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Infantile Hemangiomas

by Denise M Aaron, MD

Infantile hemangiomas (IH) are raised, red or purplish, hyperplastic vascular lesions appearing in the first year of life. Most spontaneously involute; those obstructing vision, the airway, or other structures require treatment. Ideal treatment varies based on many patient-specific factors.

IH is the most common tumor of infancy, affecting 10 to 12% of infants by age 1 yr. IH is present at birth in 10 to 20% of affected infants and almost always within the first several weeks of life; occasionally, deeper lesions may not be apparent until a few months after birth. Size and vascularity increase rapidly, usually peaking at about age 1 yr.

IH can be classified by general appearance (superficial, deep, or cavernous) or by other descriptive terms (eg, strawberry hemangioma). However, because all of these lesions share a common pathophysiology and natural history, the inclusive term infantile hemangioma is preferred.

Symptoms and Signs

Superficial lesions have a bright red appearance; deeper lesions have a bluish color. Lesions can bleed or ulcerate from minor trauma; ulcers may be painful. IH in certain locations can interfere with function. Lesions on the face or oropharynx may interfere with vision or obstruct the airway; those near the urethral meatus or anus may interfere with elimination. A periocular hemangioma in an infant is considered an emergency and should be attended to promptly to avoid permanent visual defects. Lumbosacral hemangiomas may be a sign of underlying neurologic or GU anomalies.

Lesions slowly involute starting at 12 to 18 mo, decreasing in size and vascularity. Generally, IH involute by 10%/yr of age (eg, 50% by age 5, 60% by age 6), with maximal involution by age 10. Involuted lesions commonly have a yellowish or telangiectatic color and a wrinkled or lax fibrofatty texture. Residual changes are almost always proportional to the lesion’s maximal size and vascularity.

Diagnosis

Diagnosis is clinical; the extent can be evaluated by MRI if lesions appear to encroach on vital structures.

Treatment

  • Individualized based on location, size, and severity of lesions

  • For lesions that require treatment, possibly topical, intralesional, or systemic corticosteroids; laser; or oral propranolol

  • General wound care for ulcerated lesions

There is no universal treatment recommendation. Because most lesions resolve spontaneously, observation is usually indicated before initiating treatment. Treatment should be considered for lesions that

  • Threaten life

  • Threaten function (eg, vision)

  • Involve large areas of the face

  • Are distributed over the beard area

  • Are ulcerated

  • Are multiple

  • Are lumbosacral

Topical treatments and wound care are useful for ulcerated lesions and help prevent scarring, bleeding, and pain. Compresses, topical mupirocin or metronidazole, barrier dressings (generally polyurethane film dressing or petrolatum-impregnated gauze), or barrier creams may be used.

Unless complications are life threatening or vital organs are compromised, surgical excision or other destructive procedures should be avoided because they frequently cause more scarring than occurs with spontaneous involution. To help parents accept nonintervention, the physician can review the natural history (photographic examples are helpful), provide serial photography of the lesion to document involution, and listen sympathetically to parents’ concerns.

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • BACTROBAN
  • FLAGYL
  • INDERAL

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