Infantile hemangioma in Infant/NeonateSee also in: External and Internal Eye,Anogenital
Alerts and Notices
SynopsisInfantile hemangiomas are the most common benign tumors of infancy, occurring in up to 10% of infants, with up to 50% involving the head and neck. Precursors may be present at birth, evolving into a more classic appearance within the first few months of life. Usually, infantile hemangiomas grow rapidly during the first few weeks of life. This initial proliferative phase typically peaks as early as 2 months of age. This is followed by a steady state lasting months, depending on the hemangioma type, followed by gradual involution over several years, with more than 90% completely involuting by age 10. Although infantile hemangiomas involute with time, residual skin changes such as telangiectasia, scarring, atrophy, and fibrosis persist in up to 30% of lesions after involution is complete.
Ulceration occurs in about 5% of hemangiomas and can occur at any location. Ulcerated hemangiomas are painful regardless of location, often become secondarily infected, and leave a scar. Bleeding and ulceration can incorrectly cause or increase concern for possible physical abuse; however, their characteristic development in early infancy and typical regression should help differentiate them from the former. Ulceration is of particular concern when it involves the periocular, nasal, perioral, or anogenital areas, given regional risk for severe complication. Ulceration of the nasal or laryngeal areas can cause respiratory compromise. Perioral ulceration can interfere with latching and feeding. Anogenital ulceration adversely affects diaper changes, urination, and defecation. Periocular ulceration and attendant scarring can distort the eyelids, scar the cornea, and/or affect development of binocular vision. Only about 1%-2% of hemangiomas involve the genitalia. Such hemangiomas of the urethra, the labia, hymen, vulva, or perihymenal area may raise concern for sexual abuse. When extensive ulceration is present, there may be concern that these represent perineal burns. Knowledge of the clinical appearance and natural course of untreated hemangiomas may help prevent misdiagnosis.
Segmental infantile hemangiomas raise concern for regional abnormalities. A segmental infantile hemangioma of the upper face, ears, and/or scalp requires evaluation for PHACE syndrome (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies). Involvement of the lower face and neck warrant assessment for laryngeal involvement. If the anogenital area is involved in a segmental fashion, evaluation for associated anomalies associated with the synonymous LUMBAR syndrome (lower body hemangioma, lipoma, or other cutaneous anomalies, urogenital anomalies, myelopathy, bony deformities, anorectal and arterial anomalies, and renal anomalies), SACRAL syndrome (spinal dysraphism, anogenital anomalies, cutaneous anomalies, renal and urologic anomalies, associated with angioma of lumbosacral localization), or PELVIS syndrome (perineal hemangioma, external genitalia malformations, lipomyelomeningocele, vesicorenal abnormalities, imperforate anus, and skin tags) should ensue.
D18.01 – Hemangioma of skin and subcutaneous tissue
83343001 – Infantile hemangioma
Differential Diagnosis & Pitfalls
- Congenital hemangioma (CH) – Fully formed vascular tumors at birth; 2 main types are rapidly involuting congenital hemangiomas (RICH) and noninvoluting congenital hemangiomas (NICH), and variants have been reported. The proliferative phase in these tumors occurs in utero, and tumors do not typically proliferate postnatally in the pattern seen with infantile hemangiomas. RICHs present as exophytic pink to purple vascular plaques, nodules, or tumors, sometimes with ulceration. NICH presents as a bluish patch or plaque overlaid with coarse telangiectasia and a peripheral rim of pallor. Histologically, they are GLUT-1 negative, which helps to differentiate them from other hemangiomas. Partially involuting congenital hemangiomas (PICH) add to this spectrum with features of both RICH and NICH. PICH and NICH have been shown to demonstrate delayed enlargement years after diagnosis. These can also be painful without ulceration as compared to infantile hemangiomas.
- Capillary malformation or "port-wine stain" – Early superficial or segmental infantile hemangiomas, or their precursor lesions, may be confused with port-wine stains, which are capillary malformations present at birth. They are pink or red patches that persist throughout life and do not have the typical infantile growth phase of hemangiomas. They do, however, proliferate after puberty.
- Tufted angioma and kaposiform hemangioendothelioma represent a spectrum of vascular tumors that may mimic hemangiomas. They present as deep red, purple, or brown vascular plaques or nodules, sometimes with deep fibrotic consistency. They may be localized or segmental and carry risk for the Kasabach-Merritt platelet sequestration phenomenon.
