Birthmarks

Definition

Birthmarks are areas of discolored and raised spots found on the skin. Birthmarks are groups of malformed pigment cells or blood vessels.

Description

Vascular birthmarks are benign (noncancerous) skin growths comprised of rapidly growing or poorly formed blood vessels or lymph vessels. Found at birth (congenital) or developing later in life (acquired) anywhere on the body, they range from faint spots to dark swellings covering wide areas.

Birthmarks are most often found on the head or neck but can be anywhere on the body. The common appearing birthmark is a tiny red or purple mark. A specific group of birthmarks, called "strawberry spot," "portwine stain," and "stork bite," are medically called hemangiomas. These birthmarks are essentially an overgrowth of blood vessel tissue in a specific area on the body.

Many birthmarks disappear without any special treatment, but some remain the same size or enlarge. In rare cases, the strawberry mark may cover large area of the face and body.

Demographics

About one in every three infants has a birthmark. Twice as many girls as boys have birthmarks. For appearance or cosmetic reasons, medical treatment may be necessary if the birthmark does not disappear on its own. Treatment for most birthmarks is delayed until the child is older.

About 10 in every 100 babies have vascular birthmarks. Skin angiomas, also called vascular nevi (marks), are overgrown blood vessel tissue (hemangiomas) or lymph vessel tissue (lymphangiomas) beneath the skin's surface. Hemangiomas are on the face and neck (60%), trunk (25%), or the arms and legs (15%). Congenital hemangiomas, 90 percent of which appear at birth or within the first month of life, grow quickly and disappear over time. They occur in 1–10 percent of full-term infants, and 25 percent of premature infants. About 65 percent are capillary hemangiomas (strawberry marks), 15 percent are cavernous (deep) hemangiomas, and the rest are mixtures.

Vascular malformations are poorly formed blood or lymph vessels that appear at birth. One type, the salmon patch (nevus simplex), is a pink mark comprised of dilated capillaries (also called a stork bite). It appears on the back of the neck in 40 percent of newborns and on the forehead and eyelids (also called an angel's kiss) in 20 percent. Stork bites appear in 70 percent of white and 60 percent of black newborns.

Fewer than 1 percent of newborns have port-wine stains (nevus flammeus), birthmarks. These vascular malformations of dilated capillaries appear in the upper and lower layers of the skin on the face, neck, arms, and legs. Nevus flammeus are often permanent; these flat pink to red marks develop into dark purple bumpy areas in later life; 85 percent appear on only one side of the body.

Causes and symptoms

As of 2004 there were no known causes for congenital skin angiomas or birthmarks. Most birthmarks do not hurt; most do not cause any health problems and do not need treatment. Birthmarks may be an inherited weakness of vessel walls.

The birthmark is discoloration of the skin that starts before or just after birth. These marks can appear to be a red rash or lesion. Birthmarks tend to be different color from the skin. They are mostly flat, but some are raised, bumpy, and hairy. Many birthmarks fade or disappear altogether during the preschool years, but some never disappear completely.

Diagnosis

Patients are treated by pediatricians, dermatologists (skin disease specialists), plastic surgeons (doctors who specialize in correcting abnormalities of the appearance), and ophthalmologists (eye disease specialists), depending on the type and severity of the birthmark.

Angiomas and vascular malformations are not difficult to diagnose. The doctor takes a medical history and performs a physical examination, including visual inspection and palpation (feeling with the hands) of the marks. The skin is examined for discoloration, scarring, bleeding, infection, or ulceration. The type, location, size, number, and severity of the marks are recorded. The doctor may empty the mark of blood by gentle pressure. Biopsies or specialized x rays or scans of the abnormal vessels and their surrounding areas may confirm the diagnosis. Patients with port-wine stains near the eye may need skull x rays, computed tomography scans, and vision and central nervous system tests. Most insurance plans pay for diagnosis and treatment of these conditions.

