THE
SPIDER
NEVUS
IN
INFANCY
AND
CHILDHOOD
James E. Wenzl, M.D., and E. Omer Burgert, Jr., M.D.
Section of Pediatrics, The Mayo Clinic, and Mayo Foundation, Rochester, Minnesota
(Submitted April 8; accepted for publication June 15, 1963.)
Dr. Wenzl is a Fellow in Pediatrics, Mayo Foundation.
PEDIATRICS, February 1964
227
T
HE spider nevus (nevus araneus) is avascular nevus composed of small telangiectases radiating from a central point in fine hairlike branches. The central point
or punctum is an artery; from it superficial blood vessels radiate peripherally. This unique vascular arrangement bears a super-ficial resemblance to a spider, hence the
descriptive term “spider nevus.” Since the central vessel is an artery and blood flow is centrifugal, gradually increasing pressure
over the central vessel will cause blanching of the lesion in a centripetal fashion. This
phenomenon may serve to differentiate
spider nevi from most Otiler telangiectases,
which generally blanch when pressure is
exerted over either end of the ectatic
blood vessel. The lesions of spider nevi may resemble hereditary hemorrhagic telangiec-tasia, but in the latter condition the
heredi-tary nature of the lesions, frequency of
hemorrhagic episodes, and presence of
telangiectatic vessels in the mucous
mern-branes make differentiation possible.
The spider nevus in adult patients has attracted much attention among physicians. Its association with hepatic disease and pregnancy is well documented. In addition, these lesions may be found in 10 to 15% of
normal adults.’ We know of no figures on the incidence of spider nevi in infants and children, although Bean’ has estimated that the incidence is approximately the same as among adults, that is, 10 to 15%.
Our interest in this subject was
stimu-lated by a 7-year-old girl who recently presented with tile complaint of idiopathic
hematunia. An extensive hematologic and
urologic work-up revealed nothing unusual to account for the hematuria; however, on physical examination eight spider nevi were
noted on the skin, and the question was
raised as to whether this was a significant clinical finding. Since no figures were
avail-able on the incidence of spider nevi in
children nor on how many might be seen
on a given “normal” child, we were stimu-hated to pursue the following study.
MATERIALS AND PROCEDURES
A total of 711 infants and children
rang-ing in age from 1 day to 15 years were
examined. The entire skin of each child was examined carefully for spider nevi. This
group was unselected, and each member
was seen by one of us during a 5-month
tenure on the diagnostic, well child, and hospital services at the Mayo Clinic. Care-ful records were kept on each child, includ-ing age, clinical diagnosis, associated skin
lesions, presence or absence of palmar
erythema, size of liver and spleen (by paipa-lion) and other pertinent data. If spider nevi were found, their anatomic location was recorded on an appropriate diagram on
the study card.
The clinical diagnoses encompassed a
wide variety of organic and functional ill-nesses. Approximately 2Z% of the total num-ben were regarded as being well children
(
seen for routine examination only). In 5% of the group a diagnosis of functional ill-ness was made. In approximately 30%, thediagnosis was a surgical or primarily
surgi-cal problem. In the remaining 40%, the diag-nosis encompassed a wide variety of acute
and chronic illnesses.
For the purposes of this study we elected to divide the 711 children into three groups. We considered group 1 to be “normal” con-trols. This group included all the well chil-dren, children with functional illnesses, and children with acute infectious medical ill-nesses of less than 5 days’ duration. Also
included were patients having acute and
.lge
(yr)
0-S 190
6-10 104
11-13 113
Total 407
central nervous system, comprised group 2.
The conditions encountered in this group included congenital abnormalities, collagen diseases, metabolic and nutritional
disor-ders, hepatic disease, and chronic surgical problems. Patients with a history of
polio-myelitis were arbitrarily included in this group, as were those having peripheral neuritis, mvopathy, and meningitis.
Group 3 included those patients with dis-eases of the central nervous system, includ-ing all congenital abnormalities of this
sys-tem.