- Infantile myofibromatosis – Fibrohistiocytic proliferations characterized by skin-colored to purple, firm to hard or rubbery nodules, single or multiple in presentation. Failure to thrive and spasticity may be present.
- Venous malformations have a similar blue tint as deep infantile hemangioma, but they do not proliferate rapidly unless there is vascular obstruction. Phleboliths are often seen in venous malformations on ultrasound, and compared to hemangiomas, they demonstrate slow flow.
- Neuroblastomas can mimic deep infantile hemangiomas, but they blanch when stroked / rubbed.
- Rhabdomyosarcoma – Soft tissue sarcoma of skeletal muscle origin typically seen in the first and second decades of life. In children, this presents as an asymptomatic, rapidly growing, red, firm cutaneous nodule or tumor, and may involve the head and neck.
- Lymphangiomas may mimic deep infantile hemangiomas.
- Arteriovenous malformations are pulsatile and relatively warmer than infantile hemangiomas.
- Nonvascular tumors with a nodular appearance and bluish or red / purple tint may also mimic infantile hemangiomas; not all present during the infantile period.
- Plexiform neurofibroma
- Cystic neurilemmoma
- Fibrous histiocytoma (see, eg, malignant fibrous histiocytoma)
- Vascular leiomyoma
- Kaposi sarcoma
- Epidermoid cyst
- (Nasal) glioma
- Nevus anemicus
- Leukemia / lymphoma cutis
Patient Information for Infantile hemangioma in Infant/Neonate
OverviewHemangiomas are harmless growths that are the result of rapidly dividing cells of the blood vessel walls known as endothelial cells. They appear shortly after birth and grow rapidly during the first year of life. They usually resolve on their own over the next few years. Hemangiomas can be many different colors, depending on where they are located. Superficial hemangiomas (also known as strawberry hemangiomas, due to their red color) are located in the top layer of skin. Those in the deeper layer of skin are called deep (cavernous) hemangiomas, and they can be blue or colorless. Most hemangiomas are limited to the skin. Children with multiple hemangiomas may have associated internal lesions involving the liver, lungs, or other internal organs. These are more serious in nature and are usually followed more closely by your child's pediatrician.
Who’s At RiskHemangiomas affect about 10% of infants, and the risk is about 5 times higher in females than males. White infants and premature infants are at an increased risk for hemangiomas, as are infants born to mothers with an abnormal placenta. The risk is also raised in infants of women who had chorionic villus sampling during their prenatal period.
Signs & SymptomsMost hemangiomas of infancy appear within the first 2 weeks of life. They may begin as a bump on the skin or as a flat, reddish patch that may appear similar to a bruise. Hemangiomas grow very rapidly for weeks or months, usually peaking in size at 6-9 months, and form raised areas ranging in size from a few millimeters to centimeters. They are bright red with well-defined borders. If a hemangioma grows very large, it may be prone to bleeding spontaneously.
Self-Care GuidelinesTypically, there are no self-care measures for hemangiomas, as they usually resolve without any treatment. It is important to note, though, that it can take several years for this to occur, and the color may not fade completely. Close observation for changes in the appearance is all that is needed. If the hemangioma does bleed, treatment with wet compresses and antibacterial ointment is usually sufficient. Bleeding hemangiomas need to be watched closely for infection.
When to Seek Medical CareSeek medical care if your infant's hemangioma changes in color, starts to bleed, appears infected, or appears to be blocking his or her vision, breathing, or feeding. Hemangiomas that are located in the diaper area or on the lower lip are particularly prone to bleeding, due to friction.
TreatmentsMost hemangiomas do not require any treatment. However, for those that are located in the child's airway or those that threaten eyesight, treatment is necessary to slow down the growth. Your infant's doctor may treat the hemangioma with a medication called propranolol. If you are worried about cosmetic appearance of the color later in your child's life, he/she may be able to have laser therapy to help fade the color.
Behrman RE, Kliegman R, Jensen HB, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: WB Saunders; 2007.
Habif, TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. New York, NY: Mosby Inc; 2004.
Paller AS, Mancini AJ. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. Philadelphia, PA: Elsevier; 2005.
Zitelli BJ. Atlas of Pediatric Physical Diagnosis. Davis H, ed. New York, NY: Mosby Inc; 2007.
Infantile hemangioma in Infant/NeonateSee also in: External and Internal Eye,Anogenital