Blood vessel changes during pregnancy: a review

Updates on the dermatopathology of pregnancy-associated skin conditions

Pathologists provide valuable input in the dermatological care of pregnant patients in various contexts. This article provides dermatopathology updates on cutaneous changes associated with pregnancy, organized based on the following classification system: physiological skin changes in pregnancy, specific dermatoses of pregnancy, dermatoses modified in pregnancy, and skin neoplasms in pregnancy. Awareness of the impact of pregnancy on the skin by pathologists is important, as this is an opportunity to contribute to diagnostic precision in this patient population.

Mechanisms of angioregression of the corpus luteum

The corpus luteum is a transient ovarian endocrine gland that produces the progesterone necessary for the establishment and maintenance of pregnancy. The formation and function of this gland involves angiogenesis, establishing the tissue with a robust blood flow and vast microvasculature required to support production of progesterone. Every steroidogenic cell within the corpus luteum is in direct contact with a capillary, and disruption of angiogenesis impairs luteal development and function. At the end of a reproductive cycle, the corpus luteum ceases progesterone production and undergoes rapid structural regression into a nonfunctional corpus albicans in a process initiated and exacerbated by the luteolysin prostaglandin F2α (PGF2α). Structural regression is accompanied by complete regression of the luteal microvasculature in which endothelial cells die and are sloughed off into capillaries and lymphatic vessels. During luteal regression, changes in nitric oxide transiently increase blood flow, followed by a reduction in blood flow and progesterone secretion. Early luteal regression is marked by an increased production of cytokines and chemokines and influx of immune cells. Microvascular endothelial cells are sensitive to released factors during luteolysis, including thrombospondin, endothelin, and cytokines like tumor necrosis factor alpha (TNF) and transforming growth factor β 1 (TGFB1). Although PGF2α is known to be a vasoconstrictor, endothelial cells do not express receptors for PGF2α, therefore it is believed that the angioregression occurring during luteolysis is mediated by factors downstream of PGF2α signaling. Yet, the exact mechanisms responsible for angioregression in the corpus luteum remain unknown. This review describes the current knowledge on angioregression of the corpus luteum and the roles of vasoactive factors released during luteolysis on luteal vasculature and endothelial cells of the microvasculature.

Spinal manipulation and adverse event reporting in the pregnant patient limits estimation of relative risk: a narrative review

OBJECTIVE

To describe variability in spinal manipulation technique details and adverse event (AE) documentation of spinal manipulation during pregnancy.

METHODS

Five databases were searched for peer-reviewed investigations of spinal manipulation during pregnancy. Criteria for inclusion was as follows: high velocity, low amplitude thrust manipulation performed, subjects pregnant during manipulation, and English language. Studies were excluded when participants were not currently pregnant, and when the manipulation performed was not high-velocity, low-amplitude thrust. Data extraction included study design, number of participants, gestational age, spinal region, number of manipulations, manipulation technique details, profession of manipulator, AE reporting (Yes vs. No), type, and number of AE.

RESULTS

Out of 18 studies included in the review, only three provide details of the spinal manipulation technique. The reported variables include patient position, practitioner position, and direction of thrust. Fourteen studies documented AE; however, only seven provide AE details.

DISCUSSION

Reporting of spinal manipulation techniques and AE during pregnancy were inconsistent. Replication of methods in future investigations is limited without more detailed documentation of manipulation techniques performed. Furthermore, determining the relative risk and safety of spinal manipulation during pregnancy is not possible without more detailed reporting of AE. Due to these inconsistencies, a checklist is proposed for standardized reporting of spinal manipulation techniques and AE. With more consistent reporting of these parameters, results of future investigations may allow for more definitive and generalizable safety recommendations on spinal manipulation during pregnancy.

