Infantile hemangioma

Overview

Infantile hemangiomas are a common type of birthmark, occurring in about 4 percent of infants. They are made up of collections of immature blood vessels that often grow rapidly, sometimes dramatically, during infancy. Hemangiomas vary in size, location and how large they grow. They may look like a bright red bump or area on the skin – called a "strawberry" birthmark – or like a blue or skin-colored mass if they grow deeper into the skin.

Hemangiomas usually appear in the first few weeks of life, then typically go through a period of rapid growth followed by a more gradual shrinking phase.

Hemangiomas are benign (not cancerous). In most cases, they don't cause health problems and can be left to shrink on their own. However, a significant minority of patients do need treatment. If needed, treatment should begin as quickly as possible. The UCSF Birthmarks and Vascular Anomalies Center and its physicians are internationally known for their expertise in managing infantile hemangiomas and related conditions.

The exact cause of hemangiomas is not known. They are more common among girls, babies with fair skin and premature babies. Some families may have a tendency toward the condition.

Infantile hemangioma phases

Most hemangiomas are either absent at birth or barely visible as a bruise-like area, an area of pale skin, or a flat pink or red spot. Most begin to appear in the first two to four weeks of life. They follow a predictable series of phases:

• Proliferative phase. The hemangioma begins growing rapidly at a few weeks of age, often with a period of accelerated growth between four and eight weeks of life, but sometimes continuing for several months.
• Involution phase. The growth stops and the hemangioma starts to involute (shrink). This process can take many years. Most hemangiomas have completed involution by 5 years of age.

In some cases, the involution leaves normal-looking skin or skin with only minor visible differences. In others, the skin may appear stretched or discolored. If this happens, the excess skin can be removed surgically or laser treatments can be used to improve the discoloration.

We recommend a reevaluation between 4 to 5 years of age if your child still has visible skin differences, to decide if any interventions are needed.

Signs & symptoms

Hemangiomas can be superficial, growing only in the top few layers of the skin, or deep, involving more layers of the skin. Superficial hemangiomas are initially bright red and usually elevated above the surface of the skin. Deep hemangiomas are blue or skin-colored and often feel warm to the touch. Some hemangiomas have both deep and superficial components.

Most patients have just one hemangioma, but some have multiple hemangiomas. About 60 percent of hemangiomas are located on the head and neck. Approximately 25 percent occur on the trunk and 15 percent are on the arms or legs. Hemangiomas may temporarily increase in size after crying or during colds.

Complications of infantile hemangioma

Hemangiomas are rarely painful unless the overlying skin breaks down, a complication known as ulceration. Ulceration occurs in about 10 percent of infants with hemangiomas, particularly in moist locations like the diaper area, armpit or lips.

Although hemangiomas are a growth of vascular tissue, severe bleeding is quite rare. Hemangiomas are a collection of small blood vessels, not balloons of blood that can burst. Bleeding, if it does occur, can usually be stopped with firm pressure.

Diagnosis

Most hemangiomas can be correctly diagnosed with a physical exam combined with the child's medical history and the history of the birthmark, without the need for medical tests or biopsy. Deep hemangiomas may be more difficult to diagnose, as they can appear similar to other types of vascular lesions and soft tissue tumors.

If the diagnosis is unclear, your child may undergo an ultrasound or MRI. Rarely, a skin biopsy is needed for diagnosis.

Treatment

When to consider treatment for infantile hemangioma

Most infantile hemangiomas do not need treatment, other than monitoring by the child's doctor during routine check-ups. For small hemangiomas in areas covered by clothing, for instance, no treatment is a good option. However, for hemangiomas in certain locations – particularly the face – treatment to prevent further growth or accelerate involution should be considered.

Your child should be evaluated by a vascular anomalies specialist if he or she has a hemangioma in any of the following locations:

• The face, especially the central face (the eyes, nose or lips) or hemangiomas involving a large portion of the face
• Tip of the ear
• Around or behind the eye
• "Beard area" and center of the neck
• Over the lower spine
• In the diaper area, in the armpit or in neck creases

Your child should also be evaluated by a specialist if he or she has:

• Multiple hemangiomas (there may be a hemangioma in an internal organ as well, which would require treatment)
• A hemangioma that is growing very rapidly
• An uncertain diagnosis

Any hemangioma that affects vision, breathing, hearing or eating needs prompt treatment. Even a small hemangioma on the eyelid, for instance, can permanently affect a child's vision.

Treatment options for infantile hemangioma

Hemangiomas are quite variable in terms of their size, location, whether they involve the surface or deeper parts of the skin (or other areas of the body), and in how fast and aggressively they grow. Because of this, treatment is highly individualized.

Management for hemangiomas may include:

Close observation without active treatment

Small hemangiomas that are likely to resolve without scarring, particularly if they are in areas covered by clothing, often don't need to be treated. However, periodic visits are recommended in early infancy, to be sure there are no problems developing.

Beta-blocker medications

Since 2008, beta-blocker medications have become the most commonly used treatment for hemangiomas. Oral propranolol is an FDA-approved medication for treating hemangiomas in infants who are 5 weeks of age or older. The medication is usually given twice a day for at least six months. A topical form of beta-blocker, timolol, is often given as a liquid drop. It is applied directly to the skin for more superficial, less-worrisome hemangiomas that need treatment.

Both of these medications can be extremely effective in stopping hemangioma growth, reducing hemangioma thickness and bulk, and preventing complications.

Laser therapy

Lasers can be used to treat hemangiomas in a child's airway, to heal ulcerated hemangiomas, to decrease any small blood vessels that remain on the surface of hemangiomas after involution, and to decrease texture changes left on the skin. UCSF's Birthmarks and Vascular Anomalies Center has expertise in laser therapy, including many of the lasers that are used for these indications. Lasers may cause scarring in some cases.

Surgical removal

Surgical removal is an option for some patients with hemangiomas that have already caused permanent tissue damage, are threatening a vital structure, or are causing recurrent bleeding. It always requires general anesthesia. The scarring that results from surgery must always be weighed against the benefits of removing the hemangioma and compared to other treatment options.

Corticosteroids

Before beta blockers were used, various forms of cortisone were a main treatment for hemangiomas. They can be taken by mouth, or injected into or placed on the surface of the hemangioma. They are used less frequently now, but may be given in some cases if propranolol is not tolerated. They may also be injected in small amounts in specific locations such as the lip or nose. They are most effective when given in the first six months of life.