Infantile hemangiomas, hemangiomas of infancy, are noncancerous vascular tumors. They are made up of cells that line the blood vessels (endothelial cells).
They are the most common tumor of childhood. About one in every 20 infants has a hemangioma. They are seen in all racial groups but seem to be more common in Caucasians. Hemangiomas happen more often in girls, premature infants, and multiple births like twins and triplets.
Hemangiomas of infancy may be visible at birth or may not be recognized until the first few weeks or months of life. Most hemangiomas are noted by 2 to 3 weeks of age. They can occur in any area of the body but the head and neck are the most common. Some lesions are small and barely visible. Others are large and very easy to see. Most individuals only have one hemangioma, but some patients may have multiple.
The cause of hemangiomas is not fully known. They are not related to drugs or medications that may have been taken during pregnancy. They are not related to any environmental exposures that may have occurred during that time. In some families, multiple family members over several generations have had hemangiomas. This happens because hemangiomas are common and not because of a genetic reason.
Hemangiomas of infancy almost always have a period of growth (called the proliferative phase). This is followed by a period of shrinkage (called the involutive phase). Most hemangiomas begin their growth phase shortly after birth. This phase lasts for four to nine months (average six months). Each lesion grows at a different rate. The involutive phase is much slower and can take up to 10 years (without any treatment). Most hemangiomas go away completely. Some hemangiomas do not shrink completely and may leave left over fatty tissue, skin discoloration or telangiectasias (tiny dilated blood vessels of the skin).
Infantile hemangiomas are different than congenital hemangiomas. Congenital hemangiomas are fully grown at birth and do not increase in size like infantile hemangiomas.
What do hemangiomas look like?
Infantile hemangiomas are grouped as superficial, deep, or combined. This is done based on the involvement of the skin and other soft tissues.
If the lesion is near the skin surface, it is called a superficial hemangioma. If it grows under the skin, it is considered a deep hemangioma. When it has components of both superficial and deep lesions, we call this a combined or mixed hemangioma. Superficial lesions appear as bright red, raised or flat patches on the skin. They may also have a textured area that looks like a strawberry.
Blood vessels coming from the lesion may be visible on or beneath the skin. Deep hemangiomas appear a mass or “bump” with a blue or purple color. Deep hemangiomas may not be noticed for many weeks or months after birth because they under the skin.
Combined lesions may have a layered combination of red on top and blue below. The color of hemangiomas does not completely go away when you press on the area.
As hemangiomas shrink, they change in texture and color. Over time, they become softer (fatty tissue replaces the hemangioma cells) and less vibrant (blood vessels shrink). Usually, the skin appears normal or nearly normal when the hemangioma goes away completely.
How are hemangiomas diagnosed?
A diagnosis is made by connecting medical history with a physical examination. Ultrasonography (a non-invasive diagnostic tool) can be used to confirm the diagnosis but frequently is not needed.
Rarely, magnetic resonance imaging (MRI) or computed tomography (CT or CAT scan),is needed to make a diagnosis.
If there is any question about the possibility of a malignant (cancerous) growth, a biopsy will be performed. This involves a surgical procedure to take out a small section of tissue from the lesion for examination by a pathologist. Sometimes, the surgeon will remove the entire lesion.
What are the possible complications?
The most common short-term complication is include ulceration (skin breakdown). Ulceration generally causes pain and may lead to skin infection.
Depending on the size and location of the hemangioma, other complications such as distortion of facial features or vision issues may occur.
Certain patterns of hemangiomas are more problematic. They are more likely to cause complications. Children with these hemangiomas should be evaluated by a team of pediatric specialists with special expertise.
These may include:
- Hemangiomas on the face that look like a beard can be connected with airway involvement.
- Some hemangiomas over the face and neck are associated with PHACE syndrome. This syndrome involves problems with the brain, heart, eye and chest wall.
- Hemangiomas located over the lower back and spine can be linked with spinal defects.
- Hemangiomas involving the genital area can be connected to pelvic and urinary system issues.
- When a person has multiple skin hemangiomas, he or she may also have hemangiomas of the liver. A liver ultrasound may be needed to find out how much the liver is involved.
- Large or many liver hemangiomas can cause hypothyroidism (low thyroid hormone) and rarely lead to heart failure.
Should my child receive treatment for a hemangioma?
Most hemangiomas shrink completely and do not require treatment.
Treatment decisions are made on an individual basis.
Treatment choices are determined by patient age, location of the hemangioma, how well the child is functioning and current and potential complications.
Left over fatty tissue or skin telangiectasias may remain after the hemangioma has shrunk or disappeared. Surgery and/or laser therapy may be suggested to improve appearance.
How are hemangiomas managed?
Treatment is dependent upon a variety of things.
Observation, drug therapy, laser therapy, and surgical removal are the four most common treatments.
A combination of treatments may also be used.
- Observation. In most cases, observation is the best course to follow.
- Drug therapy. Medications may be used for complicated hemangiomas in the proliferative phase. This is to slow the growth and decrease the size of the lesion to prevent further complications. Medications include:
- Timolol- This medication is a gel or solution that is applied directly on the hemangioma.
- Propranolol- This medication is taken by mouth.
- Corticosteroids- This medication can be applied on the skin for small lesions, injected into the skin or taken by mouth. This is not the first option for treatment.
- Others- Medications like sirolimus or vincristine may be used for complicated hemangiomas that are not helped by other treatments. These treatments should only be given by medical specialists with expertise in hemangiomas.
- Laser therapy. Laser therapy is used to treat ulcerated hemangiomas and superficial residual skin telangiectasias. This treatment is not effective to stop the growth of the hemangioma.
- Surgery. Surgery may be advised for patients, including:
- Children with painful and ulcerated hemangiomas that do not heal;
- Children whose lesions interfere with breathing or vision;
- Those who have hemangiomas that do not completely shrink; and
- Individuals left with unacceptable scarring or deformity.
- Wound care. Ulcerated hemangiomas may require aggressive wound care, treatment with topical or by mouth antibiotics, laser therapy, and/or surgical removal.
What are the risks and side effects of treatment?
There are certain risks or side effects to each treatment.
- Timolol – Timolol may cause skin irritation.
- Propranolol – Propranolol can cause a decrease in heart rate or blood pressure and / or low blood sugar. These side effects are monitored in the hospital setting (inpatient versus outpatient) as the medication is started.
- Corticosteroids – The most common side effects of this medication are irritability, swelling of the face, stomach irritation, and problems with sleep with short-term use. All of these side effects disappear when the medication is stopped.
- Laser therapy. Early intervention with laser therapy may cause some scarring and changes in skin pigmentation.
- Surgery. Individuals are left with a scar that may or may not be visible depending on location of the hemangioma. Bleeding and infection may occur.