Types of birthmarks

There are many types of birthmarks. Certain types of raised or flat red, pink, or bluish birthmarks need close watching by a qualified medical expert as the child grows. Description of common variations in skin color and birthmarks is as follows:

• Port-wine stains: These flat, pink, red, or purple colored birthmarks are caused by a concentration of dilated tiny blood vessels call capillaries. The stains usually occur on the head, face, and neck. They may be small, or they may cover large areas of the child's body. Port-wine stains do not change color when gently pressed and do not disappear over time. They may become darker and may bleed when the child is older or as an adult. Skin-colored cosmetics will cover small port-wine stains. The most effective way of treating port-wine stains is with a special laser when the child is older.
• Stork bites or salmon patches (called angel kisses when occurring on forehead or eyelids): These small pink or red patches are often found on the baby's eyelids or forehead, between the eyes, on the upper lip, and back of the neck. The name comes from the marks on the back of the neck where, as the myth goes, a stork may have picked up the baby. This concentration of immature blood vessels is most visible when the baby is crying. Most of these fade and disappear.
• Strawberry hemangiomas: These bright or dark red, raised or swollen, bumpy areas look like a strawberry. Hemangiomas are a concentration of tiny, immature blood vessels. Most of these occur on the head. They may not appear at birth but often develop in the first two months. Strawberry hemangiomas are more common in premature babies and in girls. These birthmarks often grow in size for several months (they stop growing around the first birthday), then the birthmarks gradually begin to fade. By age five, the birthmarks fade in half the children affected, and they disappear by age nine.
• Mongolian spots: These blue or purple-colored splotches on the baby's lower back or buttocks occur on over 80 percent of African-American, Asian, and Indian babies. They also occur in dark-skinned babies of all races. The spots, a concentration of pigmented cells, usually disappear in the first four years of life.

Treatment

Treatment choices for skin angiomas and vascular malformations depend on their type, location, severity, and degree of disfigurement.

Watchful waiting

Birthmarks are regularly examined until they disappear or require treatment. This approach is appropriate for most hemangiomas, since many eventually shrink by themselves.

Complications

When birthmarks (hemangiomas) form in an area that can interfere with the baby's normal development (for example, blocking vision or causing difficulty breathing or hearing), treatment may be necessary. If the mark begins bleeding, parents should apply pressure firmly to control the bleeding. About 5 percent of hemangiomas become ulcerated, especially if they are in an area that is under pressure or touched often.

Port-wine stains are on the forehead, sides of the face, or eyelids. They are occasionally linked with an increase of blood vessels in the brain or glaucoma. An increase in pressure in the eye can lead to blindness if not treated. Port-wine stains on the legs or arm may be linked to an overgrowth of that extremity.

Other complications, including congestive heart failure from large lesions, Kippel-Trenaunay-Weber syndrome, and Kasabach-Merrit syndrome, are rare.

Drugs

CORTICOSTEROIDS Parents may consider treatment for hemangiomas that do not shrink or fade by the time the child is four years old. The treatments include the use of high doses of steroids (either orally or injected into the lesion) to stop the growth. Steroids prevent the marks from growing; they do not make the birthmarks smaller. Other treatments include interferon alpha, laser therapy, and surgical removal.

INTERFERON ALPHA-2A This drug reduces cell growth in vascular marks that affect vision and that are unresponsive to corticosteroids. Given in daily injections under the skin, the response rate is 50 percent after seven months. Side effects include fever , chills, muscle and joint pain , vision disorders, low white and red blood cell counts, fatigue, elevated liver enzymes, nausea , blood clotting problems, and nerve damage.

ANTIBIOTICS Oral or topical (applied to the skin) antibiotics are prescribed for infected marks.

Surgery

Birthmarks may be removed by laser surgery. Lasers create intensive heat that destroys abnormal blood vessels beneath the skin, without damaging normal skin. Laser surgery is not usually painful but can be uncomfortable. Children are usually sedated or anesthetized. Healing occurs within two weeks. Side effects include bruising, skin discoloration, swelling, crusting, and minor bleeding.

In some cases, the birthmark can be surgically excised, or removed. Under local or general anesthesia, the skin is cut and vascular marks or their scars are removed. The cut is repaired with stitches or skin clips.

Cryosurgery is another technique used to remove small birthmarks. Vascular marks can be frozen with a substance that is sprayed onto the skin. Wounds heal with minimal scarring.

Birthmarks can also be treated by electrodesiccation. In this procedure, affected vessels are destroyed with the current from an electric needle.