Considerations for cutaneous physiologic changes of pregnancy that fail to resolve postpartum

Pregnancy prompts many adaptive and unique physiologic modifications, with cutaneous changes being possibly the most noticeable. These cutaneous changes are of interest to physicians, since they must be diagnosed as anticipated normal physiologic changes or potentially harmful and managed accordingly. Research has been conducted on physiologically normal and abnormal cutaneous manifestations of pregnancy but is lacking in regard to the persistence of these changes after delivery. This prompts the question as to whether these are normal physiologic changes taking longer to resolve, abnormal changes that may have been previously misdiagnosed, or a separate underlying change that is incorrectly attributed to a common dermatosis caused by pregnancy. Some of the conditions that may persist longer than expected during or after pregnancy, and thus require further workup for an underlying condition, include telogen effluvium, severe hirsutism, palmar erythema, and striae. The objective of this review is to focus on these four common cutaneous physiologic changes of pregnancy, and what to consider when they do not resolve as expected.

Spider Angioma Number and Location as Potential Prognostic Indicators in Chronic Liver Disease: A Case Report

Spider angiomas (SAs) are a well-known physical exam feature found in patients with chronic liver disease. While SAs are thought to correspond with a higher risk of mortality in chronic liver disease (CLD) patients, only few studies have been done to assess the number and location of SAs as prognostic indicators. We present a case of a 64-year-old patient with decompensated CLD who was found to have three SAs on physical exam. The patient presented to the inpatient service at a community hospital in Miami, Florida. He had experienced previous esophageal varices banding, had a Model for End-Stage Liver Disease (MELD) score of 31, and needed large-volume paracentesis due to significant ascites. It was determined that he had a very poor prognosis and was in need of a liver transplant. We suggest that more research is necessary to determine if there is a prognostic importance to the number and location of SAs in patients with CLD, as earlier interventions could potentially lead to improvements in outcomes through this physical exam finding.

The effects of alcohol and illicit drug use on the skin

Early identification of cutaneous manifestations of alcohol and illicit drug use can aid in the diagnosis and management of these uses, as well as their sequelae. In addition, the effects of alcohol and illicit drug use on the skin can result in significant morbidity. Alcohol misuse can present with jaundice, pruritus, pigmentary alterations, urticaria, hair and nail changes, and oral changes. It is also a risk factor for skin cancer and infections. Vascular disturbances associated with alcohol misuse include telangiectasias, palmar erythema, caput medusae, and flushing. Diseases related to alcohol misuse include nutritional deficiencies, porphyria cutanea tarda, psoriasis, seborrheic dermatitis, nummular dermatitis, and rosacea. Other conditions seen in alcohol misuse include Dupuytren contracture, Peyronie disease, and pancreatitis. Dermatologists should also be aware of hepatotoxic medications that are commonly prescribed for skin diseases so as to avoid initiating hepatoxicity in patients who use alcohol. Illicit drug use can manifest with cutaneous fibrosis, scarring, granulomas, ulceration, pruritus, infections, cocaine-levamisole-induced vasculitis, tooth decay, and oral disease. By recognizing the cutaneous stigmata of alcohol and illicit drug use, dermatologists can aid in the identification and treatment of patients suffering from these addictions.

A Systematic Review of Elective Laser Therapy during Pregnancy

Introduction: Currently, lasers are used to treat many diseases and their complications. However, the use of lasers in pregnant patients is still controversial. Methods: In this review, the application of lasers in the fields of urology, surgery, obstetrics, dermatology, and musculoskeletal disorders is evaluated. The following keywords were used to search through PubMed, Google Scholar, and Scopus: pregnancy, laser, urolithiasis, endovenous laser ablation (EVLA) or treatment, leg edema, varicose vein, venous insufficiencies, hair removal, pigmentation, telangiectasia, vascular lesions, Q switch laser, diode laser, holmium, holmium-YAG laser, erbium laser and Pulsed dye laser, low-level laser therapy, high-intensity laser therapy, pain, musculoskeletal disorders, twin to twin transfusion syndrome (TTTS), amnioreduction, and safety. Results: Totally, 147 articles were found, and their abstracts were evaluated; out of 53 articles extracted, 14 articles were about dermatology, 24 articles were about urology, 12 articles were about obstetrics and gynecology, 10 articles were about musculoskeletal disorders and three articles were related to surgery. Conclusion: Laser therapy can be used as a safe treatment for urolithiasis, skin diseases, TTTS and varicose veins of the lower extremities. However, the use of laser therapy for musculoskeletal disorders during pregnancy is not recommended due to lack of evidence, and also we cannot recommend endovenous ablation.

