Infantile Hemangioma Overview
Infantile Hemangiomas are a very common benign growth (benign tumor) of childhood derived of vascular (blood vessel) origin. In fact, they are widely cited as the most common tumor of childhood. They have a rapid proliferation phase (growth) followed by a regression phase. This growth phase and regression phase is one way to distinguish them from vascular malformations. Vascular malformations, in contrast, are often fully formed at birth and generally only grow in proportion to the patient without spontaneous regression.
The vast majority of infantile hemangiomas are of no consequence but there are some scenarios that may require increased attention. Special consideration should be given to hemangiomas that due to their size and location could cause functional disturbance (hearing, breathing), cosmetic complications, symptoms (ulceration bleeding). Even more rarely, they could be an indicator of an underlying systemic developmental abnormality (PHACE syndrome, lumbosacral defects) or of visceral involvement of the hemangiomas (diffuse neonatal hemangiomatosis).
Two important factors that help to classify hemangiomas include distribution (localized, segmental, diffuse), morphology (superficial, deep, subcutaneous). The vast majority of hemangiomas will be localized and superficial in nature. That common benign scenario will be the focus of the article but we will touch on some factors that would prompt more investigation below.
Infantile Hemangioma Features
Diagnosis: Infantile hemangiomas are rarely obvious at birth but typically noticed within the first few days or months of life. They may begin as a subtle pink patch before they develop into the more classic appearance of a deep red plaque. Superficial hemangiomas will have a bright red and perhaps slightly elevated appearance. Deep hemangiomas may be more skin colored with a blue hue like lump in the skin. Compound hemangiomas can have features of both. Hemangiomas can typically be diagnosed based on appearance and behavior without the need for any diagnostic tests.
Proliferation Phase: They grow the most in the within the first 5 months, then they may only slowly grow at 6-12 months.
Involution Phase: Then they start to regress (involute) at resolving at about 10% per year.
Residual (aftermath): As they regress and are resolved by the body they may leave some remnants behind. The hemangioma if large can be replaced with a fibrous/fatty tissue which can be a cosmetic issue if it is really large or in a cosmetically sensitive area.
Infantile Hemangioma Treatment
Risks and benefits of intervention should be made on an individual basis, please consult with your dermatologist. Some treatment options may be discussed as very briefly summarized below.
High risk lesions: For concerning hemangiomas (large, deep, vital functional location, cosmetic concern, symptomatic bleeding) we sometimes give oral propranolol (a beta-blocker). This has been shown to dramatically suspend or reduce the proliferation phase. A really great treatment for worrisome hemangiomas but NOT indicated the majority of situations where no high risk features are noted. Oral propranolol does require caution in infants due to small risk of low blood sugars (hypoglycemia) or blood pressures so would be administered under the guidance of a pediatric dermatologist.
Low risk lesions: In those patients where systemic (oral propranolol) is not indicated, but where the parents still desire to for some intervention there is another option. We can consider the use of a TOPICAL beta blocker (topical timolol drops) to treat these lower risk hemangiomas. This is an option if they don't appear bad enough or in a worrisome spot to warrant the oral propranolol but they appear to be growing quickly or we want to prevent worsening for cosmetic concerns.
Others may prefer to observe these areas with serial photographs to get a sense for what kind of growth trajectory they are on. If they don't appear to be growing quickly and they are not in a cosmetically sensitive location than non-intervention may be the best course with expectations they would resolve themselves during the regression phase.
High risk features
High risk locations: Large hemangiomas near sensitive cosmetic or functional locations would require quick evaluation and intervention. This includes many hemangiomas of the face including near the eye, beard, ear…etc.
Multiple hemangiomas: Infants with > 5 hemangiomas visible on the body may prompt further investigation including ultrasound imaging to exclude visceral (internal) involvement of hemangiomas.
Segmental hemangiomas: Segmental hemangiomas refer to the distribution where multiple hemangiomas occur in a large cluster over a specific strip of skin. This type of distribution may also suggest a risk of underlying abnormalities that correlate with the location of the segmental hemangiomas. For instance:
Beard segmental hemangioma (increased risk of internal hemangioma causing airway obstruction)
PHACE syndrome (underlying developmental abnormalities associated with large segmental hemangiomas of face and scalp)
Lumbosacral hemangomas (may suggest increase risk of underlying spinal abnormalities)
Symptomatic hemangiomas: ulceration, bleeding
Superficial hemangioma, arm
superficial hemangioma, scalp
Banner image at top of page compliments of Wendy Mathews