RESULTS
Group 1 (Normal Children)
GENERAL: The occurrence of spider nevi
according to age and sex distribution is
shown ill Table I. In 22% of the boys and
30% of the girls (all ages considered together
for eacil), one on more spider nevi were noted. The ages of increased incidence may he seen more clearly in Figure 1. After 2 years of age the incidence of spider nevi increases fairly rapidly (Fig. 1). It reaches
a plateau at approximately the age of pu-berty, and then appears to decrease among
adolescents after 12 to 13 years of age,
presumably toward the incidence among
adults of 10 to 15%. The incidence appears to increase more rapidly and earlier in girls
than in boys and to reach a higher plateau.
The occurrence of spider nevi appears to
increase among girls 8 to 15 years of age
The “t” test was applied to Table II for determining the significance of the differ-ences.#{176} For the total series the difference
between the two age groups (20.2 and
34.2%; 14.0 ± 4.45, p less than 0.01) was significant. For the difference between the sexes (22.1 and 30.1%; 8.0 ± 4.37) p equaled 0.06. However, for the group 8 to 15 years of age, the difference between the sexes (26.7 and 43.5%; 16.8 ± 7.67, p 0.03) was
significant. It is quite obvious that the dif-ference (2.2% = 21.5% - 19.3%) between the
two sexes in the age groups less than 8
years of age is not significant. In analyzing
the differences between the age groups by sex we find a significant difference for the girls (22.0 ± 7.08, p < 0.10), but not for the boys (7.4 ± 5.65, p = 0.19).
In group 1 a total of 199 spider nevi were found on 104 children for an incidence of 1.91 spider nevi per person. Of these 104 children, 51 were boys, on whom a total of 81 spider nevi were found (1.59 spider nevi
per person). On the 53 girls, a total of 118 spider nevi were found (2.23 spider nevi per person).
The greatest number of spider nevi found on a boy in this group was four; the great-est number on a girl was 11. In these two
children, the clinical diagnoses were “well
#{176}We are indebted to Mr. R. P. Gage, Section
of Biometry and Medical Statistics, for evaluation
of the significance of the data given in Tables II
and V.
TABLE I
AGE AN!) SEX: l)IsTIuBuTloN OF S1’IDF:lI Ni:vi IN NoIlst.L (‘IlIi.DIIEN
Boys and Girls Boy.’ (‘irls
J1it/i Spider \‘evi JJith Spider ‘e,’i JJ’itlz Spider Veri
Total
--
Total-
Total-Number Per cent \‘ui,iler Per rent Xii inber Per rent
14.7 109 15 13.8 81 13 16.1
39 37.5 58 17 9.3 46 47.8
37 37.7 64 19’ 9.7 49 18 36.7
Aqe,years
q)
E
13
-5
vs I::
.4.-vs
Fic. 1. The age-Sex distribution of spider nevi in normal children.
child” and “conversion reaction,” respec-tively.
ANATOMIC DISTRIBUTION: Most of the
spider nevi occurred over the dorsum of the hands and fingers, forearms, and facial areas (Table III). This pattern of
distribu-tion is at variance with Bean’s’ data con-cerning sites of spider nevi in adults. In his series, spider nevi occurred relatively
more frequently over the arms, neck and
thoracic areas both in normal adults and in
patients afflicted with hepatic disease.
The high incidence of occurrence over
the dorsum of the hands and fingers appears to be characteristic of the pediatric age group, as it was comparable in each of the three groups in our series.
DESCRIPTION OF INDIVIDUAL LESIONS: The essential elements of the spider nevi noted in this group were a body or central point
which was elevated in some but not in
others, the legs or radicals, and a
surround-TABLE II
Co%IPARISoN OF INCIDENCE OF SPIDER NEVI IN NORMAL Boys AND GulLs IN Two AGE Giioui’s
Boy.i and Girls
Age With Spider Nevi
(yr) Total
-Number Per cent
Boys Girls
Total
With Spider Neri
Number Per cent
Total
JJ7th Spider Neri
-Number Per cent
<8
8-13
252
153
51
53 34.2
143
86
28
23
19.3
26.7
107
69
23
30
21.5
43.5
i’:,-
-- ..
Fic. 2. Large spider nevus on facial area of a normal child.
