DEFINITION
Infantile hemangioma (IH) is a benign vascular tumor of infancy commonly called a “strawberry mark” characterized by excess blood vessel proliferation primarily involving the skin. Also referred to as “capillary hemangioma”, It is the most common benign vascular tumor in infants: it occurs in 3% to 10% of infants under the age of 1 and up to 30% of premature infants.
Infantile hemangioma belongs to the vascular tumor group (classification of vascular anomalies adopted by the International Society for the Study of Vascular Anomalies (ISSVA). The strawberry hemangioma is benign and never metastasizes. IH is distinguished from other vascular malformations, the best-known ones being the birthmark (angioma) or port-wine stain. The main difference lies in the evolution of these pathologies.
STRAWBERRY HEMANGIOMA STAGES
- Infantile hemangiomas are usually not present at birth but appear within the first days or first weeks of life.
- There may be early signs of hemangiomas in approximately 50% of cases. These signs can be either a pinkish-red layer (often with a noticeable vessel network), or a white vasoconstriction spot.
Characteristic evolution phases of hemangiomas in newborns:
The first is a proliferation (growth) phase, with rapid growth of the red birthmark, which begins between the 2nd and 6th week after birth. Proliferation may extend up to the 12th month: 80% of hemangiomas reach their final size in the first 5 months after birth.
The second is an infantile hemangioma stabilization phase of varying duration (12 to 36 months).
The last is a slow and progressive spontaneous regression phase that may last from 3 to 7 years and end with the disappearance of the lesion. In 70% of cases, an infantile hemangioma may leave more or less significant sequelae for patients seen for a specialized consultation. The first signs of regression, particularly for the superficial types of IH, are seen as a change from a bright red birthmark to a pale, even purplish red with the onset of grey/white areas at the center of the lesion. The second signs of regression, for all types of infantile hemangiomas, are softening and reduction.The majority of lesions appear on a visible area of the head or neck.
Causes
There are no clearly established causes of infantile hemangiomas. A temporary and localized lack of oxygen, mainly to the skin, seems to be the starting point that results in a strawberry birthmark on a newborn.
The most common hemangioma risk factors are:
- Extreme prematurity
- Being female
- Advanced maternal age
- Being Caucasian
- Multiple pregnancy
- Pregnancy complicated by abnormalities of the placenta or high blood pressure
- Family history of hemangioma, etc.
TYPES OF HEMANGIOMAS IN BABIES
Infantile hemangiomas have common features: they are firm, slightly warm to the touch and generally painless (except in the case of ulceration).
Hemangiomas
infantile hemangioma
hemangioma
Photos of hemangioma on babies are presented as examples and do not enable a diagnosis to be established.
types
types
types
Photos of hemangiomas are presented as examples and do not enable a diagnosis to be established.
DISEASES SIMILAR TO INFANTILE HEMANGIOMA
Non-Involuting Congenital Hemangiomas (NICHs)
- Non-involuting congenital hemangiomas (NICHs) are a particular type of congenital hemangioma. They are fully formed at birth. They do not regress and follow the child’s development.
- Their prevalence is unknown but the lesions seem to be rare. They have long been confused with infantile hemangiomas in their involutive (regression) phase. They are now clearly distinguished based on their clinical characteristics.
- NICHs are single, flat or slightly raised, round or oval lesions. The outside area is white. The center varies from pink, with minor telangiectasias (small visible vessels that still persist after involution), to dark purple, with very dense thin telangiectasias.
- NICHs are mainly located on the head or neck (43% of cases) and limbs (38% of cases).
- Treatment generally involves surgical excision, sometimes, first with embolization (blocking blood flow inside the vessel)
Rapidly Involuting Congenital Hemangioma (RICH)
- Rapidly involuting congenital hemangioma (RICHs) are congenital hemangiomas that are fully formed during pregnancy.
- They are different from non-involuting congenital hemangiomas (NICHs) mainly because they undergo rapid postnatal involution.
- The prevalence of RICHs is unknown but these lesions seem to be rare.
- RICHs are round or oval, solitary and most often located close to a joint on the limbs, on the scalp, the forehead or around the ear. Involution is completed at approximately 1 year.
- Treatment may be required in the event of incomplete resorption.
Venous malformations
- These are the most common vascular malformations. They consist of bluish tumors under the skin or superficial dilated vein networks or resemble soft and depressible varicose veins. Worsening occurs slowly throughout life.
- They empty upon pressure or when the limb is raised. They swell in an inclined position during exercise or crying (face), and range in volume and scope.
- A Doppler ultrasound reveals the venous networks.
- They are often obvious at birth but not always.
- Venous malformations appear in the following areas:
- Neck and face (40%)
- Extremities (40%)
- Trunk (20%)
- Treatment involves venous compression, aspirin and sclerotherapy (injection of a medicine in the lesion to shrink blood vessels). Surgery will be used as second-line treatment.
Lymphatic malformations
- These lesions are localized malformations of the lymphatic system, with most being present at birth or detected before the age of 2. They are always more complex than what can be seen during a clinical examination. Prenatal diagnosis of these malformations is possible with an ultrasound. After birth, ultrasound, CT and MRI are effective for identifying these lesions.
- Macrocystic types create elastic and sometimes bumpy masses, which are generally translucent under normal skin.
- The most common sites are the armpit and neck.
- Treatment begins with sclerotherapy (injection of a medicine in the blood vessel to eliminate it). Surgery is used as second-line treatment if sclerotherapy fails.
Port wine stains
- Port wine stains, which are also called birthmarks, are present from birth and persist throughout life. They do not tend to spread, but they will grow proportionally as the child grows.
- Most often a birthmark is only an esthetic problem; however, its location on certain areas of the body should draw attention to the possibility of complications.
EDUCATIONAL VIDEO ABOUT INFANTILE HEMANGIOMAS BY FRAME
This short video by FRAME, a web-based educational library explains how families can cope with Infantile Hemangiomas. FRAME is created by Positive Exposure, an organization that changes how medical information is presented to health care professionals in training, clinicians, families, and communities.
For more information about FRAME & Positive Exposure, please visit the website: https://positiveexposure.org
Sources
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- Hartzell Larry D., Buckmiller Lisa M. Current management of infantile hemangiomas and their common associated conditions. OtolaryngolClin N Am 45. 2012;545–56
- European Medicines Agency gives second positive opinion for a paediatric-use marketing authorisation. Press release – EMA/99224/2014;2014.
- Enjolras O, Mulliken JB. Vascular tumors and vascular malformations (new issues). Adv Dermatol 1997;13:375–423.
- Holland K et al. Approach to the patient with an infantile hemangioma. Dermatil Clin. 2013
- Chen et al. Update on pathogenesis and therapy. Pediatrics. 2012
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- Baulland CG et al. Untreated hemangiomas: growth pattern and residual lesions. Plast Reconstr Surg 2011;127(4):1643-1648.
- Holland K. E. – Approach to the Patient with an Infantile Hemangioma – Dermatol Clin 31 (2013) 289–301
- Leauté-Labrèze C et al. Hémangiomes infantiles ; actualités dans le traitement (Infantile hemangiomas; what’s new in treatment). Elsevier Masson 2012
- Drolet B A et al. Initiation and use of propanolol for infantile hemangioma; Report of a consensus conference. Pediatrics 2013;128:128-40