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Updated: Dec 16 2021

Infantile Hemangioma

  • 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
    • 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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