Other treatments

Other treatments include the following:

• Sclerotherapy: Injection of a special solution causes blood clotting and shrinkage with little scarring. Side effects include stinging, swelling, bruising, scarring, muscle cramping, and allergic reactions. This treatment is used most commonly for spider angiomas.
• Embolization: A special material is injected into the vessel blocks blood flow, which helps control blood loss from a bleeding birthmark or reduces the size of inoperable growths. A serious side effect, stroke , can occur if a major blood vessel becomes blocked.
• Make-up: Special brands designed to cover birthmarks are sold. Two of these are Covermark and Derma blend.
• Cleaning and compression: Bleeding marks are cleaned with soap and water or hydrogen peroxide, and compressed with a sterile bandage for five to 10 minutes.

Prognosis

Many birthmarks fade or disappear before the child is school age. Some may never go away. Most of them are benign and do not need treatment. Babies with birthmarks are examined and diagnosed by the doctor. Those birthmarks that cause complications in normal childhood growth and development may require medical and surgical treatment.

The various types of birthmarks have different prognoses:

KEY TERMS

Angioma —A tumor (such as a hemangioma or lymphangioma) that mainly consists of blood vessels or lymphatic vessels.

Benign —In medical usage, benign is the opposite of malignant. It describes an abnormal growth that is stable, treatable, and generally not life-threatening.

Capillaries —The tiniest blood vessels with the smallest diameter. These vessels receive blood from the arterioles and deliver blood to the venules. In the lungs, capillaries are located next to the alveoli so that they can pick up oxygen from inhaled air.

Corticosteroids —A group of hormones produced naturally by the adrenal gland or manufactured synthetically. They are often used to treat inflammation. Examples include cortisone and prednisone.

Cutaneous —Pertaining to the skin

Cutaneous angiolipomas —Benign growths consisting of fat cells and blood vessels just underneath the skin.

Hemangioma —A benign skin tumor composed of abnormal blood vessels.

Hereditary —Something which is inherited, that is passed down from parents to offspring. In biology and medicine, the word pertains to inherited genetic characteristics.

Incidence —The rate of development of a disease in a given population over time.

Kasabach-Merrit syndrome —A combination of rapidly enlarging hemangioma and thrombocytopenia; it is usually clinically evident during early infancy, but occasionally the onset is later. The hemangiomas are large and may increase in size rapidly and may cause severe anemia in infants.

Lymphangioma —A benign skin tumor composed of abnormal lymph vessels.

Lymphatic vessels —Part of the lymphatic system, these vessels connect lymph capillaries with the lymph nodes. They carry lymph, a thin, watery fluid resembling blood plasma and containing white blood cells. Also called lymphatic channels.

Nevus —Any pigmented blemish of the skin present at birth, including moles and various types of birthmarks.

Seizure —A sudden attack, spasm, or convulsion.

Subcutaneous —Referring to the area beneath the skin.

Syndrome —A group of signs and symptoms that collectively characterize a disease or disorder.

Ulcer —A site of damage to the skin or mucous membrane that is characterized by the formation of pus, death of tissue, and is frequently accompanied by an inflammatory reaction.

Vascular malformation —Abnormally formed blood or lymph vessels.

• Capillary hemangiomas: Fewer than 10 percent need treatment. Without treatment, 50 percent disappear by age five; 70 percent by age seven; and 90 percent by age nine. No skin changes are found in half, while others have some discoloration, scarring, or wrinkling. From 30 to 90 percent respond to oral corticosteroids, and 45 percent respond to injected corticosteroids; 50 percent respond to interferon Alpha-2a. About 60 percent improve after laser surgery.
• Cavernous hemangiomas: Many do not disappear and are complicated by ulceration or infection. About 75 percent respond to laser surgery but have scarring.
• Spider angiomas: These fade in children but may recur. About 90 percent respond to sclerotherapy, electrodesiccation, or laser therapy.
• Cherry angiomas: These are easily removed by electrodesiccation.
• Lymphangiomas: These marks require surgery.
• Salmon patches on eyelid marks: These marks disappear by six to 12 months of age, and forehead marks fade by age six; however, 50 percent of stork bites on the neck persist into adulthood.
• Port-wine stains (flat birthmarks): These marks are easily covered with make-up. Treatment during infancy or childhood improves results. About 95 percent of the stains respond to FPDL surgery with minimal scarring; 25 percent will disappear, and 70 percent will partially disappear. For unknown reasons, 5 percent show no improvement.

