A 3-month-old baby is brought to the clinic by her parents for assessment of an ulcerative lesion on her left labia. Her parents state that she was born with a birthmark at the ulcer site, which has rapidly changed over the past 3 weeks and occasionally bleeds. Palpation of the area does not elicit tenderness and her lymph nodes are not enlarged. The patient is afebrile and has no similar lesions elsewhere on her body.
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Infantile hemangiomas are dull to bright red, dome-shaped lesions with a soft texture made up of blood vessels. Ulceration is the most common complication occurring in up to 16% of patients.1 The onset of ulceration is usually between age 2 to 4 months.2
Ulcerated infantile hemangiomas are most likely to occur on the anogenital region or face and may be preceded by whitish discoloration.3 The cause of ulceration is unknown, but patients at increased risk of developing ulcerating IH are female, premature, have a low birth weight, or have a larger lesion at a site of friction.3
Nonulcerated infantile hemangiomas do not require treatment as most will shrink spontaneously after a few years without complication. Ulcerated lesions may warrant prompt treatment due to an increased risk of infection, pain, bleeding, and scarring.2,3 Therapeutic options include topical medications (timolol, propranolol), oral propranolol, surgery, or laser therapy with pulsed dye laser and management of infection, pain, and wound care.2-4 Monitoring for systemic side effects, even with topical therapy, is warranted.2
Brittany Spinosa-Weber, PA-C, works at the DermDox Dermatology Centers in Bethlehem and Leola, Pennsylvania. Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
1. Almebayadh M. Successful treatment of ulcerated infantile hemangioma with brimonidine-timolol cream: 2 cases report and review of the literature. J Dermatolog Treat. 2020;31(4):433-434. doi:10.1080/09546634.2019.1603991
2. McCuaig CC, Cohen L, Powell J, et al. Therapy of ulcerated hemangiomas. J Cutan Med Surg. 2013;17(4):233-242. doi:10.2310/7750.2012.12037
3. Chang CS, Kang GC. Efficacious healing of ulcerated infantile hemangiomas using topical timolol. Plast Reconstr Surg Glob Open. 2016;4(2):621. doi:10.1097/GOX.0000000000000605
4. Morelli JG, Tan OT, Yohn JJ, Weston WL. Treatment of ulcerated hemangiomas in infancy. Arch Pediatr Adolesc Med. 1994;148(10):1104–1105. doi:10.1001/archpedi.1994.02170100102023