Review Question - QID 107543

This 8-week old girl presents with a capillary hemangioma, a benign lesion that will likely resolve without intervention. Since this particular hemangioma is not in a location that could compromise her airway, visual development, or feeding, observation is an appropriate treatment.

Infantile capillary hemangiomas (also described as "strawberry" hemangiomas) are benign vascular tumors that result from abnormal overgrowth of capillary blood vessels. They typically present in the first 1-4 weeks of life, continue to grow until 7-9 months of age, and then slowly recede by 5-9 years of life. They occur most commonly on the head and neck. If the hemangioma is not blocking vital organs, observation is an acceptable form of treatment. If the hemangioma is ulcerated or blocking vital organs, then urgent treatment with a beta-blocker (either topical timolol or oral propranolol) is recommended.

McLaughlin et al. review the epidemiology and management of common birthmarks in neonates. Infantile hemangiomas occur in 1.1-2.6% of newborns. 50% of hemangiomas resolve by five years of age, 70% by seven years of age, and 90% by 10 years of age. Hemangiomas may leave residual atrophy, telangiectasias, hypopigmentation, or scars. Treatment of pulsed dye laser may hasten clearance by school age.

Shah et al. provide a review of the efficacy of beta-blocker therapy for treating infantile hemangiomas. Mechanistically, beta-blockers hasten hemangioma involution via vasoconstriction and inhibition of angiogenesis. Pooled response rates of various meta-analyses have shown that propranolol is effective in the treatment of 97-98% of infantile hemangiomas. Side effects of propranolol therapy requiring parental anticipatory guidance include hypoglycemia, hypotension, acrocyanosis, bradycardia, and wheezing.

Figure A is a photograph of a single blanchable, well-demarcated, pink plaque representative of a benign infantile capillary hemangioma.

Incorrect Answers:
Answers 1 & 4: Initiation of beta blocker therapy is appropriate if the hemangioma is in such a location that it might compromise the airway, restrict feeding, or adversely affect visual development. Therapy may also be initiated if the lesion is unsightly to the parents or potentially disfiguring. Presence of ulceration due to overly rapid tumor growth is also an indication for initiating therapy.
Answer 3: If an infant presents with 5 or more capillary hemangiomas, a hepatic ultrasound is warranted to assess for liver hemangiomas (Horii et al).
Answer 5: Surgical intervention would not be appropriate. Large or slow involuting hemangiomas may leave loose skin outpouchings in older children. Surgical intervention may be requested for cosmetic improvement, but such an intervention would take place after full hemangioma involution.