Prevention

Birthmarks are congenital hemangiomas or vascular malformations and cannot be prevented.

Parental concerns

Though no treatment is needed in many of these cases, a child with a hemangiomas should be watched carefully by a doctor skilled in pediatric skin disorders. The hardest part for parents is to wait until the birthmarks begin to fade on their own or, in the case of a birthmark that does not fade, waiting until the child is old enough for surgical management.

When to call the doctor

Parents should report any birthmarks they notice to the child's pediatrician. They should call the pediatrician if they notice bleeding from the birthmark, if a sore develops on the birthmark, if the mark is growing larger.

Resources

BOOKS

Birthmarks: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Group International, 2004.

Thompson, June. Spots, Birthmarks, and Rashes: The Complete Guide to Caring for Your Child's Skin. Westport, CT: Firefly Books, 2003.

WEB SITES

"Birthmarks: Red." MedlinePlus, April 17, 2003. Available online at <www.nlm.nih.gov/medlineplua/ency/article/001440.htm> (accessed December 12, 2004).

Aliene S. Linwood, RN, DPA, FACHE

Birthmarks

Definition

Birthmarks, including angiomas and vascular malformations, are benign (noncancerous) skin growths composed of rapidly growing or poorly formed blood vessels or lymph vessels. Found at birth (congenital) or developing later in life (acquired) anywhere on the body, they range from faint spots to dark swellings covering wide areas.

Description

Skin angiomas, also called vascular (pertaining to vessel) nevi (marks), are composed of blood vessels (hemangiomas) or lymph vessels (lymphangiomas), that lie beneath the skin's surface. Hemangiomas, composed of clusters of cells that line the capillaries, the body's smallest blood vessels, are found on the face and neck (60%), trunk (25%), or the arms and legs (15%). Congenital hemangiomas, 90% of which appear at birth or within the first month of life, grow quickly, and disappear over time. They are found in 1-10% of full-term infants, and 25% of premature infants. About 65% are capillary hemangiomas (strawberry marks), 15% are cavernous (deep) hemangiomas, and the rest are mixtures. Hemangiomas are three times more common in girls. Usually, only one hemangioma is found, in 20% two are found, while fewer than 5% have three or more. Lymphangiomas are skin bumps caused by enlarged lymph vessels anywhere on the body.

Vascular malformations are poorly formed blood or lymph vessels that appear at birth or later in life. One type, the salmon patch (nevus simplex), a pink mark composed of dilated capillaries, is found on the back of the neck (also called a stork bite) in 40% of newborns, and on the forehead and eyelids (also called an angel's kiss) in 20%. Stork bites are found in 70% of white and 60% of black newborns.

Found in fewer than 1% of newborns, port-wine stains (nevus flammeus), are vascular malformations composed of dilated capillaries in the upper and lower layers of the skin of the face, neck, arms, and legs. Often permanent, these flat pink to red marks develop into dark purple bumpy areas in later life; 85% appear on only one side of the body.

Acquired hemangiomas include spider angiomas (nevus araneus), commonly known as spider veins, and cherry angiomas (senile angiomas or Campbell de Morgan spots). Found around the eyes, cheekbones, arms, and legs, spider angiomas are red marks formed from dilated blood vessels. They occur during pregnancy in 70% of white women and 10% of black women, in alcoholics and liver disease patients, and in 50% of children. Cherry angiomas, dilated capillaries found mainly on the trunk, appear in the 30s, and multiply with aging.

Causes and symptoms

There are no known causes for congenital skin angiomas; they may be related to an inherited weakness of vessel walls. Exposure to estrogen causes spider angiomas in pregnant women or those taking oral contraceptives. Spider angiomas tend to run in families, and may be associated with liver disease, sun exposure, and trauma.

Hemangiomas

Hemangiomas first appear as single or multiple, white or pale pink marks, ranging from 2-20 cm (average 2-5 cm) in size. Some are symptomless while others cause pain or bleeding, or interfere with normal functioning when they are numerous, enlarged, infected, or ulcerated. Vision is affected by large marks on the eyelids. Spider and cherry angiomas are unsightly but symptomless.

KEY TERMS

Angioma— A benign skin tumor composed of rapidly growing, small blood or lymph vessels.

