Hemangioma

A hemangioma is a benign (non-cancerous) vascular tumor composed of abnormally proliferating blood vessels. Most commonly appearing as bright red or purple birthmarks on the skin, hemangiomas are the most frequent tumor of infancy, affecting approximately 4-5% of newborns. While they can look concerning to parents, most hemangiomas are harmless and resolve on their own without treatment during childhood.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. If you notice any concerning skin changes or growths in yourself or your child, consult with a healthcare provider for proper evaluation.

Overview

Hemangiomas are vascular anomalies characterized by the abnormal proliferation of endothelial cells that form blood vessels. They represent the most common benign tumor in infants and children, with a distinct natural history of rapid growth during the first year of life followed by slow spontaneous regression over several years.

There are several types of hemangiomas, categorized by their location and appearance. Superficial hemangiomas appear as bright red, raised lesions on the skin surface, often called "strawberry marks." Deep hemangiomas develop beneath the skin, appearing as bluish or skin-colored swellings. Mixed hemangiomas contain both superficial and deep components, presenting as raised red lesions with deeper blue areas.

Most hemangiomas appear within the first few weeks of life, grow rapidly during the first 6-12 months, and then enter a slow involution phase that can last until age 5-10. By age 10, approximately 90% of hemangiomas have significantly regressed, often leaving minimal to no residual marks. However, some may leave behind residual tissue, scarring, or skin changes that may require intervention.

While the majority of hemangiomas are cosmetic concerns that resolve without complications, some can cause functional problems depending on their location and size. Hemangiomas near the eyes, nose, mouth, or genital area may interfere with normal development or function and often require early intervention. Large hemangiomas can occasionally cause complications such as ulceration, bleeding, or in rare cases, congestive heart failure due to high blood flow through the tumor.

Symptoms

Hemangiomas present with distinctive visual characteristics that evolve over time. The appearance and symptoms depend on the type, location, and phase of development of the hemangioma.

Common Visual Signs

  • Skin swelling - raised, tumor-like growth on the skin surface
  • Lip swelling - enlarged appearance when hemangiomas affect lip tissue
  • Abnormal appearing skin - distinctive red, purple, or bluish discoloration
  • Skin lesion - well-demarcated growths with distinct borders
  • Skin growth - progressively enlarging masses during proliferative phase
  • Skin moles - some hemangiomas may be confused with pigmented lesions
  • Lymphedema - swelling in surrounding tissues, particularly with large lesions
  • Irregular appearing scalp - when hemangiomas occur on the head
  • Irregular appearing nails - rare involvement of nail bed areas
  • Skin dryness, peeling, scaliness, or roughness - surface changes as hemangiomas evolve

Superficial Hemangioma Characteristics

  • Bright red color (strawberry appearance)
  • Raised, bumpy texture
  • Well-defined borders
  • Soft, compressible feel
  • May blanch with pressure

Deep Hemangioma Characteristics

  • Bluish or skin-colored appearance
  • Deeper, nodular swelling
  • Warmer to touch than surrounding skin
  • May have overlying dilated blood vessels
  • Less defined borders than superficial types

Potential Complications

  • Ulceration with bleeding and pain
  • Secondary bacterial infection
  • Functional impairment (vision, breathing, feeding)
  • Cosmetic concerns and psychological impact
  • Scarring or residual tissue after regression

Location-Specific Symptoms

  • Periocular: Vision obstruction, refractive errors
  • Nasal: Breathing difficulties, nasal obstruction
  • Lip/Oral: Feeding difficulties, speech problems
  • Genital/Perianal: Ulceration, pain with defecation
  • Large segmental: Association with underlying anomalies

Causes

The exact cause of hemangiomas remains incompletely understood, but research has identified several factors that contribute to their development. Current understanding suggests a complex interplay of genetic, environmental, and developmental factors.