Cardiovascular Medications in Pregnancy: A Primer

Cardiovascular disease and cardiovascular disease-related disorders remain among the most common causes of maternal morbidity and mortality in the United States. Due to increased rates of obesity, delayed childbearing, and improvements in medical technology, greater numbers of women are entering pregnancy with preexisting medical comorbidities. Use of cardiovascular medications in pregnancy continues to increase, and medical management of cardiovascular conditions in pregnancy will become increasingly common. Obstetricians and cardiologists must familiarize themselves with the pharmacokinetics of the most commonly used cardiovascular medications in pregnancy and how these medications respond to the physiologic changes related to pregnancy, embryogenesis, and lactation.

Middle range theory for the nursing diagnosis Excess Fluid Volume in pregnant women

OBJECTIVE

To stablish a middle range theory for the understanding of the causal mechanisms and clinical consequentes of the nursing diagnosis Excess Fluid Volume (00026) among pregnant women.

METHOD

The Middle Range Theory was constructed in five stages: defining of construction approach, establishing main concepts, elaborating propositions, developing a pictorial diagram, and establishing the causal relationships and evidence for practice of the Middle Range Theory.

RESULTS

We identified 14 clinical indicators and 6 causal factors of Excess Fluid Volume. A pictorial diagram was developed and relationships between Excess Fluid Volume elements were established with 6 propositions for them.

CONCLUSION

The Middle Range Theory included both physiological and pathological conditions to explain Excess Fluid Volume. This Middle Range Theory might help in the better understanding of interactions between causal factors and clinical indicators of Excess Fluid Volume.

Pre-existing liver disease in pregnancy: Cirrhosis, autoimmune hepatitis and liver transplantation

Liver disease during pregnancy is one of the least studied topics, but it links the interests of hepatologists, gynaecologists and family physicians. Approximately 3% of pregnant woman experience some type of liver disease. Liver disease can occur as a result of pregnancy, before pregnancy and coincidence-related during pregnancy. Pregnancy in women with pre-existing liver disease is essential that the clinicians are familiar with this disorder so they can respond promptly and appropriately in all of these situations. So, because of the complications for both mother and child, it is important that liver disease is recognized in a timely manner to avoid undesirable outcomes.

Pyogenic granuloma gravidarum: a case in the nasal cavity and the use of MRI as a preoperative surgical aide

Pyogenic granuloma gravidarum is a benign fibrovascular proliferative lesion usually involving the oral gingivae in pregnant patients. While it also occurs, although less frequently, on other oral sites such as lips, tongue and palate, it is relatively unusual to find it in the nasal cavity. Furthermore, lesions normally involute spontaneously after childbirth. For persistent lesions requiring surgical management, imaging has historically been limited to CT. This case is notable not only for its uncommon location but also for its recurrent nature, failure to regress post partum and the use of MRI in the preoperative planning.

Liver Diseases During Pregnancy

Liver diseases during pregnancy pose a unique clinical challenge because they can affect the lives of both the mother and unborn child. Although severe liver disease is rare, pregnancy-related liver disease affects approximately 3% of pregnancies and can be fatal. Timely recognition and diagnosis are essential in order to institute appropriate management strategies. This article provides an overview of liver diseases during pregnancy and is divided into 2 sections: (1) liver diseases specific to pregnancy, and (2) preexisting or coincident liver diseases during pregnancy.

Liver Disease During Pregnancy: A Challenging Clinical Issue

One of the least studied topics in the field of obstetrics is liver disease during pregnancy, which creates a challenge for both gynecologists and hepatologists. Approximately 3% of pregnant women are affected by some form of liver disease during pregnancy. Some of these conditions can be fatal for both the mother and child. In addition, 3 types of liver disease need to be differentiated during pregnancy. One type is liver disease directly related to pregnancy, which can occur at a specific time during pregnancy. Another type is liver disease not related to pregnancy, which can occur at any time, such as viral- or drug-induced hepatitis. Furthermore, pregnancy can occur in women with pre-existing liver disease. It is essential that the clinicians are familiar with this disorder so they can respond promptly and appropriately in all of these situations, especially when emergency delivery is needed and must not be postponed.

