Infantile hemangiomas: benign lesions with potential complications

Sometimes called a strawberry mark, a hemangioma grows during the first year of life, and then recedes over time.
Sometimes called a strawberry mark, a hemangioma grows during the first year of life, and then recedes over time.

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Infantile hemangiomas are common benign tumors that occur in childhood, and it is important for clinicians who work with children to be familiar with methods of identifying these lesions. Although the patient's caretakers may be concerned about them, many infantile hemangiomas resolve without treatment and complications. When complications do arise, it is important for health care providers to know how to recognize them and to be aware of the treatment options available.

Infantile hemangiomas may appear as erythematous lesions or tumors on the body, but they are often seen on the head and neck.1,2 The diagnosis is based mainly on clinical findings.3,4 Infantile hemangiomas occur most often in female or white infants.2 Factors that may predispose infants to the development of hemangiomas are low birth weight and premature birth.4 In most cases, there is no past family history of infantile hemangiomas, although in rare cases, they are associated with a hereditary condition.3,5

Phases and subtypes

There are three different phases observed in infantile hemangiomas. The proliferative phase can occur between 2 to 3 weeks and 5 to 9 months after birth. In this phase, the infantile hemangioma can grow very quickly and may be noncompressible.1,3 Within 5 months, 80% of the growth of the hemangioma is completed, and after approximately 9 months, most hemangiomas are fully developed.1,4 Next is the plateau phase, in which slight variation in the infantile hemangioma can be observed. The final stage, or involutional phase, occurs between age 1 year and 5 to 10 years. The infantile hemangioma becomes more compressible, and the original erythematous lesion may acquire a purple or gray tone.4 Infantile hemangiomas often regress; however, fibrofatty or scar tissue may remain.3,6 

The three clinical subtypes of infantile hemangiomas are superficial, deep, and mixed.2 Superficial hemangiomas are located in the upper portion of the dermis and can appear erythematous. Deep hemangiomas may appear as purple or flesh-colored protuberances and are located in the lower portion of the dermis or in subcutaneous tissue.3 Mixed hemangiomas may combine features of superficial and deep hemangiomas.1,4 Hemangiomas may also be described according to their distribution on the skin. Localized hemangiomas appear more focal, with a round shape, whereas segmented hemangiomas cover a large area and are more likely to ulcerate and cause complications.2,7

Quick facts about infantile hemangiomas
  • They often occur in female or white infants.
  • They frequently appear on the head and neck.
  • Infantile hemangiomas evolve through a proliferative phase, a plateau phase, and an involutional phase.3
  • Some types of infantile hemangiomas are cutaneous, periorbital, hepatic, lumbosacral, and airway.
  • Treatments for the complications of infantile hemangiomas include propranolol, corticosteroids, laser therapy, and surgery.

Complications

Most infantile hemangiomas do not cause complications or require therapy.3 If the hemangioma is potentially fatal, affects the patient's ability to function, or is physically deforming, then therapy is warranted.4 Complications that may be observed in patients with infantile hemangiomas are ulcers, infections, bleeding, visceral issues, vision problems, and difficulty breathing.1,3

Ulcers are the most frequently observed complication of infantile hemangiomas.3 Ulcers can cause pain, difficulty eating, and infections. Locations where ulcers commonly develop from infantile hemangiomas are the lower lip, neck, genital and anal areas, and regions of the body where apposed skin surfaces may rub against each other.3,4 If an infection develops, a culture may be required, followed by the administration of appropriate antibiotics. Pulsed dye laser can also be used to treat ulcers that are a complication of infantile hemangiomas.1,3

Vision may also be affected; periorbital infantile hemangiomas most often lead to astigmatism.4 Amblyopia may occur, resulting in blindness, and exophthalmos can arise if an infantile hemangioma is located in the posterior region of the eye.3 An ophthalmologist should be consulted when a patient has a periorbital infantile hemangioma, and therapy should be considered if needed.1,3 A beta-blocker, such as oral propranolol, may be useful for treating periorbital hemangiomas associated with astigmatism, causing them to involute.4

Difficulty breathing may develop if an airway is obstructed by an infantile hemangioma. Respiratory difficulty may become apparent when the patient is aged between 6 and 12 weeks. An airway hemangioma may manifest as coughing or stridor.1 For patients with airway hemangiomas, it is necessary to consult an otolaryngologist, and a coordinated medical team should treat this condition.3

Hemangiomas may develop in the viscera. If a patient has five or more skin hemangiomas, then an ultrasound should be performed to check for hepatic and other visceral involvement. Heart failure may arise in patients with hepatic hemangiomas.1,3 Hemangiomas in the lumbosacral region may be associated with spinal dysraphism, and magnetic resonance imaging may be required in these cases.3 A patient may have multiple hemangiomas, although multiple hemangiomas on the skin are found in only approximately 30% of cases.1

Complications of infantile hemangiomas
  • Bleeding
  • Difficulty breathing
  • Infections
  • Ulcers
  • Visceral issues
  • Vision problems

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