Location Number Per cent
1)orsum of han(ls 78 39.2
Forearms 47 23.6
Face and ears 43 22.6
Arms H 6.0
Palnis (hands) 6 3.0
Lower extremities 4 2.0
Abdomen 3 1 .5
‘Fborax
Bk 2 1.0
Front 1 0.5
Neck 1 0.5
ing erythema. The erythema was inconstant and less apt to be seen with the smaller lesions. The size varied from several
milhi-meters to 2 cm or more in diameter. The
largest spider nevi seen were situated on the facial areas. Pulsations occasionally could be noted in the larger ones, but were
not detectable in the smaller ones. The
color ranged from a fiery red to lesser hues of the same color. A typical spider nevus
on the facial area of a normal child is shown
in Figure 2. No differences were noted
be-tween the anatomic characteristics of spider
nevi in tile control group as contrasted with those of tile otiler two groups.
EFFECT OF ACE: Spider nevi tended to occur less frequently in the first 4 years of
life; when present, however, they were
fre-quently large and prominent as compared to those seen ill older children. In this age
group they were found relatively oftener on
the inferior extremities, the abdomen and
PALMAR ERYTHEMA AND OTHER CUTANE. OUS ABNORMALITIES: Palmar erythema, of
the magnitude seen during pregnancy or in adults with cirrhosis, was not seen in this
group, although we specifically searched
for it. There was nO apparent association of spider nevi with other skin lesions.
Group 2 (Chronic Illness)
GENERAL: This group included 220
pa-tients. Tile age-sex distribution is
summar-ized ill Table IV. Although group 2 is
smaller than group 1, the age-sex
distribu-tiOll is approximately tile same. However,
there is one notable exception: in group 2 the increased incidence of spider nevi in girls more than 8 years of age as contrasted
with their male peers is not evident. In
fact, tile ratio is reversed. This discrepancy
may be a sampling error caused by the relatively smaller number of patients at
this age level, or it may reflect an
associa-tiOIl with diseases predominating in the males. If tile latter is true, it is not readily apparent from our analysis of the data.
A total of 65 spider nevi were found #{248}n
34 boys (1.91 spider nevi per patient); 55
spider nevi were noted on 25 girls (2.20 spider nevi per patient). These figures are similar to those in group 1.
The anatomic distribution was almost
identical to that seen in group 1, and the individual lesioiis vere of similar character.
DISEASE OF LIVER: Four patients in group
Age (yr)
---;i;---Boys and Girls Boys (,‘irl.
With Spider Ncri JVit/e Spider Xcvi
Total Total
46 Number 27 Number
Total
-;;---JJ’ith Spider Xeri
Number Percent 6-10 68 11-15 79 23 33 33.8 41.8 36 42 12 20 33.3 32 47.6 37 11 34.7 13 ‘35.1
Total 220 59 26.8 H4 34 27.4 96
TABLE IV
AGE AND SEX DISTRIBuTIoN OF SPIDER NEVI IN CHILDREN WITH Cimitoxic ILLNES.s
liver. A total of 19 spider nevi were found
on three of these patients. In the fourth patient, a girl, fibrocystic disease of the pancreas was manifested by cirrhosis, but tilere was no evidence of spider nevi. It may be of interest that only three spider nevi were found in the thoracic region in the total series of 711 patients, and two of these three occurred in patients with hepatic
disease.
Group 3 (Diseases of Central Nervous
System)
A total of 86 patients (all ages) were
diagnosed as having diseases of the central
nervous system which included various
types of seizure disorders, brain tumors,
hydrocephalus, microcephaly, mental and
motor retardation, and others. Patients hay-ing myopathies, peripheral neuritis,
men-ingitis and a ilistory of pohionlyelitis were
not included in this group. Of the 86
pa-tients, 34 (39.5%) were noted to have one or more spider nevi, as compared to an in-cidence of 25.6% in the normal children studied (Table V).
