Hemangioma

Hemangiomas are benign (not cancer) growths of extra blood vessels in the skin and are one of the most common skin conditions seen in children in the first year of life. About 5% of all children will develop a hemangioma. What causes hemangiomas is not known, but they are more common in girls, Caucasians, premature and low birth-weight infants, and multiple births (twins, triplets).

Symptoms/History

Most often hemangiomas appear during the first one to four weeks after birth. Hemangiomas usually grow most in the first 3-4 months of life. Later, generally around 6 to 18 months of age, they begin to very slowly improve, a process called involution. Most hemangiomas have started to involute significantly between 1 and 3 years of age, and many are much better or hard to notice by the time a child starts kindergarten.

Especially during infancy, hemangiomas may feel warm to the touch. They will also commonly change in appearance, temporarily, with a child’s body temperature, so may be more noticeable and look bigger in a warm bath or with crying. While parents often worry about the possibility that a hemangioma will bleed, significant bleeding is very rare. Hemangiomas occur in the skin and rarely affect any part of the body underneath. They are not painful unless they ulcerate. Ulceration is a complication when a small scab or sore appears on the hemangioma. This is most likely to happen early in the first year, during the rapid growth period, and especially when a hemangioma is in a location of pressure or trauma (like the back, back of the scalp, diaper area, or lip).

Special Locations (Large Face, Mid-Lower Back) and Multiple Hemangiomas

Facial hemangiomas are considered large when they are more than 5 centimeters (about 2 inches) in size. When hemangiomas are both large and develop in certain patterns on the face, there is a chance of other associated problems such as those seen in PHACE syndrome. Large hemangiomas of the lower half of the face (in a “beard” location) may also be associated with a hemangioma in a child’s airway that can sometimes affect breathing.

Infantile hemangiomas of the mid lower back may uncommonly be associated with a spinal cord problem underneath. At-risk hemangiomas are usually large and cross over the middle of the skin of the lower back just above the buttocks (lumbosacral area). The most common associated problem is a tethered spinal cord, which means the spinal cord is abnormally stretched and anchored to the spinal canal and thus can’t move normally. Over time this can lead to spinal cord damage, although symptoms may not appear until later in childhood or adulthood. Common symptoms are lower back pain, pain and weakness of the legs, walking problems, and loss of control of the bladder and bowel.

It is common for infants to have up to several hemangiomas, but some can have numerous hemangiomas (“hemangiomatosis”). Hemangiomas in this situation tend to be small in size and are more likely to occur in multiple (twin or triplet) births. Most commonly hemangiomas in hemangiomatosis only affect the skin, but they can develop in internal organs as well. The greater the number of skin hemangiomas, the greater the risk of internal hemangiomas. The most common internal organ affected is the liver, but even when present, internal hemangiomas rarely affect a child’s health, but may require close monitoring.

Diagnosis

Clinical exam. Hemangiomas differ in appearance depending upon how deep they develop in the skin. Hemangiomas on the surface of the skin (superficial hemangiomas) are commonly bright red and raised. Often they will first appear as a flat, red area. Deeper hemangiomas tend to be skin-colored or slightly bluish with a smooth surface. Often, hemangiomas will have both superficial and deep parts (combined or mixed hemangioma).

Imaging. Imaging is not usually necessary except under special circumstances (see PHACE syndrome). If your child has a hemangioma of the middle lower back, see your doctor to decide whether imaging of the spine (special pictures, most commonly MRI) may be appropriate. If your child has multiple (more than 5) hemangiomas, it is recommended your child be seen by a doctor to determine whether an ultrasound of the liver or other evaluation is appropriate.

Pathology. Hemangiomas are most often diagnosed by physical examination and so rarely require a skin biopsy (when a small piece of skin is taken for examination under the microscope).

Genetics (if applicable) There is no known gene that causes hemangiomas and thus genetic testing is unnecessary.

Treatment

Since all hemangiomas involute, not every child needs treatment. Similarly, since internal hemangiomas involute just as they do on the skin, and don’t usually affect a child’s health, they rarely require treatment.

The most common reasons for treatment include concerns about appearance, especially when a hemangioma is located on the face, or ulceration. Less commonly, the location of a hemangioma may cause problems with vision, hearing, eating or breathing.

A number of treatment options may be offered. These include:

  • oral (by mouth) medications (usually propranolol, less commonly steroids)
  • topical (applied directly to the hemangioma) medications (such as timolol or antibiotic ointment for ulceration)
  • cortisone (steroid) injected directly into the hemangioma
  • laser therapy and
  • surgery.

In general, medical (oral, topical, injection) therapies are used during infancy to control hemangioma growth. Surgical and laser options are generally considered later, following some or complete involution, to improve appearance when needed.

The choice of which treatment is best is individual and depends on:

  • your child’s age
  • hemangioma location, size, and appearance
  • how quickly the hemangioma is growing or involuting, and
  • the type and severity of any associated complications.