Capillaries— The smallest blood vessels, they connect the arteries and veins.

Corticosteroids— Drugs that fight inflammation.

Hemangioma— A benign skin tumor composed of abnormal blood vessels.

Lymph vessels— Part of the lymphatic system, these vessels connect lymph capillaries with the lymph nodes; they carry lymph, a thin, watery fluid resembling blood plasma and containing white blood cells.

Lymphangioma— A benign skin tumor composed of abnormal lymph vessels.

Nevus— A mark on the skin.

Ulcer— A red, shallow sore on the skin.

Vascular malformation— A poorly formed blood or lymph vessels.

Each type of hemangioma has a characteristic appearance:

• Capillary hemangiomas (strawberry marks). These round, raised marks are bright red and bumpy like a strawberry, and become white or gray when fading.
• Cavernous hemangiomas. These slightly raised, dome-shaped, blue or purple swellings are sometimes associated with lymphangiomas or involve the soft tissues, bone, or digestive tract.
• Spider angiomas. These are symptomless, reddish blue marks formed from blood-filled capillaries radiating around a central arteriole (small artery) in the shape of a spider web.
• Cherry angiomas. These harmless, dilated capillaries appear as tiny, bright red-to-violet colored bumps.
• Lymphangiomas. These dilated lymph vessels form light pink or yellow cysts (fluid- filled sacs) or swellings.

Vascular malformations

These are faint, flat, pink stains that grow as the child grows into larger dark red or purple marks. Some are symptomless but others bleed if enlarged or injured. Disfiguring port-wine stains can cause emotional and social problems. About 5% of port-wine stains on the forehead and eyelids increase eye pressure due to involvement of the eye and surrounding nerves. Abnormalities of the spinal cord, soft tissues, or bone may be associated with severe port-wine stains.

Each type has a characteristic appearance:

• Salmon patches. These symptomless, light red-to-pink marks usually fade with time.
• Port-wine stains. These flat, pink marks progress to raised, dark red-to-purple grape-like lumps distorting the facial features, arms, or legs.

Diagnosis

Patients are treated by pediatricians (doctors who specialize in the care of children), dermatologists (skin disease specialists), plastic surgeons (doctors who specialize in correcting abnormalities of the appearance), and ophthalmologists (eye disease specialists).

Angiomas and vascular malformations are not difficult to diagnose. The doctor takes a complete medical history and performs a physical examination including inspection and palpation of the marks. The skin is examined for discoloration, scarring, bleeding, infection, or ulceration. The type, location, size, number, and severity of the marks are recorded. The doctor may empty the mark of blood by gentle pressure. Biopsies or specialized x rays or scans of the abnormal vessels and their surrounding areas may be performed. Patients with port-wine stains near the eye may require skull x rays, computed tomography scans, and vision and central nervous system tests. Most insurance plans pay for diagnosis and treatment of these conditions.

Treatment

Treatment choices for skin angiomas and vascular malformations depend on their type, location, and severity, and whether they cause symptoms, pain, or disfigurement.

Watchful waiting

No treatment is given, but the mark is regularly examined. This continues until the mark disappears, or requires treatment. This approach is particularly appropriate for the treatment of hemangiomas, which often do not require treatment, since they eventually shrink by themselves.

Drugs

CORTICOSTEROIDS. Daily doses of the anti-inflammatory drugs prednisone or prednisolone are given for up to 2 months with gradual reduction of the dose. The marks begin to subside within 7-10 days, but may take up to 2 months to fully disappear. If no response is seen in 2 weeks, the drug is discontinued. Treatment may be repeated. Side effects include growth retardation, increased blood pressure and blood sugar, cataracts, glandular disorders, and infection. The corticosteroids triamcinolone acetate and betamethasone sodium phosphate or acetate are injected directly into the marks with a response usually achieved within a week; additional injections are given in 4-6 weeks. Side effects include tissue damage at the injection site.

INTERFERON ALPHA-2A. This drug reduces cell growth, and is used for vascular marks that affect vision, and that are unresponsive to corticosteroids. Given in daily injections under the skin, a response rate of 50% is achieved after about 7 months. Side effects include fever, chills, muscle and joint pain, vision disorders, low white and red blood cell counts, fatigue, elevated liver enzymes, nausea, blood clotting problems, and nerve damage.

