A baby girl is brought to the office because her mother is concerned over the growing strawberry hemangioma on her face. Her mother is reassured that most of these childhood hemangiomas regress over time and that there is no need for immediate treatment (Figure 109-1).
Strawberry hemangioma on the face causing no functional problems. Treatment is reassurance and watchful waiting. (Courtesy of Richard P. Usatine, MD.)
Hemangiomas are the most common benign tumors of infancy. They can be problematic if they block vision or interfere with any vital function. Most hemangiomas are small and of cosmetic concern only.
Infantile hemangiomas, angiomas. Strawberry hemangiomas are also called superficial hemangiomas of infancy. Cavernous hemangiomas are also called deep hemangiomas of infancy.
Early lesions may be subtle, resembling a scratch or bruise, or alternatively may look like a small patch of telangiectasias or an area of hypopigmentation. Hemangiomas can start off as a flat red mark, but as proliferation ensues, it grows to become a spongy mass protruding from the skin. The earliest sign of a hemangioma is blanching of the involved skin with a few fine telangiectasias followed by a red macule. Rarely, a shallow ulceration may be the first sign of an incipient hemangioma.1 Hemangiomas are typically diagnosed based on appearance, rarely warranting further diagnostic tests.
Hemangiomas may be superficial, deep, or a combination of both. Superficial hemangiomas are well defined, bright red, and appear as nodules or plaques located above clinically normal skin (Figures 109-1, 109-2, 109-3). Deep hemangiomas are raised flesh-colored nodules, which often have a bluish hue and feel firm and rubbery (Figure 109-4).
Strawberry hemangioma present since birth on the face of a 22-month-old girl. Although it is close to her eye, her vision has never been occluded. She has been followed by ophthalmology and no active treatment was recommended. The hemangioma grew larger during the first year of life and is now beginning to involute without treatment. (Courtesy of Richard P. Usatine, MD.)
Deep (cavernous) hemangioma on the arm in a 9-month-old child. Treatment is watchful waiting. (Courtesy of Richard P. Usatine, MD.)
Most are clinically insignificant unless they impinge on vital structures, ulcerate, bleed, incite a consumptive coagulopathy, or cause high output cardiac failure or structural abnormalities. Blocking vision is a common reason needed for treatment (Figure 109-2).
Anywhere on the body, most often on the face, scalp, back, or chest.
Most hemangiomas of infancy do not need imaging. If the hemangioma is very large, deep or undefined, MRI with and without IV gadolinium helps delineate the location and extent of the hemangioma while also differentiating them from high flow vascular lesions, like arteriovenous malformations.1 Ultrasound is a useful tool to differentiate hemangiomas from other subcutaneous structures such as cysts and lymph nodes as well as from other soft-tissue masses.1
Plain radiography may be useful for evaluating hemangiomas that impinge on an airway.1
Biopsies are rarely needed and can be risky because vascular lesions may bleed profusely. If a biopsy is being considered, it might be best to refer to a specialist.
Watchful waiting and serial observations during well-child examinations are recommended for uncomplicated hemangiomas of infancy. Hemangiomas with complicating factors need close follow-up on an individual basis.
Hemangiomas are benign and not cancer. They are common and up to 1 in 10 white babies will have one. Most hemangiomas will go away spontaneously and not need treatment. For those needing treatments, there are new treatments that are safe and effective (oral propranolol and topical timolol).