Screen for varices (upper GI endoscopy) and hepatocellular carcinoma (USS + AFP)

2. Local treatment of the spider angioma (cosmetic/secondary)

  • Pulsed dye laser (PDL) - most effective, no scarring
  • Electrodesiccation / electrocautery - effective in experienced hands
  • Cryotherapy - alternative option
Note: In this patient's context (abdominal distension = likely ascites from cirrhosis), systemic management is the priority. Cosmetic treatment is secondary. - Andrews' Diseases of the Skin; Harrison's Principles of Internal Medicine, 22e

Full Clinical Picture of Alcohol-Associated Cirrhosis

Spider angiomas in this patient are part of a wider constellation of signs. Other findings to look for include:
  • Palmar erythema - peripheral erythema of palms
  • Terry's nails - white nails with distal pink band
  • Jaundice / scleral icterus
  • Gynecomastia + testicular atrophy (males) - due to hyperestrogenism
  • Parotid enlargement
  • Caput medusae - dilated periumbilical veins (portal hypertension)
  • Ascites - the abdominal distension this patient presented with
  • Dupuytren's contracture
  • Leukonychia / half-and-half nails
The classic triad of spider angiomas + palmar erythema + pallid nails with distal hyperemic bands should strongly raise suspicion for cirrhosis. - Harrison's Principles of Internal Medicine, 22e
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