[Management of oral diseases during pregnancy]

Management of oral diseases during pregnancy prefers to be a comprehensive oral health care strategy throughout pre-pregnant, pregnant and prenatal stages. It provides guidance not only to promote the overall health in pregnant women, but also concern fetus development and children's oral health. Pregnancy is a time of particular vulnerability in terms of oral health due to complex physical and physiological changes. Physicians and dentists are responsible for providing professional medical care and treatment following clinical guidelines especially for pregnancy. It is also an opportune time in pregnancy to educate women about oral health care and preventing oral problems in young children. This article reviews the commonly occurring oral problems and their pathogenesis during pregnancy, dental procedures that can be carried out by physicians and preventive strategies that could be helpful in promoting oral health in both pregnant women and young children.

Pyogenic Granuloma: A Retrospective Analysis of Cases Treated Over a 10-Year

BACKGROUND

Pyogenic granuloma (PG) is a benign vascular lesion of the mucosa and skin. Recent studies of the epidemiology of PG are rare. We aimed to retrospectively analyze characteristics of PG cases in South Korea.

METHODS

We reviewed the medical records of 155 patients treated for PG between March 2005 and May 2014. The male-to-female ratio was 1:1.2 (70 males, 85 females). The mean age of patients was 35.3 years.

RESULTS

A high occurrence was observed in the first and third decades in males, and the fourth to fifth decades in females. There was a statistically significant difference between genders according to age group (p<0.05). The average lesion diameter was 0.84±0.46 cm (long axis). The most frequently involved site was the face (n=47). Bleeding was the primary complication (n=41). PG was mostly treated with excisional biopsy (n=74). The recurrence rate was 7.7% (n=12).

CONCLUSION

We concluded that most common site of PG was the face, the age of female with PG is higher than previous studies, and finger is associated with trauma more than other sites. The most recent epidemiological information on PG of this study will support the treatment and diagnosis of PG and future research objectives.

Pregnancy and liver disease

Pregnancy associated liver diseases affect up to 3% of pregnant women and are the most frequent cause of liver dysfunction in pregnancy. When severe, they are associated with significant morbidity and mortality for both mother and infant. A rapid evaluation to distinguish them from non-pregnancy related liver dysfunction is essential, in order to facilitate appropriate management. Liver disease unrelated to pregnancy can present de novo in pregnancy, or pregnancy can occur in women with preexisting liver pathology (Table 1). Research and subsequent advances in medical care have resulted in improved but still not satisfactory maternal and fetal outcomes. In this review we provide an overview of the liver diseases specific to the pregnant state and an update on their pathogenesis, treatment and outcomes. The risks of pregnancy in women with pre-existent liver pathology is detailed and recent advances in our understanding of specific risks and outcomes are discussed.

Oral and vulvovaginal changes in pregnancy

Physiologic alterations of the oral and vulvovaginal mucosal surfaces result from the profound hormonal and immunologic changes of gestation. High estrogen levels are responsible for the vascular changes noted on mucosal surfaces. Gingival hyperemia and edema, gingivitis and pyogenic granuloma are the most common alterations of the oral mucosa during gestation. Physiologic changes of the vulvovaginal area are mainly of vascular nature, and include among others varicose veins. The oral and vulvovaginal mucosal surfaces can be affected by diseases that can worsen or develop in pregnancy. Oral lesions are encountered in a large spectrum of diseases including aphthosis, pemphigus vulgaris, systemic lupus, and Behçet disease. Pregnancy dermatoses such as impetigo herpetiformis and gestational pemphigoid can exceptionally affect the oral mucosa. Infections of the vulvovaginal region by Candida species, Trichomononas vaginalis, human papilloma virus, and herpes simplex virus have been associated with fetal risks. The dermatologist, obstetric medicine physician, and neonatologist should be familiar with the above physiologic changes as well as maternal/fetal risks relevant to disease affecting these mucosal surfaces during gestation.

