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Infantile Hemangiomas

By

Denise M. Aaron

, MD, Dartmouth-Hitchcock Medical Center

Last full review/revision Sep 2020| Content last modified Sep 2020
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Infantile hemangiomas 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.

Infantile hemangioma is the most common tumor of infancy, affecting 10 to 12% of infants by age 1 year. Infantile hemangioma 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 year.

Infantile hemangiomas 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.

Infantile hemangiomas 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 genitourinary anomalies.

Lesions slowly involute starting at 12 to 18 months, decreasing in size and vascularity. Generally, infantile hemangiomas involute by 10%/year 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

  • Clinical evaluation

Diagnosis of infantile hemangiomas 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 superficial or uncomplicated lesions that require treatment, possibly topical or intralesional corticosteroids or topical beta-blockers (1)

  • For complicated or high-risk lesions requiring treatment, oral propranolol (2)

  • General wound care for ulcerated lesions

  • Usually avoidance of surgery

There is no universal infantile hemangioma treatment recommendation. Because most lesions resolve spontaneously, observation is usually indicated before initiating treatment. Treatment should be considered for complicated or high-risk lesions, ie, those 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 to prevent infection and/or reduce colonization.

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.

Treatment references

  • 1. Boos MD, Castelo-Soccio: Experience with topical timolol maleate for the treatment of ulcerated infantile hemangiomas (IH). J Am Acad Dermatol 74(3):567-570, 2016. doi: 10.1016/j.jaad.2015.10.021

  • 2. Hogeling M, Adams S, Wargon O: A randomized controlled trial of propranolol for infantile hemangiomas. Pediatrics 128(2):e259-266, 2011. doi: 10.1542/peds.2010-0029

Key Points

  • Infantile hemangiomas affect 10 to 12% of infants by age 1 year.

  • Lesions slowly involute starting at 12 to 18 months, with maximal involution by age 10 years.

  • Use topical treatments and wound care for ulcerated lesions and to help prevent scarring, bleeding, and pain.

  • Unless complications are life threatening or vital organs are compromised, avoid surgery.

Drugs Mentioned In This Article

Drug Name Select Trade
FLAGYL
INDERAL
BACTROBAN
TIMOPTIC
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