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Infantile Hemangioma

Overview

Some infants develop a type of birthmark, either at birth or soon thereafter, called an infantile hemangioma. This is a growth formed by collections of extra blood vessels in the skin and is considered to be among the most common vascular birthmarks. About 4 to 5% of infants have an infantile hemangioma, and some babies are born with more than one. Their specific cause is unknown, but they tend to be more common in girls, in premature babies, and in twins and triplets.

What does an infantile hemangioma look like?

Hemangiomas usually appear as bright red bumps or patches or bluish lumps anywhere on the surface of the skin, says Yale Medicine pediatric dermatologist Richard J. Antaya, MD. These growths tend to grow quickly and go away very slowly.

Hemangiomas are noted about 30 percent of the time at birth as a little spot that's red. Otherwise they first appear in babies from the ages of 2 weeks to 2 months, growing fairly rapidly for the first month or so, then continuing to grow up until about 5 or 6 months of age. The time period when they are growing is called proliferation.

About 80 percent of hemangiomas stop growing by about 5 months, Dr. Antaya says. After hitting this plateau phase, they stay unchanged for several months, and then begin to slowly disappear over time (called involution). By the time children reach 10 years of age, hemangiomas are usually gone.

What are the risks for babies with hemangiomas of the skin?

Most of the time, hemangiomas are harmless. But in about some cases, the growths will ulcerate or form sores, which can be extremely painful for babies. Ulcerations can appear anywhere, but high-risk sites include the lips, the neck, the diaper area, the lower back, and folds such as the armpit.

Once a baby with an infantile hemangioma gets an ulcer, it’s sure to leave a scar. If it is on a cosmetically sensitive area, such as the face, a scar left behind after the hemangioma shrinks may leave a permanent mark. The high-risk areas for scarring are the lip, nose, ear, cheek, forehead, or eyelid.

Hemangiomas near the eye may compromise an infant’s vision either by closing the eyelid completely or by putting pressure on the eye and blurring vision. According to Dr. Antaya, if a baby has a hemangioma on or near the eye, parents should seek an evaluation by a pediatric ophthalmologist, who will perform a special examination to make sure that the baby’s visual acuity is not compromised.

And while it’s a good idea to bring any hemangioma to your doctor’s attention, large hemangiomas on the face, head and/or neck are especially concerning. Although rare, infants with large infantile hemangiomas in these locations can have multiple other birth defects. This condition is called PHACE syndrome. PHACE is an acronym that stands for:

  • Posterior fossa (refers to possible abnormal structures in the brain, especially the cerebellum)
  • Hemangioma
  • Arterial (refers to possible abnormal arteries in the brain, neck, eye or heart)
  • Cardiac (refers to possible heart abnormalities)
  • Eyes (refers to possible eye abnormalities)

In addition, if a baby has a large hemangioma on the lower back, it could be a sign of associated spinal cord abnormalities.

Even if the hemangioma looks like it’s not causing the baby any problems, babies who have involvement of any of these particular locations should be evaluated promptly by a doctor.

What causes infantile hemangioma?

Unfortunately, many parents blame themselves for their infant’s hemangioma, but the truth is there are no known links between the condition and maternal diet, genetics, environmental factors, or parental behavior. The cause of these birthmarks is unknown.

How is infantile hemangioma diagnosed?

Usually a doctor needs only to see the skin marks to diagnose infantile hemangioma. The condition has a fairly straightforward appearance and pattern of growth and coloration with hemangiomas near the surface of the skin evolving from red little patches to bright red papules or bumps. Hemangiomas lacking the bright red color and/or with a purplish or bluish hue probably originate deeper below the skin.

While most diagnoses can be made in the doctor’s office, some hemangiomas in deeper tissues require further evaluation through ultrasound with Doppler or magnetic resonance imaging (MRI). The Pediatric Vascular Anomalies Clinic (PVAC) in Yale Medicine’s Pediatric Dermatology section utilizes handheld Doppler technology to detect increased blood flow in hemangioma, helping in early detection, diagnosis, and treatment in some cases.

It's Yale Medicine’s practice that if an infant comes in with multiple hemangiomas on the skin’s surface and is younger than 6 months of age, the doctors will perform an ultrasound of the liver to make sure that the baby doesn’t have liver (or other internal) hemangiomas. (While internal hemangiomas are rare, they most commonly appear on the liver.)

How is infantile hemangioma treated?

Over the years, treatment for infantile hemangioma has generally followed a “watch and wait” approach. For most hemangiomas, that's still okay, since the natural history is that they will involute, or disappear, on their own with time. But for more medically or cosmetically concerning cases—such as mid-facial hemangiomas, ones that appear on free edges or are ulcerated, ones that are near the eye or very large ones—doctors now treat them with a class of drugs called beta blockers, in order to prevent disfigurement, scarring, or a medical complication such as impaired vision.

The most widely used beta blocker is the oral medicine propranolol, which can be started when the baby is just a few weeks old and is usually taken for one year. Another potent beta blocker, timolol, which only comes as an eye drop, can be used “off-label” and be applied topically to the skin surface of certain types of hemangiomas to help them shrink. Ideally, this topical medication can shrink them enough so that the infant doesn’t require oral beta blockers.

Another treatment option is pulsed dye laser treatment. It works well for superficial hemangiomas and is used to heal ulcerating hemangiomas and for the residual red vessels that are left behind after the hemangioma resolves. Once hemangiomas disappear, they can leave a scar or some saggy skin. The pulsed dye laser works well to remove any residual red discoloration from the skin.

What makes Yale Medicine’s approach to treating infantile hemangiomas unique?

We offer inpatient and outpatient treatment, including laser treatments in the office to surgeries performed under general anesthesia at our pediatric surgical center. The doctors take the time to explain every part of the process to parents.

“We are equipped to diagnose and treat nearly all vascular lesions at our center,” says Dr. Antaya. After patients go home, Yale Medicine doctors continue to work with their local pediatricians and dermatologists to ensure a seamless transition of care.