Infantile hemangiomas
Learn more about the Birthmarks and Vascular Anomalies Center and current infantile hemangioma research at Children's Hospital of Wisconsin.
What is an infantile hemangioma?
An infantile hemangioma (hem-an-gee-o-ma), or "strawberry mark," is a very common type of birthmark made of blood vessels. Most hemangiomas are not visible at birth. They may at first only appear as a small bruise, scratch, or a tiny red bump. Unlike other types of birthmarks, hemangiomas grow and change greatly during the first months of life. They may occur anywhere on the skin surface but are most common on the scalp, face, and neck. All skin hemangiomas are seen by 6 months of age.
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| An example of a combined superficial and deep hemangioma on the forehead of a 6-month-old infant. | What do Hemangiomas look like?
Hemangiomas can occur anywhere on the skin and rarely in the organs of the body. Hemangiomas are most often found on the skin of the head or neck. They may be located in the outer layers of the skin (superficial hemangioma) or under the skin in the fat (deep hemangioma). Hemangiomas that are on the surface of the skin are typically bright red to purple in color, while deep hemangiomas may be blue, purple, or even normal skin color if they are located deep under the skin surface. Most hemangiomas are round or oval in shape, but larger lesions may follow the shape of the affected body part. The size of hemangiomas varies. Some are very small (1 mm), while others are very large (20 cm or larger). Every hemangioma differs in how fast it grows and how long it grows before it stops.
What causes an infantile hemangioma?
The cause of an infantile hemangioma is not known. They are more common in girls than boys and are more often seen in Caucasian children. We have learned that hemangiomas are seen more frequently in babies born very small or those born several weeks before their due date. Thus far, we have not identified what may put these infants at risk. Research continues at our institution to find the causes of hemangiomas so we can begin to prevent these lesions and control their growth.
Will my baby's hemangioma grow?
Infantile hemangiomas grow rapidly for the first few weeks or months. They enter a rest phase by about 8 months of age. They usually begin to shrink (involution phase) around one year of age. As the lesion shrinks, the color may change from red to purple and gray. It may take several years for the hemangioma to go away completely. Larger lesions take a longer time to go away and have a greater chance of scarring.
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PHASE |
APPROXIMATE AGE |
WHAT'S HAPPENING? |
EXAMPLES |
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GROWTH |
Newborn to 14 months (average 8 months) |
Hemangioma is growing rapidly (puffs out) and the color is bright red |
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RESTING |
8-14 months old |
No change in size and the skin is less shiny |
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SHRINKING (INVOLUTION) |
One to five Years |
Lesion shrinks and color changes to purple and gray and may fade completely |
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What problems or complications can infantile hemangiomas cause?
Most hemangiomas will go through growth and involution without problems. About 25 percent of hemangiomas will have a complication. Your doctor will help you determine if your child's hemangioma may be likely to have a complication based on the size, location, and how fast it is growing. Listed below are the complications that can arise:
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Locations where a hemangioma has an increased risk of complication:
As a hemangioma grows, it can interfere with function. This is most often observed around the eye. If a hemangioma around the eye grows rapidly, it may obstruct the infant's vision. This may cause irreversible loss of sight. It is important to closely monitor hemangiomas on the eyelids. Other areas that may need urgent treatment are the diaper area and around the mouth.
- Ulceration
The skin over the hemangioma can break down. The skin may appear raw or shiny and might even develop a scab or crust. Ulcerations can be very painful for the child, which can lead to irritability, poor feeding and difficulty sleeping. Ulceration increases the risk of infection and scarring. Hemangiomas that are located around the mouth, nose, ear and the skin under the diaper carry a higher risk of ulceration. Ulcerations heal slowly and treatment might be recommended to speed this process and to prevent infection and scarring.
- Bleeding
The skin overlying the hemangioma protects it from bleeding easily. If a hemangioma is cut or injured, it can bleed or develop a crust or scab. The blood vessels that make up hemangiomas are not normal. When hemangiomas bleed, they tend to bleed rapidly but only for a short period of time. The bleeding should stop with gentle, direct pressure for fifteen minutes. If bleeding returns or does not stop with pressure, you should contact your child's doctor.
Does the hemangioma hurt?
Most hemangiomas do not cause discomfort for your baby unless ulceration occurs. Ulcerations can be painful, even before it is seen. If you think your baby is experiencing pain, you should discuss that with your doctor.
Will the hemangioma leave a scar?
The final appearance of the skin depends on the size and location of the hemangioma. It also varies from patient to patient and from one hemangioma to another. It will also depend on if the hemangioma became ulcerated or infected. Some areas are more prone to scarring than others. Areas that are prone to scarring include areas where the skin doesn't stretch as easily, such as the nose, lip, forehead and ear. Sometimes, extra skin is left in these areas once the hemangioma has shrunk. Once the hemangioma has completed the shrinking phase (involution), extra skin can be removed by a plastic surgeon, if necessary. If there is any remaining discoloration, laser therapy can be helpful.
How is the diagnosis made?
A diagnosis is usually made by the appearance of the lesion. Occasionally, a Doppler (sound device) can be used to check the blood flow through the birthmark to help distinguish it from other vascular lesions. This is frequently used in our clinic and can also help the doctor know which phase the hemangioma is in. A skin biopsy or an imaging study can help make the diagnosis if the lesion is not typical in its appearance or in its behavior.