ANTIBIOTICS. Oral or topical (applied to the skin) antibiotics are prescribed for infected marks.

Surgery

LASER SURGERY. Lasers create intense heat that destroys abnormal blood vessels beneath the skin, without damaging normal skin. Two types of lasers are used: the flashlamp-pulsed dye laser (FPDL) and the neodymium:YAG (Nd:YAG) laser. The FPDL, used mainly for strawberry marks and port-wine stains, penetrates to a depth of 1.8 mm and causes little scarring, while the Nd:YAG laser penetrates to a depth of 6 mm, and is used to treat deep hemangiomas. Laser surgery is not usually painful, but can be uncomfortable. Anesthetic cream is used for FPDL treatment. Treatment with the Nd:YAG laser requires local or general anesthesia. Children are usually sedated or anesthetized. Healing occurs within 2 weeks. Side effects include bruising, skin discoloration, swelling, crusting, and minor bleeding.

SURGICAL EXCISION. Under local or general anesthesia, the skin is cut with a surgical instrument, and vascular marks or their scars are removed. The cut is repaired with stitches or skin clips.

CRYOSURGERY. Vascular marks are frozen with an extremely cold substance sprayed onto the skin. Wounds heal with minimal scarring.

ELECTRODESICCATION. Affected vessels are destroyed with the current from an electric needle.

Other treatments

These include:

• Sclerotherapy. Injection of a special solution causes blood clotting and shrinkage with little scarring. Side effects include stinging, swelling, bruising, scarring, muscle cramping, and allergic reactions. This treatment is used most commonly for spider angiomas.
• Embolization. Material injected into the vessel blocks blood flow which helps control blood loss during or reduces the size of inoperable growths. A serious side effect, stroke, can occur if a major blood vessel becomes blocked.
• Make-up. Special brands are designed to cover birthmarks (Covermark or Dermablend).
• Cleaning and compression. Bleeding marks are cleaned with soap and water or hydrogen peroxide, and compressed with a sterile bandage for 5-10 minutes.

Alternative treatment

Alternative treatments for strengthening weak blood vessels include eating high-fiber foods and those containing bioflavonoids, including citrus fruit, blueberries, and cherries, supplementing the diet with vitamin C, and taking the herbs, ginkgo (Ginkgo biloba ) and bilberry (Vaccinium myrtillus.)

Prognosis

The various types of birthmarks have different prognoses:

• Capillary hemangiomas. Fewer than 10% require treatment. Without treatment, 50% disappear by age 5, 70% by age 7, and 90% by age 9. No skin changes are found in half while others have some discoloration, scarring, or wrinkling. From 30-90% respond to oral corticosteroids, and 45% respond to injected corticosteroids; 50% respond to interferon Alpha-2a. About 60% improve after laser surgery.
• Cavernous hemangiomas. Some do not disappear and some are complicated by ulceration or infection. About 75% respond to Nd:YAG laser surgery but have scarring. Severe marks respond to oral corticosteroids, but some require excision.
• Spider angiomas. These fade following childbirth and in children, but may recur. About 90% respond to sclerotherapy, electrodesiccation, or laser therapy.
• Cherry angiomas. These are easily removed by electrodesiccation.
• Lymphangiomas. These require surgery.
• Salmon patches. Eyelid marks disappear by 6-12 months of age, and forehead marks fade by age 6; however, 50% of stork bites on the neck persist into adulthood.
• Port-wine stains. Some flat birthmarks are easily covered with make-up. Treatment during infancy or childhood improves results. About 95% of the stains respond to FPDL surgery with minimal scarring; 25% will completely and 70% will partially disappear. For unknown reasons, 5% show no improvement.

Prevention

Congenital hemangiomas or vascular malformations cannot be prevented, but spider angiomas may be prevented by exercise, weight control, and a high-fiber diet, as well as avoidance of sun exposure, alcohol drinking, or wearing tight hosiery.

Resources

ORGANIZATIONS

American Academy of Dermatology. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-0230. Fax: (847) 330-0050. 〈http://www.aad.org〉.

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000. 〈http://www.aap.org〉.

Congenital Nevus Support Group. 1400 South Joyce St., Number C-1201, Arlington, VA 22202. (703) 920-3249.