Skin disease in pregnancy

Skin manifestations during pregnancy are common and diversified. This review will focus on the most important entities to be recognized by obstetricians. These are, on the one hand, physiological changes, where unnecessary investigations should be avoided, and on the other, the specific dermatoses of pregnancy. These develop electively in pregnancy, and they are currently grouped into three disorders: polymorphic eruption of pregnancy, atopic eczema of pregnancy, and pemphigoid gestationis. Arguments for recognition of these are presented including detection of anti-BP180 antibodies. Follow-up and treatment depend on the precise diagnosis. Risks in fetal prognosis may occur in rare pemphigoid gestationis cases.

Effective Management of a pregnancy tumour using a soft tissue diode laser: a case Report

BACKGROUND AND AIMS

Pregnancy tumours (PTs) are a non-neoplastic, reactive, inflammatory conditional gingival enlargement which occurs in the oral cavity during pregnancy. The lesion most frequently occurs on the gingiva but may also develop on the lip, tongue, oral mucosa and palate. When a large PT develops, it can interfere with mastication, speech, maintenance of oral hygiene and can be aesthetically disfiguring. The treatment of PTs depends upon the size of the lesion; smaller lesions can regress after parturition however large lesions need to be surgically removed. Conventional surgical techniques have the disadvantage of more bleeding from the surgical site and delay in healing of the scar tissue. The diode laser is a relatively new alternative to conventional surgical technique in intra-oral areas with the added advantage of bloodless procedures and rapid healing.

CASE REPORT

The purpose of the present study is to highlight the management of a PT in a 25-year-old female using a diode laser delivering a painless, bloodless procedure with rapid postoperative healing.

CONCLUSIONS

Diode laser excision of a persistent pregnancy tumour in a postpartum patient was safe and effective with minimal bleeding, good coagulation, and good wound healing. Among other lasers, the diode laser can therefore be considered for excisional treatment of persistent PTs.

'Granuloma gravidarum': persistence in puerperal period an unusual presentation

Granuloma gravidarum (GG), an inflammatory lesion, develops in the oral mucosa of pregnant women in response to chronic low-grade irritants and hormonal factors. A persistent granuloma gravidarum post partum and appropriate management strategies are discussed. Patients must be encouraged to undergo regular dental check-ups during the gestational period. Simple oral hygiene measures are highly effective in combating most oral lesions encountered in pregnancy.

Effect of Pregnancy Upon Facial Anthropometrics and Respirator Fit Testing

Workers required to wear respirators must undergo additional respirator fit testing if a significant change in body weight occurs. Approximately 10% of working women of reproductive age will be pregnant and experience a significant change in weight, yet the effect of pregnancy-associated weight gain on respirator fit is unknown. Cephalo-facial anthropometric measurements and quantitative fit testing of N95 filtering facepiece respirators (N95 FFR) of 15 pregnant women and 15 matched, non-pregnant women were undertaken for comparisons between the groups. There were no significant differences between pregnant and non-pregnant women with respect to cephalo-facial anthropometric measurements or N95 FFR quantitative fit tests. Healthy pregnant workers, who adhere to the recommended weight gain limits of pregnancy, are unlikely to experience an increase in cephalo-facial dimensions that would mandate additional N95 FFR fit testing above that which is normally required on an annual basis.

Giant granuloma gravidarium of the oral cavity

Oral health is affected by hormonal changes during pregnancy but is usually neglected by both the obstetrician and the patient during follow-up visits. Gingival enlargement is one of the most common oral lesions seen during pregnancy. Rarely, gingival enlargement can be very big, significantly affecting maternal nutrition and impairing haemodynamic status. A giant granuloma gravidarium and appropriate management strategies are discussed. Patients must be encouraged to undergo regular dental check-ups during pregnancy. Simple oral hygiene measures are highly effective in mitigating most oral lesions of pregnancy.