Vascular Development Abnormalities

Hemangiomas result from abnormal proliferation of endothelial cells during blood vessel formation. Key mechanisms include:

  • Dysregulation of angiogenesis (blood vessel formation)
  • Abnormal response to growth factors like VEGF (vascular endothelial growth factor)
  • Imbalance between pro-angiogenic and anti-angiogenic signals
  • Altered endothelial cell differentiation during fetal development

Genetic Factors

  • Somatic mutations: GNAQ and GNA11 gene mutations in some cases
  • Familial clustering: Increased risk with family history (10-15% have affected relatives)
  • Chromosomal abnormalities: Rare associations with specific genetic syndromes
  • Imprinting disorders: Possible role of genomic imprinting in development

Placental and Fetal Factors

  • Placental abnormalities: Hypoxia and placental dysfunction
  • Embolization theory: Placental endothelial cells entering fetal circulation
  • Fetal hypoxia: Tissue hypoxia promoting angiogenesis
  • Invasive prenatal procedures: Chorionic villus sampling, amniocentesis

Hormonal Influences

  • Estrogen and progesterone effects during pregnancy
  • Growth hormone and insulin-like growth factors
  • Thyroid hormone influence on vascular development
  • Maternal age-related hormonal changes

Environmental and Developmental Factors

  • Premature birth and associated complications
  • Low birth weight and intrauterine growth restriction
  • Multiple gestation pregnancies
  • Maternal diabetes and hypertension
  • Advanced maternal age

Risk Factors

Several demographic and perinatal factors significantly increase the likelihood of developing hemangiomas. Understanding these risk factors helps identify infants who may be at higher risk and require closer monitoring.

Demographic Risk Factors

  • Female gender: 2-3 times more common in girls than boys
  • Caucasian ethnicity: Higher incidence in fair-skinned populations
  • Family history: 10-15% of patients have affected family members
  • Geographic location: Possible regional variations in incidence

Pregnancy and Birth-Related Factors

  • Premature birth: Risk increases with decreasing gestational age
    • 15-20% incidence in infants born before 32 weeks
    • 30% incidence in infants weighing less than 1000g at birth
  • Low birth weight: Independent risk factor regardless of gestational age
  • Multiple births: Twins and higher-order multiples at increased risk
  • Intrauterine growth restriction: Small for gestational age infants

Maternal Factors

  • Advanced maternal age: Mothers over 35 years old
  • Maternal diabetes: Both pre-gestational and gestational diabetes
  • Hypertensive disorders: Pre-eclampsia and pregnancy-induced hypertension
  • Smoking during pregnancy: Potential increased risk
  • Assisted reproductive technology: IVF and other fertility treatments

Placental and Obstetric Factors

  • Placenta previa or placental abruption
  • Oligohydramnios (decreased amniotic fluid)
  • Prolonged rupture of membranes
  • Invasive prenatal diagnostic procedures
  • Cesarean delivery (possible association)

Protective Factors

  • Term birth at normal birth weight
  • Single pregnancies
  • Uncomplicated pregnancies
  • Breastfeeding (possible protective effect)

Diagnosis

The diagnosis of hemangiomas is primarily clinical, based on characteristic appearance and natural history. Most hemangiomas can be diagnosed through careful physical examination and medical history, though imaging may be helpful in certain situations.

Clinical Diagnosis

Key diagnostic features include:

  • Typical appearance: Bright red, raised lesions (superficial) or bluish deep swellings
  • Age of onset: Appear in first weeks to months of life
  • Growth pattern: Rapid proliferation in first year, then slow regression
  • Location and distribution: Can occur anywhere but common on head and neck
  • Physical characteristics: Soft, compressible, warm to touch

Physical Examination

  • Visual inspection: Color, size, surface characteristics
  • Palpation: Texture, temperature, compressibility
  • Functional assessment: Impact on vision, breathing, feeding
  • Photography: Document size and appearance for monitoring
  • Measurement: Record dimensions for growth tracking

