Updated: 12/16/2021

Infantile Hemangioma

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  • Snapshot
    • A new mom brings her 4-month-old girl to the pediatrician’s office for a new red spot. She noticed a faint red spot around 1 week of age on the left cheek. Since then, it has progressed into a bigger and brighter red birth mark. It does not appear to bother the child. Physical exam reveals a 3-cm bright red and sharply demarcated raised plaque on the left cheek. The pediatrician counsels that these lesions typically resolve spontaneously, but they can consider topical β-blockers.
  • Introduction
    • Clinical definition
      • infantile hemangiomas are benign vascular tumors that occur in infancy
        • also known as strawberry hemangioma
          • appears in newborn period
          • spontaneously resolves by 5-8 years old
        • distinct from
          • vascular malformations
            • e.g., port-wine stain
          • cherry hemangioma
            • benign capillary hemangioma in adulthood that does not spontaneously resolve
          • cavernous hemangioma
  • Epidemiology
    • Incidence
      • the most common tumor of infancy
    • Demographics
      • females > males
    • Location
      • head and neck
    • Risk factors
      • low birth weight
      • preterm infants
      • multiple gestation babies
  • ETIOLOGY
    • Pathogenesis
      • capillary hemangiomas are benign endothelial neoplasms with two phases
        • the proliferative phase is characterized by rapid growth and increase in the number of endothelial and mast cells
          • a stimulus for blood vessel proliferation
        • the involutional phase is characterized by regression of the lesion and decrease in the number of mast cells
      • hypoxia may be the initiating factor in the development of hemangiomas
  • Presentation
    • Symptoms
      • appears within the first few weeks of life
    • Physical exam
      • two presentations
        • raised and bright red papule, nodule, or plaque
        • raised and flesh-colored nodule with a blue or dark hue
          • may have central telangiectasias
      • sharply demarcated
      • typically unilateral
      • commonly on the face and neck
  • Imaging
    • Magnetic resonance imaging (MRI)
      • indications
        • used to delineate the location of the lesion
        • to determine the extent of the hemangioma
      • modality
        • with and without gadolinium
    • Ultrasound of liver
      • indications
        • if patient has 5 or more cutaneous hemangiomas
        • to evaluate for hepatic hemangiomas
  • Studies
    • Biopsy
      • indication
        • if malignancy is suspected or needs to be ruled out
    • Histology
      • proliferation of endothelial cells
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Differential
    • Port-wine stain
    • Pyogenic granuloma
  • Treatment
    • Treatment and management is highly individualized based on the size of lesion, morphology, location, and age
    • Conservative
      • observation
        • indication
          • first-line since most lesions will spontaneously resolve
    • Medical
      • β-blockers
        • topical
          • indications
            • small capillary hemangiomas
            • primarily for cosmetic reasons or at the parents’ request
          • drugs
            • topical propranolol or timolol
        • systemic
          • indications
            • larger hemangiomas that are deemed to be at risk for future scarring
            • hemangiomas that can cause functional impairment, such as periocular hemangiomas
            • hemangiomas with ulceration
          • drugs
            • propranolol
      • corticosteroids
        • topical or intralesional
          • indication
            • small capillary hemangiomas that ulcerate
        • systemic
          • indication
            • same as for systemic β-blockers and if β-blockers are contraindicated
    • Procedural
      • pulsed dye laser
        • indication
          • hemangiomas with ulcerations or telangiectasias
  • Complications
    • Functional impairment
      • if hemangioma occurs on or near eyelids
  • Prognosis
    • Infantile hemangiomas often appear in the first few weeks of life
      • these proliferate for 6-12 months and regress over months to years
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(M2.DM.16.4688) An 8-week-old girl is brought by her mother to a pediatrician for concern regarding a new red "bump" over her right thigh. The mother first noticed it about four weeks ago, and she thinks that it has been growing slowly. She isn't particularly concerned about its appearance. She is certain that there was nothing present at birth. On physical exam, you see the following 1cm by 1.5cm skin finding (Figure A). Her skin exam is otherwise unremarkable. What is the best initial management for this patient?

QID: 107543
FIGURES:

Topical timolol

0%

(0/1)

Observation

100%

(1/1)

Hepatic ultrasound

0%

(0/1)

Oral propanolol

0%

(0/1)

Surgical removal

0%

(0/1)

M 7 E

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(M2.DM.14.53) A 6-month-old boy is brought in by his mother who is concerned about a raised red lesion on his scalp (Figure A). The mother reports that she first noted it at birth, and that it has increased in size over the past two months. The patient was born from a full-term pregnancy with no complications and an unremarkable vaginal delivery. He has no medical problems and takes no medications except for Vitamin D. He breast feeds and his mother supplements with formula. His vital signs are stable and his physical examination is unremarkable with the exception of the lesion in question. What is the appropriate next step in management?

QID: 104264
FIGURES:

Mohs surgery

3%

(3/91)

Laser therapy

1%

(1/91)

Excisional biopsy

4%

(4/91)

Observation

88%

(80/91)

Cryotherapy

2%

(2/91)

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