Asymmetrical nevus flammeus (overview) Q82.5

Non-recoverable vascular, primarily capillary malformation (CM), which is visible at birth or manifests itself at a later age, but can also affect venous and/or arterial vascular systems of the skin and/or other organs. S. and vascular malformations.

From a clinical point of view, a distinction can be made:

• The homogeneous "Port-wine" type
• The teleangiectatic type
• Naevus flammeus with associated symptoms
  • phacomatosis pigmentovascularis
    • Type I: Nevus flammeus combined with Nevus pigmentosus verrucosus
    • Type II: Nevus flammeus combined with mongol stain (dermal melanocytosis)
    • Type III: Nevus flammeus combined with Nevus spilus
    • Type IV: Nevus flammeus combined with Nevus spilus and Mongolian stain, possibly also Nevus anaemicus.
  • Vascular vascularis mixtus (Vascular twin nevus): Rare clinical picture characterized by the combination of a flammeus nevus with an anaemic nevus .
  • Klippel-Trénaunay syndrome
  • Sturge Weber Crab Syndrome
  • Proteus syndrome
  • Cloves Syndrome

Capillary malformations (KM) occur in about 0.3% of the population (exact epidemiological data are not available). There is no gender preference.

Usually bizarrely configured, light red spot in the first years of life, later deep red to blue-red (red wine) spot (completely compressible by glass spatula printing). The size ranges from 0.5 cm in diameter to large patches that extend over wide areas of the body. Bizarre formations can occur. An arrangement in the Blaschko lines does not exist.

A nevus flammeus does not show spontaneous area growth, but only increases in size according to the growth of the body. After decades of existence, bumpy, blue-red plaques, papules or nodules form. There is a tendency to bleed with banal injuries.

• Pale nevi (infancy and childhood): The best results are achieved with the pulsed dye laser (585 nm or 577 nm, see also laser). Disadvantage: Financially expensive, only available in specialized institutions. Lightening effects in approx. 70% of the nevi. Scarring occurs only very rarely with proper application. Nevi on the head, trunk or neck respond best. As a rule, 5-7 sessions at intervals of 6-8 weeks with energy densities of 5.5-8 J/cm2 are sufficient, depending on the best lightening after previous test lasing (1 cm2). Preparation: Especially in children, the prior administration of local anaesthesia (e.g. EMLA cream) is often used because of the painfulness. If necessary, systemic analgesics or general anaesthesia may also be used. However, local anaesthesia (injection or cream) should be avoided if possible, as the resulting vasoconstriction reduces the availability of the target chromophore (haemoglobin) for the laser and the effect can therefore be considered to be smaller. However, 10-year results show that almost 60% of laser-treated nevi flammei darken again.
• Dark nevi (adult age): Dark nevi often respond relatively well to the argon laser. A prolonged treatment is usually necessary. The response can often only be assessed after several sessions. The risk of scarring and hypopigmentation can be greatly reduced by careful dosing. In case of insufficient response, pulsed dye lasers may be considered. Here, too, 5 or more sessions are usually necessary. Nodular areas show only little response, in this case Photoderm VL (high-energy flash lamp with a broad wavelength spectrum) may be able to achieve more.
• Before starting a laser treatment: Inform the patient about discoloration persisting for 1-2 weeks, avoid direct sun exposure and use light protection (e.g. Anthelios) for the entire duration of the laser treatment. Alternative: Cosmetic covering, e.g. with Dermacolor. Use cryosurgery only if sufficient experience with the therapy is available.
• Clarification and, if necessary, treatment of accompanying anomalies, see below respective syndrome.

Remember! A facial nevus flammeus is a compelling indication for ophthalmological clarification (glaucoma, retinal damage). The dogma that facial nevi flammeus reflect the trigeminal dermatomes V1,V2 and V3 has obviously been rightly doubted (Happle R 2014). The patients treated with laser should be informed about a possible darkening of the areas.

The frequent nuchal-frontal capillary malformations of the neck or the upper eyelids (stork bite, angel kiss), formerly called "Naevus flammeus medialis", are completely harmless. The capillary nuchal nevus persists in most cases for life.

1. Happle R (2014) How common are genetic mosaics of the skin? dermatologist 65: 536-541
2. Huikeshoven M et al (2007) Redarkening of port-wine stains 10 years after puls-dye-laser-treatment. N Engl J Med 156: 1235-1240
3. Katugampola GA et al (1996) The clinical spectrum of naevus anaemicus and its association with port
   winestains: report of 15 cases and a review of the literature. Br J Dermatol 134:292-295.
4. Larralde M et al (2014) Capillary malformation-arteriovenous malformation: a clinical review of 45 patients. Int J Dermatol 53:458-461.