Imaging Studies

Ultrasound

  • First-line imaging for deep or complex hemangiomas
  • Shows characteristic high-flow vascular pattern
  • Helpful for monitoring treatment response
  • Non-invasive and radiation-free

MRI (Magnetic Resonance Imaging)

  • Gold standard for complex or deep hemangiomas
  • Excellent soft tissue contrast and anatomical detail
  • Useful for pre-surgical planning
  • Can differentiate from other vascular malformations
  • May require sedation in young children

CT Scan

  • Limited use due to radiation exposure
  • May be helpful for skeletal involvement assessment
  • Useful in emergency situations

Differential Diagnosis

Conditions that may be confused with hemangiomas include:

  • Vascular malformations: Arteriovenous malformations, venous malformations
  • Other tumors: Hemangioendothelioma, angiosarcoma (rare)
  • Birthmarks: Port-wine stains, salmon patches
  • Inflammatory lesions: Pyogenic granuloma, dermatitis
  • Infections: Cellulitis, abscess

Special Considerations

  • Multiple hemangiomas: Screening for liver involvement
  • Large facial hemangiomas: Evaluation for PHACE syndrome
  • Lumbosacral hemangiomas: Assessment for spinal abnormalities
  • Ulcerated hemangiomas: Rule out secondary infection

Treatment Options

Treatment approaches for hemangiomas depend on multiple factors including size, location, growth phase, complications, and functional or cosmetic concerns. Many hemangiomas require no treatment other than observation, while others need prompt intervention to prevent complications.

Observation and Monitoring

Appropriate for uncomplicated hemangiomas that do not interfere with function:

  • Regular follow-up: Monitor growth and regression patterns
  • Photography: Document changes over time
  • Parent education: Expected natural history and warning signs
  • Psychosocial support: Address parental anxiety and cosmetic concerns

Medical Therapy

Propranolol (First-line therapy)

  • Mechanism: Beta-blocker that inhibits angiogenesis and promotes regression
  • Indications:
    • Life-threatening or function-threatening hemangiomas
    • Large facial hemangiomas causing disfigurement
    • Ulcerated hemangiomas not responding to wound care
  • Dosing: 1-3 mg/kg/day divided into 2-3 doses
  • Monitoring: Blood pressure, heart rate, blood glucose
  • Duration: Typically 6-12 months, depending on response
  • Side effects: Hypotension, bradycardia, hypoglycemia, sleep disturbances

Topical Beta-blockers

  • Timolol gel or solution for superficial hemangiomas
  • Useful for small, uncomplicated lesions
  • Lower systemic absorption and fewer side effects
  • Applied twice daily to affected area

Corticosteroids

  • Systemic steroids: Second-line therapy when propranolol contraindicated
  • Intralesional injection: For localized problematic hemangiomas
  • Topical steroids: Limited efficacy for superficial lesions
  • Side effects: Growth suppression, immune suppression, Cushingoid features

Surgical Treatment

Indications for Surgery

  • Life-threatening complications
  • Functional impairment not responsive to medical therapy
  • Residual tissue after involution with cosmetic concerns
  • Persistent ulceration with poor healing

Surgical Options

  • Complete excision: For well-circumscribed lesions
  • Debulking: Partial removal to reduce mass effect
  • Staged procedures: Multiple operations for large lesions
  • Reconstructive surgery: Address residual deformity or scarring

Laser Therapy

  • Pulsed dye laser: Most common, targets hemoglobin
  • Indications: Superficial hemangiomas, residual telangiectasias
  • Nd:YAG laser: For deeper penetration
  • Limitations: Risk of scarring, limited depth of penetration
  • Timing: May be used during proliferative or involuting phase

Wound Care for Ulcerated Hemangiomas

  • Gentle cleansing with saline or dilute antiseptic
  • Topical antibiotics for secondary infection
  • Non-adherent dressings to protect surface
  • Pain management with topical or systemic analgesics
  • Barrier creams to protect surrounding skin

Emergency Treatment

  • Massive bleeding: Direct pressure, emergency surgery if needed
  • Airway obstruction: Immediate medical intervention, possible tracheostomy
  • High-output heart failure: Cardiology consultation, urgent treatment
  • Visual obstruction: Ophthalmology evaluation, prompt treatment

Prevention

While hemangiomas cannot be completely prevented due to their largely developmental and genetic nature, certain measures during pregnancy may help reduce risk factors associated with their development.

