A potentially effective itsy-bitsy therapy for spider angiomas: Topical timolol

By Warren R. Heymann, MD, FAAD
Oct. 22, 2025
Vol. 7, No. 42

The joys of compressing the central arteriole of a spider angioma (SA), letting go, and watching the peripheral vessels fill have never diminished. I can reassure patients that the lesion is benign, tell them it may resolve with time (especially if predisposing factors are removed), and offer successful treatment options if desired.

The first description of a SA is attributed to the English surgeon Sir Erasmus Wilson (1809-1884). He used the term nevus araneus (Latin for spider nevus); it is unclear if the appellation originated with him. (1)

Solitary SA are seen in 15% of young adults who usually have fewer than 3 lesions. (2) In children, SA tend to arise after age 2 years, peaking between 6 and 10 years, and mostly remitting around puberty, although lesions may persist. (3) More than 6 SA is considered abnormal. (4) SA are commonly found in areas supplied by the superior vena cava (face, neck, upper chest, and arms), and range in size up to 2 centimeters. (5) Although classically associated with chronic liver disease, SA have been associated with other conditions such as pregnancy, rheumatoid arthritis, thyrotoxicosis, and severe malnutrition. (6)

Samant and Kothadia succinctly review current hypotheses regarding the pathogenesis of SA: “Spider naevus is dilation of preexisting central arterioles from which numerous thin-walled capillary branches radiate like spider legs, carrying away freely flowing blood. They form due to the failure of the sphincteric muscle surrounding a cutaneous arteriole leading to dilatation of central arteriole. The exact cause of spider angioma is not known. For decades, there have been many hypotheses of possible mechanisms that lead to the arteriolar vasodilation. Important among those are direct vasodilatory effects of alcohol, substance P, hyperestrogenism, and inadequate hepatic metabolism of steroid hormones. Angiogenesis as a possible mechanism in the pathogenesis of spider nevi has been proposed due to elevated serum vascular growth factors, such as vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) levels in patients with liver cirrhosis. Sex hormone imbalance predominantly hyperestrogenism has also been implicated for the development spider naevi. This is also suggested by the occurrence of spider angioma in individuals with a hyperestrogenic state, like pregnancy.” (4)

SA will resolve when inciting factors are no longer present, such as post-partum or following a liver transplantation. For example, Ankur et al. reported the case of a 55-year-old man with severe alcoholic hepatitis with a large number of trucal SA. Two months post-liver transplantation, most of the SA had faded or disappeared. (7)

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Treatment for SA is usually for cosmetic reasons; only rarely are they symptomatic or bleed. Fine needle electrocautery, electrodesiccation, and lasers (585 nm pulsed dye, 532 KTP, 1064 Nd:YAG) are all effective. (1,3) Cyanoacrylate glue has been reported to stop bleeding in a SA of the lower lip in a cirrhotic man. (8) Availability, cost, discomfort, and potential scarring risk must all be considered when deciding whether (and how) to treat SA, especially in children.

The inspiration for this commentary is the article by Caussade et al., detailing the use of topical timolol for SA in children. Five children (ages 8-10 years) with SA, without any predisposing disorders, were treated with topical timolol 0.5% (either solution or gel-forming solution) dosed at one drop twice daily. No adverse effects were observed during the mean follow-up time of 6.8 months. Two patients cleared completely, two had a partial response, and one had no clinical change. Although the mechanism of action of non-selective beta-blockers on SA is incompletely understood, presumably vasoconstriction, downregulation of pro-angiogenic factors, and apoptosis are at play. The authors acknowledge this is a small retrospective study that warrants further analysis. “This pilot case series shows that topical timolol may prove useful as a noninvasive, available and well-tolerated treatment option for spider angiomas in children who seek a treatment alternative to pulsed dye laser.” (3) It is hard to argue that conclusion. I look forward to prescribing topical timolol the next time I see patients with SA who desire treatment but are equivocal about standard modalities.

Point to Remember: Spider angiomas are common lesions that may be secondary to underlying conditions, notably pregnancy or chronic liver disease. Although destructive modalities such as lasers are highly effective, topical timolol may be a valuable option for those who prefer a nonsurgical approach to therapy.

Our expert’s viewpoint

Albert C. Yan, MD, FAAP, FAAD
Section of Pediatric Dermatology
Children's Hospital of Philadelphia
Professor, Pediatrics and Dermatology
Perelman School of Medicine at the University of Pennsylvania

While spider angiomas (SA) are seen in adults in the contexts of chronic liver disease, in children, they are most commonly attributed to antecedent trauma and most commonly encountered in sun-exposed areas. While older studies indicate eventual spontaneous regression in the majority of these lesions, having them persist on the face is often viewed as a nuisance by both patients and parents prompting them to seek treatment. In one of our patients who received topical timolol, the patient treated one lesion and left an adjacent one untreated; only the treated lesion resolved, suggesting a real effect to us and prompting us to investigate this further. With larger numbers of patients, we hope to untangle the true efficacy of timolol and see if it can potentially weave its way into becoming a fruitful treatment for spider angiomas.

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References

1. Hoenig LJ. Along came a spider: Medicine's most famous spider eponyms. Clin Dermatol. 2020 Mar-Apr;38(2):257-261. doi: 10.1016/j.clindermatol.2019.06.001. Epub 2019 Jun 21. PMID: 32513406.

2. Samant H, Kothadia JP. Spider Angioma. 2023 Jul 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 29939595.

3. Caussade MC, Stockton Hogrogian G, Yan AC. Topical Timolol for Treatment of Spider Angiomas in Children: A Case Series. Pediatr Dermatol. 2025 Mar-Apr;42(2):339-341. doi: 10.1111/pde.15788. Epub 2024 Oct 22. PMID: 39439069.

4. Sivanandam LK, Kannan A, Srinivasan AA, Bammigatti C. A rare case of extensive cutaneous spider angioma in Zieve's syndrome: A case report and review of literature. J Family Med Prim Care. 2022 Jul;11(7):4036-4038. doi: 10.4103/jfmpc.jfmpc_2373_21. Epub 2022 Jul 22. PMID: 36387672; PMCID: PMC9648283.

5. Alabdullah H, Almousa M, Alabdullah MN, Al-Shawaf AZ, Douri T. Spider angioma at the injection site of the meningitis vaccine. Oxf Med Case Reports. 2024 Feb 16;2024(2):omae001. doi: 10.1093/omcr/omae001. PMID: 38370498; PMCID: PMC10873702.

6. Terp K, Izquierdo-Pretel G. Spider Angioma Number and Location as Potential Prognostic Indicators in Chronic Liver Disease: A Case Report. Cureus. 2023 Jan 25;15(1):e34193. doi: 10.7759/cureus.34193. PMID: 36843700; PMCID: PMC9951817.

7. Jindal A, Gupta A, Bhadoria AS. Resolution of Multiple Large Spider Angiomas After Liver Transplantation in Severe Alcoholic Hepatitis. Indian J Dermatol. 2022 Nov-Dec;67(6):837. doi: 10.4103/ijd.IJD_761_16. PMID: 36998878; PMCID: PMC10043698.

8. Gandotra A, Taneja S, Premkumar M, Verma N, De A, Rathi S, Duseja A. Bloody Lips - Gluing Bleeding Lower Lip Spider Angioma in Decompensated Cirrhosis. J Clin Exp Hepatol. 2024 Mar-Apr;14(2):101308. doi: 10.1016/j.jceh.2023.101308. Epub 2023 Dec 9. PMID: 38261889; PMCID: PMC10797178.

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