Can my baby have hemangiomas anywhere else besides on the skin?
About 80 percent of patients have one skin hemangioma, but it is not uncommon for some infants to have more then one skin hemangioma. It is very uncommon to have internal hemangiomas, but they may occur on internal organs. The risk of internal hemangiomas increases if your child has more than six skin hemangiomas. During your child's physical exam, your doctor might feel your child's liver and spleen to determine if the size is normal. Your doctor may order imaging studies if he or she thinks that your child has any risk of internal hemangiomas.
How is a hemangioma treated?
In general, infantile hemangiomas will shrink over time, and most disappear completely on their own. There are some situations when hemangiomas need treatment. Whether to treat a hemangioma or not is determined by the age of the patient, size of the hemangioma, location, and how rapidly the hemangioma is growing. Hemangiomas that are located in areas that can threaten health (airway, liver) or normal development (ear canal or on the eye), and those hemangiomas that are potentially disfiguring (face) are treated more quickly and aggressively than hemangiomas that pose less of a risk. Your doctor will discuss with you whether treatment is needed and what treatment is best for your child.
Treatment options include:
- Observation - Watch the hemangioma; no other treatment is necessary. Your doctor may schedule regular follow-up visits and take photographs to monitor the hemangioma. Very young infants will need closer observation and the frequency of follow-up visits generally decreases as your child gets older. Close observation allows your doctor to start treatment right away if this becomes necessary.
- Topical steroid ointment - This is applied to the hemangioma one to two times daily and can help slow or stop the growth of the lesion. This can be effective for small, superficial hemangiomas.
- Steroid injections in the lesion- Steroids can be injected directly into the hemangioma to help slow its growth. This works best for smaller hemangiomas. Some locations, such as skin near the eye, cannot be injected because of the potential for serious complications.
- Oral steroids - Based on the location, rate of growth, and size of the hemangioma, your doctor may recommend oral steroids to slow the growth of the hemangioma. There is a potential risk of side effects such as irritability, gastrointestinal upset, immunosuppression, hypertension, and growth retardation with oral steroids. If your doctor thinks oral steroids are best for your child, he or she will monitor your child closely for these side effects and change the dose as needed. Most children do well on this medication and their growth improves once the medication is no longer needed.
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| Laser treatments are available through the Laser Clinic at Children's Hospital of Wisconsin. | Laser treatment - Laser treatment is helpful to stop bleeding hemangiomas or help the healing of ulcerated hemangiomas. The laser can only penetrate the outer portion of the hemangioma and therefore cannot treat the deep component of the hemangioma. It is not recommended during the rapid growth phase. Laser during that time can cause skin breakdown and potential scarring. Laser can be helpful in removing residual discoloration once the hemangioma has completed involution.
- Surgical excision - In general, nature does a good job at resolving most hemangiomas. Surgery is reserved for a smaller hemangioma that is in an area where the hemangioma can cause a problem if not removed, or for a small hemangioma that is prone to skin breakdown. Surgery can also be used to repair residual cosmetic deformities such as excess or sagging skin.
- Regranex (becaplermin) gel - This medication, applied to the hemangioma once daily, can be useful to heal ulcerations. It does not appear to slow the growth of hemangiomas. It is a fairly new medication that the U.S. Food and Drug Administration approved to treat diabetic ulcers in adults. It is very expensive and usually requires a special letter to your insurance to get assistance with the cost.
- Other topical therapies – Antibiotic ointment or thick barrier creams such as triple paste may be used to protect the hemangioma.
Learn more about hemangioma treatments.
What about my next baby?
Traditionally, hemangiomas have not been considered to be inherited; however, a recent study completed by our group has demonstrated a tendency for hemangiomas to run in families. Further studies need to be completed before the true risk of having a second infant with a hemangioma is known. Hemangiomas are very common, and in our experience, hemangiomas do not tend to occur in the same location within families.Is there research being conducted on hemangiomas?
There are several clinical and basic science studies being conducted on hemangiomas at the Medical College of Wisconsin and Children's Hospital of Wisconsin. You can contact our study coordinator at svue@mcw.edu to get details.
More facts about hemangiomas.
The cells that make up a hemangioma are most like the cells that line blood vessels. Under the microscope, a hemangioma looks like a cluster of tangled blood vessels.
A hemangioma's cells multiply, which cause the hemangioma to grow or thicken. The lesion usually swells, rather than spreading on the skin surface. A hemangioma is a form of a tumor that will stop growing and go away with time, unlike cancer tumors.
In the past, many different types of red skin lesions were incorrectly called hemangiomas. This has produced a considerable amount of confusion in the medical field regarding their prognosis and treatment. Even today, many textbooks and scientific papers will use the term to describe other blood vessel tumors in older children and adults. The term hemangioma of infancy or infantile hemangioma is often used to help clarify these lesions.
Remember...
Hemangiomas do not result from anything you did or did not do during the pregnancy. Hemangiomas are noncancerous and eventually shrink, but they can be treated if necessary.
Learn more
Learn more about the Birthmarks and Vascular Anomalies Center and current hemangioma research at Children's Hospital of Wisconsin.
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