Prenatal Prevention Strategies

  • Optimal prenatal care: Regular check-ups to monitor fetal development
  • Managing maternal health conditions:
    • Diabetes control before and during pregnancy
    • Blood pressure management
    • Treatment of maternal infections
  • Avoiding harmful substances:
    • Smoking cessation before conception and during pregnancy
    • Limiting alcohol consumption
    • Avoiding unnecessary medications and toxins
  • Nutritional support: Adequate folic acid and vitamin supplementation

Reducing Premature Birth Risk

  • Proper management of multiple pregnancies
  • Prevention and treatment of preterm labor
  • Cervical length monitoring in high-risk pregnancies
  • Progesterone supplementation when indicated
  • Avoiding unnecessary invasive procedures

Early Detection and Monitoring

  • Newborn examination: Careful skin inspection after birth
  • Family history awareness: Inform healthcare providers of family history
  • Regular pediatric visits: Monitor for developing lesions in first months
  • Parental education: Recognition of early signs and symptoms

Secondary Prevention (After Diagnosis)

  • Prevent complications:
    • Protect from trauma and injury
    • Maintain good hygiene to prevent infection
    • Monitor for ulceration or bleeding
  • Early intervention: Prompt treatment when indicated to prevent functional problems
  • Regular monitoring: Track growth and development patterns
  • Psychosocial support: Address family concerns and provide resources

When to See a Doctor

Seek immediate emergency care for:

  • Significant bleeding that doesn't stop with direct pressure
  • Signs of breathing difficulty or airway obstruction
  • Sudden change in color to blue or gray
  • Signs of infection: fever, increasing redness, warmth, pus
  • Loss of consciousness or signs of heart failure in infants

Schedule urgent appointment for:

  • Rapid growth of hemangioma in first weeks of life
  • Hemangioma near the eye causing vision obstruction
  • Lesions around the nose or mouth affecting breathing or feeding
  • Ulceration or breakdown of hemangioma surface
  • Multiple hemangiomas appearing simultaneously
  • Any new skin growth or skin lesion in infants

Routine evaluation recommended for:

  • Any new red or purple birthmark in newborns
  • Family history of hemangiomas or vascular birthmarks
  • Cosmetic concerns about existing hemangiomas
  • Questions about treatment options or prognosis
  • Regular monitoring of known hemangiomas
  • Concerns about skin swelling or changes in appearance

Specialist referrals may be needed for:

  • Pediatric dermatology for complex or large hemangiomas
  • Ophthalmology for periocular lesions
  • Plastic surgery for cosmetic or functional concerns
  • Cardiology if heart failure is suspected
  • Psychology for significant psychosocial impact

Related Conditions

References

  1. Léauté-Labrèze C, Harper JI, Hoeger PH. Infantile haemangioma. Lancet. 2017;390(10089):85-94.
  2. Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics. 2019;143(1):e20183475.
  3. Darrow DH, Greene AK, Mancini AJ, Nopper AJ. Diagnosis and Management of Infantile Hemangioma: Executive Summary. Pediatrics. 2015;136(4):786-791.
  4. Hoeger PH, Harper JI, Baselga E, et al. Treatment of infantile haemangiomas: recommendations of a European expert group. Eur J Pediatr. 2015;174(7):855-865.
  5. Chinnadurai S, Sathe NA, Surawicz T. Laser Treatment of Infantile Hemangioma: A Systematic Review. Lasers Surg Med. 2016;48(3):221-233.