The incidence of spider nevi in tile chil-dren having diseases of the central nervous system was found to be significantly higher
than that found in the normal child (39.5
and l5.6%). The difference is 13.9 ± 5.33,
p < 0.01. For the group of children more than 4 years of age, the difference (16.1 ±
6.8, p = 0.02) also is significant. For the
children less than 4 years of age, the differ-ence obviously is not significant. In both
series the differences between the age
groups were significant (diseased 50.8 - 8.7 = 42.1 ± 11.9; normal 34.7 - 9.0 = 25.7 ± 4.52, p < 0.01). In the 34 patients with
dis-TABLE V
C0MP.uusoN OF INCIDENCE OF SPIDER NEvI IN Two AGE GROUPS OF NORMAL ChILDREN AND ChILDREN
WIT!! DISEASE OF TIlE CENTRAL NElivous SYSTEM
Group
Boys and Girls
Age
Less than 4 Years More than .4 l’ears
-Total
With Spider Neri
Z%umber Per cent
Total
With Spider Neci
Number Per cent
Total
With Spider Nevi
Number Per cent
nevi per patient). Again the anatomic
dis-tribution and individual lesions appeared similar to findings in group 1.
COMMENT: The incidence of spider nevi
in children was rather surprising to us. It
appears that these lesions, like many others, generally are unnoticed unless a specific search for them is made. From this study, it may be seen that the presence of spider nevi
in otllerwise healthy children is an
insignif-icant stigma.
The age-frequency distribution seen in
this series suggests that there may be a re-lationship between spider nevi and puberty, possibly through some as yet undefined hor-monal mechanism. The known association of spider nevi with pregnancy tends to
sup-port this concept, as does the apparent in-crease in spider nevi seen in normal puber-tal females in our series. Bean’ stated that he suspected a relationship between spider
nevi and estrogenic hormones but that he
had been unable to confirm it.
The apparent association between spider
nevi and disorders of the central nervous system is more difficult to explain. In this regard, at least three possibilities come to mind. First, this relationship may not be borne out in a larger series, a possibility, however, that seems unlikely. Second, there
may be some association with medications which these patients have received. This
hypothesis seems unlikely because a sizable
number of children in this group had not
received any specific medication. Third, there may be a direct relationship between
spider nevi and disease of tile central nerv-ous system per se. The latter choice would seem the most plausible explanation. The
various neurocutaneous syndromes are well known to pediatricians and neurologists. Studies elsewhere’ have shown a correlation
between the existence of pigmented nevi
and the diagnosis of epilepsy, even among those persons who did not have a family his-tory or other stigmas of neurofibromatosis.
The anatomic distribution of spider nevi in the area drained by the superior vena
propensity to occurrence over the periph-eral superior extremities, and the dorsum of the wrist and hand appears to be the site
of predilection. The occurrence over the
neck and thoracic areas is relatively less frequent among children than among adults. The reasons for these particular
relation-ships are not clear.
SUMMARY
At the Mayo Clinic 711 children, ranging in age from birth to 15 years, were
exam-med for the presence of spider nevi. The children were divided into three groups:
normal controls, patients with chronic ill-ness, and patients with disease of the cen-tral nervous system. In the normal children, the incidence of spider nevi increased
rap-idly after 2 years of age to reach a plateau at about the time of puberty for both sexes. In children more than 13 years of age the incidence appeared to be decreasing,
pre-sumably toward the stated incidence of 12 to 15% in so-called normal adults. In normal children, spider nevi appeared to occur more frequently in pubertal females than in pubertal males. The incidence was increased
in both sexes in patients more than 4 years of age with disease of the central nervous system. In I)atients with chronic illnesses,
there was no significant increase in spider nevi, but the ratio of pubertal females to pubertal males was reversed. The anatomic distribution ill all groups differed from that
of adults, tile dorsum of the hands and fore-arms being tile sites of predilection in
chil-dren. In view of the frequency of these
lesions in childhood, it appears that the presence of spider nevi in otherwise llealthy
children is an insignificant stigma.
REFERENCES
1. Bean, V. B.: Vascular Spiders and Related
Lesions of the Skin. Springfield, Illinois:
Charles C Thomas, Publisher, 1958, pp. 28,
51, 101-110.
2. Masland, R. L.: Personal communication to
