Infantile hemangiomas

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.

What do hemangiomas look like?
Hemangiomas can occur anywhere on the skin but 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 Children's 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.

An example of a combined superficial and deep hemangioma on the forehead of a 6-month-old infant.

PHASE	APPROXIMATE AGE	WHAT'S HAPPENING?	EXAMPLES
GROWTH	Newborn to 14 months (average 8 months)	Hemangioma is growing rapidly (puffs out) and the color is bright red.
RESTING	8-14 months old	No change in size and the skin is less shiny.
SHRINKING (INVOLUTION)	1-5 years	Lesion shrinks and color changes to purple and gray and may fade completely.

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:

• 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 block 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 overl 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 also will 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 or 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 - Even though most hemangiomas will not require an oral medication or surgery, we believe all hemangiomas should be watched closely, especially during infancy. Hemangiomas grow fastest during the first months of life. Hemangiomas should be watched during this period for rapid growth and complications.
   
• Oral systemic corticosteroids have become a mainstay in the treatment of hemangiomas, yet their mechanism of action is not well understood. The oral steroids are used to control or stop the growth of the hemangioma. They are only used during the growth period, and in most cases do not ususally shrink the hemagioma but slow its growth. Despite a list of potential side effects, including irritability, gastrointestinal upset, immunosuppression, hypertension, and growth retardation, most treated infants do well. By closely watching the patient, parents and physicians can usually minimize the chances of any ill effects from this treatment.  The duration of treatment ranges from a few weeks to many months, depending on the child's age, the indications for treatment and the growth characteristics of the hemangioma.
  
  Corticosteroids can also be injected directly into the hemangioma and are effective for small, localized hemangiomas on the skin. Topical steroids also have been found to be effective in controlling the growth of small superficial hemangiomas, particulary on the eyelid and around the mouth.    
   
• Surgical excision is used most frequently to reconstruct scars or to remove fibrofatty tissue, but early excision is a reasonable option in selected cases where a residual abnormality is virtually inevitable or where the hemagioma threatens life or bodily function and drug therapy is not effective or well tolerated. In cases without medical complications, where uncertainty exists about outcome, the pros and cons of surgery must be weighed carefully since the scar left from an surgery may be worse then the results from allowing the hemangioma to shrink by itself. Reevaluation is recommended at about age 4 to assess how much hemangioma is still present and to consider surgery for hemangiomas that are causing scarring or shrinking very slowly.
   

• Laser treatments are available through the Laser Clinic at Children's Hospital of Wisconsin.

  Laser therapy also has been used to treat hemangiomas. Because of its limited depth of penetration, the flash-lamp pulsed dye laser works well for superficial hemangiomas but has no impact on deeper or thicker hemangiomas. It is most often used to improve the telangiectasia (broken blood vessels) after regression, and is effective in treating ulcerated hemagiomas resulting in decreased pain and more prompt healing. Continuous-wave lasers such as the Argon, Neodymium:yttrium-aluminium-garnet and potassium titanyl phosphate have also been used but are more operator dependent and have a greater risk of scarring.

Injection of a recombinant interferon-alpha has been used successfully in treating life-theatening hemagiomas that have failed to respond to oral corticosteroid therapy. Interferon-alpha has been shown to decrease new blood vessel growth (angiogenesis) and therefore, was theorized to be effective for hemangiomas. Common side effects include irritability, neutropenia, and liver enzyme abnormalities. A particularly worrisome neurologic side effect, spastic diplegia, has recently been reported in as many as 20 percent of patients. Therefore, interferon-alpha should be reserved for only the most serious, life-threatening hemangiomas that have failed high-dose corticosteroid therapy; and when administered, neurologic status should be monitored closely. Rarely, embolization has been used in the treatment of hemangiomas on the skin that have failed medical therapy.

• Vincristine is a medication that is used to treat a variety of tumors. Recently, it has been used successfully to treat hemangiomas that threaten to affect a vital function. Vincristine may be used if there is concern that the hemangioma may cause loss of sight or compromise the infant's airway. This medication is given as a weekly injection into a central venous line.
  
  
• Propranolol is a medication that has been used for many years to treat high blood pressure. Recently, it was recognized that Propranolol may work for the treatment of hemangiomas. It must be used with caution because it can cause a drop in blood sugar if the infant does not eat regularly. It also may cause a drop in blood pressure or heart rate. Close observation is necessary. This medication is given by mouth two to three times a day.
   
• 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.

The FDA has not approved the use of any medication for the treatment of infantile hemangiomas. There are research studies being done at Children's to find the safest and best treatments for hemangiomas.

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. For more information, contact Shawna Joachim, clinical research coordinator, at (414) 955-2817.

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.  

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.