Immunohistochemical patterns in the interfollicular Caucasian scalps: influences of age, gender, and alopecia

Skin ageing and gender influences on the scalp have been seldom studied. We revisited the changes in the interfollicular scalp. The study was performed on a population of 650 volunteers (300 women and 350 men) for over 7 years. Three age groups were selected in both genders, namely, subjects aged 20–35, 50–60, and 60–70 years. The hair status was further considered according to nonalopecic and alopecic patterns and severity (discrete, moderate, and severe). Biopsies from the parietal area were processed for immunohistochemistry. Stromal cells were distinguished according to the presence of vimentin, Factor XIIIa, CD117, and versican. Blood and lymphatic vessels were highlighted by Ulex europaeus agglutinin-1 and human podoplanin immunoreactivities, respectively. Actinic elastosis was identified by the lysozyme coating of elastic fibres. The epidermis was explored using the CD44 variant 3 and Ki67 immunolabellings. Biplot analyses were performed. Immunohistochemistry revealed a prominent gender effect in young adults. Both Factor XIIIa+ dermal dendrocytes and the microvasculature size decreased with scalp ageing. Alopecia changes mimicked stress-induced premature senescence.

Assessment of angiogenic markers and female sex hormone receptors in pregnancy tumor of the gingiva

PURPOSE

Oral pregnancy tumors (OPTs) arise on the inflamed gingiva of women after the first trimester of pregnancy. The expression of angiogenic markers and female hormone receptors was assessed.

MATERIALS AND METHODS

Immunohistochemistry was used to analyze the expression of estrogen and progesterone receptors and the expression of angiogenic factors, such as vascular endothelial growth factor (VEGF) and its receptor, fibroblast growth factor (FGF), and hypoxia inducible factors 1α and 3α (HIF1α and HIF3α). Experimental groups included 9 OPTs, 10 oral pyogenic granulomas from nonpregnant women of the same age, and 9 oral pyogenic granulomas from postmenopausal women.

RESULTS

VEGF expression in stromal histiocytes and endothelial cells of small vessels was positively correlated in the OPT group (P < .05 by χ(2) test). VEGF receptor also was overexpressed in stromal histiocytes and endothelial cells of OPTs compared with oral pyogenic granulomas from nonpregnant and postmenopausal women (P < .005 by χ(2) test). No correlation was detected among estrogen and progesterone receptors, FGF and HIF1α and HIF3α (ER and PgR respectively) in the 3 experimental groups.

CONCLUSIONS

VEGF-associated angiogenesis is most likely involved in the pathogenesis of the lesion. These results imply that local inhibition of VEGF activity could be an adjuvant therapeutic approach for OPTs to control hemorrhage, which can be massive at the surgical excision of such lesions during pregnancy.

Pyogenic granuloma, an impaired wound healing process, linked to vascular growth driven by FLT4 and the nitric oxide pathway

Pyogenic granuloma, also called lobular capillary hemangioma, is a condition usually occurring in skin or mucosa and often related to prior local trauma or pregnancy. However, the etiopathogenesis of pyogenic granuloma is poorly understood and whether pyogenic granuloma being a reactive process or a tumor is unknown. In an attempt to clarify this issue, we performed genome-wide transcriptional profiling of laser-captured vessels from pyogenic granuloma and from a richly vascularized tissue, placenta, as well as, from proliferative and involutive hemangiomas. Our study identified a gene signature specific to pyogenic granuloma. In the serial analysis of gene expression (SAGE) database, this signature was linked to 'white blood cells monocytes'. It also demonstrated high enrichment for gene ontology terms corresponding to 'vasculature development' and 'regulation of blood pressure'. This signature included genes of the nitric oxide pathway alongside genes related to hypoxia-induced angiogenesis and vascular injury, three conditions biologically interconnected. Finally, one of the genes specifically associated with pyogenic granuloma was FLT4, a tyrosine-kinase receptor related to pathological angiogenesis. All together, these data advocate for pyogenic granuloma to be a reactive lesion resulting from tissue injury, followed by an impaired wound healing response, during which vascular growth is driven by FLT4 and the nitric oxide pathway.

