Derm Dx: Red, subcutaneous nodule on an infant’s scalp


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An 8-month-old female was referred by her pediatrician for evaluation of a red lesion that has been present on her head since birth. Her mother’s pregnancy was normal, and the baby was born by vaginal delivery. Her medical history is unremarkable, and her immunizations are up-to-date. Physical examination revealed a well-circumscribed, slightly compressible, deeply erythematous, subcutaneous nodule arising from the vertex of the scalp. No bleeding or ulceration was apparent.

This child presents with a cavernous hemangioma, a benign vascular neoplasm. It is the most common tumor of infancy and has an estimated incidence of 1 in 100 to 250 people. The lesions are more common in white children with...

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This child presents with a cavernous hemangioma, a benign vascular neoplasm. It is the most common tumor of infancy and has an estimated incidence of 1 in 100 to 250 people. The lesions are more common in white children with a predominance in females at a ratio of 3 to 1.1 Infantile hemangiomas may be noted as early as the first few days of life but can arise several months later.2,3 Most occur sporadically, but there are reported cases of autosomal dominant transmission.4

Cavernous hemangiomas are made of hyperplastic endothelial cells that have a proliferative and involution phase.5 For the first few months, lesions undergo rapid growth, followed by a slower proliferation phase. This stage typically occurs in children aged 1 year or less and is uncommon after the first year. The involution phase is characterized by a change in color: from bright strawberry red to a violaceous hue or gray. The tumor will also flatten and become softer.6,7 The majority of these hemangiomas will eventually involute completely by age 7 years.

Most hemangiomas require no intervention; however, lesions near the eye or neck often require treatment to prevent visual defects and airway compromise.8 Therapeutic options include steroids, surgery, and laser. Propranolol is now considered a first-line therapy for problematic lesions and has received approval from the FDA for this condition.9,10 Close monitoring of patients on propranolol is essential as adverse events include bradycardia, hypotension, and hypoglycemia. A safer alternative is topical timolol, and several studies document efficacy in promoting involution.11,12

Megha D. Patel is a student at the Commonwealth Medical College, Scranton, Pennsylvania.

Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College and an adjunct assistant professor of dermatology at the University of Pennsylvania Medical College. He practices dermatology in Hazleton, Pennsylvania.


  1.   Hemangioma of infancy. Wolff K, Johnson RA, Saavedra AP, eds. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 7th ed. New York, N.Y.: McGraw Hill Education;2013:155.
  2.  Pratt AG. Birthmarks in infants. AMA Arch Derm Syphilol. 1953; 67(3):302-305.
  3.  Jacobs AH. Strawberry hemangiomas; the natural history of the untreated lesion. Calif Med. 1957;86(1):8-10.
  4.  Blei F, Walter J, Orlow SJ, et al. Familial segregation of hemangiomas and vascular malformations as an autosomal dominant trait. Arch Dermatol. 1998;134(6):718-722.
  5.  Congenital Vascular Lesions. In: Habif TP, ed. Clinical Dermatology. 5th ed. New York, N.Y.: Elsevier; 2010:891.
  6.  Drolet BA, Esterly NB, Frieden IJ. Hemangiomas in children. N Engl J Med. 1999;341(3):173-181.
  7.  Chang LC, Haggstrom AN, Drolet BA, et al. Growth characteristics of infantile hemangiomas: implications for management. Pediatrics. 2008;122(2):360-367.
  8.  Orlow SJ, Isakoff MS, Blei F. Increased risk of symptomatic hemangiomas of the airway in association with cutaneous hemangiomas in a “beard” distribution. J Pediatr. 1997;131(4):643-646.
  9.   Brooks M. FDA OKs propranolol hydrochloride for infantile hemangioma. Medscape Medical News. Available at
  10.   Léaute-Labréze C, Hoeger P, Mazereeuw-Hautier J, et al. A randomized, controlled trial of oral propranolol in infantile hemangioma. N Engl J Med. 2015;372(8):735-746.
  11.   Chambers CB, Katowitz, WR, Katowitz, JA, et al. A controlled study of topical 0.25% timolol maleate gel for the treatment of cutaneous infantile capillary hemangiomas. Ophthal Plast Reconstr Surg. 2012;28(2):103-106.
  12.  Chakkittakandiyil A, Phillips R, Frieden IJ, et al. Timolol maleate 0.5% or 0.1% gel-forming solution for infantile hemangioma: A retrospective, multicenter, cohort study. Pediatr Dermatol. 2012;29(1):28-31. 
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