Birthmarks and Vascular Anomalies Center
Infantile hemangiomas are among the most common birthmarks in children and the most common benign tumor in children. Hemangiomas are collections of blood vessels that have increased cell division and growth. Approximately 2.5% of newborns have hemangiomas. They are more common in girls, fair-skinned people, premature babies, and infants whose mothers have had chronic villus sampling.
Many hemangiomas are signaled by a precursor lesion at birth. The progression of infantile hemangiomas involves several predictable steps. The patient below illustrates several of the features of hemangioma growth.
- Proliferative phase: Rapid growth starts in the first several weeks of life and continues for weeks to months.
- Involution phase: As growth is ending the hemangioma starts to involute. This process moves slowly and can last from one to nine years. Fifty percent of hemangiomas have involuted completely by five years, 70% by seven years, and 90% by nine years.
- Involuted phase: The hemangioma is in its final state and will never recur. Involution may leave normal-appearing skin or discolored or stretched looking skin as in this patient. If this occurs surgery can help to remove excessive skin.
Infantile Hemangioma in early proliferative phase
Infantile Hemangioma in proliferative phase
Involuting Infantile Hemangioma
The appearance of a hemangioma depends on whether it is superficial (just in the top few layers of the skin) or deep (involving more layers of the skin). Superficial hemangiomas are bright red and elevated ("strawberry" marks). Deep hemangiomas are blue or skin-colored. They usually feel warm to touch. Some hemangiomas have both superficial and deep components. More than half of hemangiomas are on the head and neck. Most hemangiomas are solitary, but some patients may have multiple hemangiomas.
Superficial and Deep Hemangioma
Hemangiomas: The Role of a Vascular Anomalies Specialist
Most infantile hemangiomas completely involute without any treatment and can be managed by the child's primary care physician.
Many of the associated risks of hemangiomas are related to their location on the body. Approximately 60% of hemangiomas occur in the head and neck area. About 25% occur in the trunk and 15% occur in the arms or legs. The following is a list of the locations and types of hemangiomas that should be evaluted by a vascular anomalies specialist.
- Large segment of the face
- Tip of the nose or ear
- Deep hemangioma on a large part of the face
- Around or behind the eye
- "Beard area" and center of the neck
- Around the mouth or on the lips
- Over the lower spine
- Perianal, under-arm, or neck creases.
- Multiple hemangiomas
Hemangiomas in the locations listed above, growths that have unclear diagnosis, or are growing very rapidly, need to be evaluated by a specialist because of the risks of disfigurement or endangering complications. These hemangiomas may require more aggressive treatment and follow-up.
Infantile Hemangioma over the lumbosacral spine
Someone with multiple hemangiomas requires evaluation by a specialist because of the risks of inolvement of the internal organs (especially the liver) and the risk of congestive heart failure.
Symptoms and Complications
Infantile hemangiomas are rarely painful, unless ulcerated. They may be warm to the touch and temporarily increase in size after crying or with colds.
Ulceration (breakdown of overlying skin) occurs in 15% of cases and can be painful. Excessive bleeding is uncommon in hemangiomas and most often occurs in deeply ulcerated hemangiomas and those on the scalp. Bleeding can usually be controlled by applying pressure to the area. Infection can also occur in ulcerated hemangiomas and can be treated with antibiotics.
Hemangiomas in the more concerning locations listed above can have serious complications. Any hemangioma that affects vision, breathing, hearing, or eating requires prompt treatment. Even a small hemangioma on the upper eyelid can permanently affect a child's vision and requires evaluation by a vascular anomalies specialist and a pediatric ophthamologist (eye doctor).
Because disfiguring facial hemangiomas can cause emotional distress and permanent tissue damage, these hemangiomas often warrant more aggressive treatment.
Most hemangiomas can be correctly diagnosed by correlating physical exam with the history of the lesion and the child's medical history. Correct diagnosis is important because hemangiomas are treated differently from other conditions such as vascular malformations. Deep hemangiomas can be particularly difficult to differentiate from other vascular lesions and soft tissue tumors. Other ways to help diagnose a hemangioma include:
- Ultrasound, CT and MRI: methods used to image the lesion.
- Biopsy: a piece of tissue taken from the lesion and analyzed by a pathologist.
Many hemangiomas are small and harmless. For these hemangiomas the cosmetic results of spontaneous involution (no treatment) may be better than cosmetic results seen with surgery or laser therapy.
Other hemangiomas require treatment because they interfere with vital functions or are potentially permanently disfiguring. Possible treatments include:
- Corticosteroids: Medications that can be taken by mouth, injected into, or placed on the surface of the hemangioma that slow the growth or cause shrinkage of the hemangioma. Corticosteroids are most effective when started in the first six months of life.
- Vin Cristine: An intravenous medication used in severe cases if corticosteroids fail.
- Alfa-Interferon: A more potent medication that is injected daily into dangerous hemangoimas. Side effects are potentially serious.
- Surgical Removal: An option for a select group of patients that have eyelid involvement or hemangiomas that are dangerous and unresponsive to other treatments. Surgery can also be considered for children who have partially involuted hemangiomas that cause serious emotional distress. The scarring that results from surgery must always be weighed against the benefits of removal of the hemangiomas.
- Laser Therapy: Lasers can be used for treating hemangiomas in a child's airway, treating ulcerated hemangiomas, and treating the small blood vessels that often remain on the surface of an involuted hemangioma. Lasers may cause scarring in some cases.