Periungual and subungual pyogenic granuloma

BACKGROUND

Nail pyogenic granuloma (PG) is common, often seen as an urgent case, given the recent onset as a bleeding nodule. Nail PGs are due to different causes that act through different pathogenetic mechanisms and may be treated in several ways. Both causes and treatments of nail PG have never been classified.

OBJECTIVES

To classify nail PG according to the pathogenesis, describe the clinical and pathological features and provide guidelines for a correct diagnosis and treatment.

METHODS

A retrospective, observational study was performed reviewing epidemiological and clinical features of 58 cases of PG seen at our Departments in the last 5 years. A review of the literature was also carried out, using PubMed database and dermatological textbooks.

RESULTS

Nail PG is usually due to the following causes: drugs, local trauma and peripheral nerve injury. Histopathology shows similar features in every type of PG, irrespective of cause and location.

CONCLUSIONS

The localization of nail PG, the number of digits involved and clinical history help to identify the cause. When PG is single, especially if it involves the nail bed, histological examination is necessary to rule out malignant melanoma. Treatment must be chosen according to the underlying cause.

[Pregnancy follow-up and outcome in women with superficial vascular malformations]

Superficial vascular malformations (MAV), so far called "superficial angioma", are uncommon and often unknown. The last classification, done by the "International Society for the Study of Vascular Anomalies", is essential to avoid diagnostic and therapeutic mistakes. Extramedullar localisations are rare. The coexistence of a pregnancy and a MAV states two problems: the medical and paraclinic supervision of the volume of the MAV and its risk of thrombosis with the choice of thrombosis prevention, and the mode of delivery and type of anaesthesia depending on its anatomical location. We revised the management of pregnant women with a MAV illustrating possible troubles to deal with. We reported the cases of two women having for the first one a pharyngolaryngeal MAV, the second a cutaneous MAV located on the leg and needing a multidisciplinary management with obstetricians, anaesthesists, hematologists, dermatologists, ENT, radiologists and pediatricians.

[Spectral analysis of the microvasculature of primary cutaneous melanoma]

Cutaneous malignant melanoma represents one of the most dramatic skin cancers because its incidence is steadily growing in White populations. Of note, its metastatic risk and mortality dramatically increase when the primary neoplasm reaches about one millimeter thick. It is believed that angiogenesis and lymphangiogenesis associated with cutaneous melanoma potentially influence the neoplastic progression of the primary tumor and its metastases. In some instances, both the intratumoral and peritumoral microvasculature are correlated to booming of the tumoral growth fraction. In addition, the vascular network serves as a migration path for the intravascular and perivascular neoplastic spread. Hence, the quantification of the microvasculature might help establishing a prognostic factor of evolution. Among the available methods, spectral analysis of immunohistochemical sections highlighting vessels helps defining the microvasculature distribution. The benefit of using spectral analysis is discussed and the modalities of application of this analytical method are scrutinized.

Treatment of pyogenic granulomas with the Nd‐YAG laser

Pyogenic granuloma is a common vascular tumour that can be treated by various means. However, some large lesions and those located on some difficult-to-treat body sites may represent a difficult challenge to the clinician (residual pain after treatment, difficult to cover with a dressing, or risk of sequelae). We report the successful treatment of such lesions in three patients using the Nd-YAG laser.

Immunohistochemical clues at aging of the skin microvascular unit

BACKGROUND

Skin aging is a multifaceted process influenced by various factors affecting at variable degree at different body sites. This study focused on the aging process affecting dermal dendrocytes and the microvasculature. We also explored the effect of substance P released by capsaicin because this neuropeptide is known to affect the microvasculature environment.