National Congenital Port Wine Stain Foundation. 123 East 63rd St., New York, NY 10021. (516) 867-5137.

birthmark persistent, visible marks on the surface of the body, present from the time of birth, usually a naevus: a local overgrowth of blood vessels, or haemangioma.

From ancient times, birthmarks have traditionally been seen as a consequence of a mother's fears, fantasies, or unfulfilled cravings, and this idea acquired a certain doctrinal character during the Enlightenment. Before the eighteenth century the association of maternal passions and emotions with skin blemishes, with certain forms of bodily deformities, and, ultimately, with ‘monsters’ was based on little more than numerous testimonials and anecdotes. Both Aristotle and Hippocrates had cited the maternal imagination to account for birthmarks and abnormalities. It was also in that vein of pathological explanation that the theory survived during the Middle Ages and the Renaissance. Though it was provisionally abandoned by the scientific élite of the seventeenth century, discussion on whether there was any form of correlation between maternal emotions and fetal conformation continued during the eighteenth century and in Romanticism, in popular culture, in folklore, and, to a lesser extent, in scientific and pseudoscientific literature.

Prior to the first important systematization of the powers of maternal imagination, by the French theologian and philosoper Malebranche in the late seventeenth century, stories about the effects of the mother's thoughts upon the fetus had been on the increase, mainly in compendia and treatises of natural history. These sources show, however, considerable variation in the basic principles: similar causes, the fears and cravings of the mother, did not produce the same effects in all cases, and for the most part, they did not produce any effect whatsoever. On the other hand, even the most fervent upholder of the powers of the imagination on the fetus was willing to call into question the veracity of many of the stories compiled within scholarly or popular traditions. Beginning with the book of Genesis, where Jacob is said to have produced spotted cattle by presenting the animals with lined rods, the alleged powers of the mother's imagination resulted in the most extraordinary fabrications. The French historian Paradin, for example, wrote about the niece of Pope Nicholas III, who gave birth to a child covered with hair, and with bear claws instead of fingers. Another was born with his tripes hanging from his belly because the slaughter of a sheep was contemplated by the mother. And the Dutch scholar Schenkius informs us that a woman from Louvain who conceived on the day of the Epiphany gave birth to three children of three different races.

Despite the lack of evidence traditionally associated with these stories, from 1690 to 1700, communications concerning teratology (the science that deals with fetal malformations) in the Philosophical Transactions of the Royal Society London and the Mémoires of the French Académie, Paris, frequently debated the possibility of the power of the maternal imagination. Furthermore, after the publication in 1714 of De morbis cutaneis, by the English surgeon Daniel Turner, a dispute occurred, first in England and then on the Continent, about the influence of the maternal imagination on the creation of birthmarks and other forms of major or minor abnormalities. The repercussions of this ongoing debate lasted until the late eighteenth century: even after the English surgeon John Hunter had denied the reality of the power of the mother's imagination in a thoughtful empirical study, the French physician Louis Nicolas Benjamin Bablot wrote opposing treatises on the subject. The French surgeon Jean-Baptista Demangeon did likewise at the beginning of the nineteenth century. Even in the late nineteenth century numerous articles were published in the Journal of the American Medical Association which supported the theory. The scholars Gould and Pyle in their famous book Anomalies and Curiosities of the Medicine, published in 1896, also supported the belief. And even though most teratologists today would agree that major physical malformations do not result from maternal impressions, some behavioural scientists still consider that certain prenatal events, such as maternal stress, may have an effect on fetal development.

Javier Moscoso

birthmark pigmented maldevelopment of the skin that varies in size, either present at birth or developing later. Birthmarks may appear as moles (melanocytic nevi) that vary in color from light brown to blue, and are either flat or raised above the surface of the skin. They are usually benign, but do rarely develop into malignant melanoma, a form of skin cancer . The so-called port-wine stains and strawberry marks involve vascular tissue. The flat port-wine stains can be made lighter with the use of laser therapy. The strawberry marks generally disappear a few years after birth.

birth·mark / ˈbər[unvoicedth]ˌmärk/ • n. an unusual and typically permanent brown or red mark on someone's body from birth.

birthmark (berth-mark) n. a skin blemish or mark present at birth.

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