METHODS

The first part of the present study was undertaken in two groups of 35 men who were younger than 30 years and older than 65 years, respectively. A skin biopsy was taken from the intact skin of a thigh during orthopedic surgical intervention after road accident. The second part of the study was performed on 30 men aged 65-68 years. They applied once daily a 0.05% capsaicin gel and the vehicle in a randomized design on the volar forearms. A skin biopsy was taken at inclusion and after a 5-month treatment phase. Immunohistochemistry was performed using a panel of antibodies. Dermal cells were distinguished according to the presence of factor XIIIa, CD34 or thrombomodulin. Blood and lymphatic vessels were studied by Ulex europaeus agglutinin-1, human podoplanin, human vascular endothelial growth factor-C (H-VEGF-C) and alpha-actin immunoreactivities.

RESULTS

In the study phase 1, a significant decrease in thrombomodulin-positive cells and vascularity were evidenced in the aged group. In the study phase 2, capsaicin appeared to boost the factor XIIIa-positive dendrocytes, the thrombomodulin-positive cells and the blood vessel network as well.

CONCLUSIONS

Specific subsets of the dermal dendrocyte populations and the blood microvasculature appear affected by aging. Capsaicin may limit these aging effects.

Palmar erythema

Palmar erythema (PE), an often overlooked physical finding, is due to several physiologic or systemic pathologic states. PE can exist as a primary physiologic finding or as a secondary marker of systemic pathology. Primary or physiologic PE can be due to heredity, occurs in at least 30% of pregnant women as a result of associated alterations in the function of the skin and its microvasculature, or may be a diagnosis of exclusion (i.e. idiopathic PE). Secondary PE from systemic pathology encompasses a wide range of disease states. Twenty-three percent of patients with liver cirrhosis, from varying causes, can manifest PE as a result of abnormal serum estradiol levels. Patients with a rare neonatal liver disease such as Wilson disease and hereditary hemochromatosis may exhibit PE along with the other systemic manifestations of the genodermatoses. PE has been reported to occur in >60% of patients with rheumatoid arthritis and is associated with a favorable prognosis. Up to 18% of patients with thyrotoxicosis and 4.1% of patients with diabetes mellitus can have PE. This cutaneous manifestation of diabetes occurs more often than the more classic diseases such as necrobiosis lipoidica diabeticorum (0.6%). PE can be seen in early gestational syphilis and among patients with human T-lymphotrophic virus-1-associated myelopathy. Drug-induced PE with hepatic damage has been documented with use of amiodarone, gemfibrozil, and cholestyramine, while topiramate and albuterol (salbutamol) have been reported to cause PE in the setting of normal liver function. Fifteen percent of patients with both metastatic and primary brain neoplasms may have PE. Increased levels of angiogenic factors and estrogens from solid tumors have been postulated as the cause of PE in such cases. Erythema ab igne can mimic PE, and patients with atopic diathesis are more likely to have PE than matched control subjects. Smoking and chronic mercury poisoning are environmental causes of PE.No treatment of primary PE is indicated. If medication is the cause of PE, the drug responsible should be discontinued if possible. Identification of PE related to underlying disorders should be followed by treatment of the underlying condition. In light of the numerous etiologies of PE, this article reviews the current literature and provides a framework to help guide the clinician in determining the cause of PE in patients presenting with this finding.

Oral pyogenic granuloma: a review

Pyogenic granuloma is one of the inflammatory hyperplasias seen in the oral cavity. This term is a misnomer because the lesion is unrelated to infection and in reality arises in response to various stimuli such as low-grade local irritation, traumatic injury or hormonal factors. It predominantly occurs in the second decade of life in young females, possibly because of the vascular effects of female hormones. Clinically, oral pyogenic granuloma is a smooth or lobulated exophytic lesion manifesting as small, red erythematous papules on a pedunculated or sometimes sessile base, which is usually hemorrhagic. The surface ranges from pink to red to purple, depending on the age of the lesion. Although excisional surgery is the treatment of choice for it, some other treatment protocols such as the use of Nd:YAG laser, flash lamp pulsed dye laser, cryosurgery, intralesional injection of ethanol or corticosteroid and sodium tetradecyl sulfate sclerotherapy have been proposed. Because of the high frequency of pyogenic granuloma in the oral cavity, especially during pregnancy, and necessity for proper diagnosis and treatment, a complete review of published information and investigations about this lesion, in addition to knowledge about new approaches for its treatment is presented.