What is a hemangioma?

Hemangiomas are benign blood vessel tumors that occur in childhood. The most common type of hemangioma is the “infantile” version (referred to sometimes as “strawberry mark”). Children are not born with these tumors typically. They appear in the first few days to weeks of life as a faint red or pink blemish that can rapidly grow into a larger mass. Growth will peak at around 12 months of age and plateau thereafter.

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Nasal tip infantile hemangioma.
Nasal tip infantile hemangioma.

It will then take several years for the hemangioma to disappear or involute. This takes place usually between 3 and 7 years of age. Hemangiomas that are present at birth are called “congenital” hemangiomas. These do not follow the same life cycle as the infantile kind. Rapidly-involuting congenital hemangiomas (RICH) will disappear by 12 months of age, whereas non-involuting congenital hemangiomas (NICH) will persist throughout life.

What causes hemangiomas?

There’s currently no known cause for hemangiomas, and it is not hereditary. Approximately 1 in 10 children born will demonstrate some type of hemangioma early in life. It usually occurs in the head and neck region and more prevalently in girls. Children who are twins and/or premature also seem to have a higher tendency for having hemangiomas. Theories suggest that hemangiomas may be derived from the same tissues as placenta. This would seem to fit well with the peculiar life cycle of these tumors, however, there are other differences that still cannot be explained by this theory.

Non-involuting congenital hemangioma of arm.
Non-involuting congenital
hemangioma of arm.

What are options for hemangioma treatment?

Most hemangiomas, being of the “infantile” variant, require no specific intervention. Over time, the hemangioma will initially increase in size, then plateau, and continue on to involution. Often, the entire hemangioma will disappear at the end of this process with no residual signs that it ever was there. Sometimes, hemangiomas may require treatment. This is true of large hemangiomas, those that cause visible disfigurement, ones that have failed to involute completely, or those that can obstruct vital functions such as vision or breathing. In these cases, treatment can take the form of medication or surgery.

Rapidly-convoluting congenital hemangioma of a child's shoulder.
Rapidly-convoluting congenital
hemangioma of a child’s shoulder.

Currently, medical treatment has taken a big leap forward with the discovery of propranolol for hemangiomas. Propranolol is a blood pressure lowering medication used all over the world and for many decades in adults. It is known as a beta-receptor blocker (or, a beta-blocker). In 2008, it was discovered that children with hemangiomas that were incidentally treated with the medication demonstrated sudden improvement in the appearance of the birthmarks. Although it will not work in all hemangiomas, there does seem to be an excellent response rate. It is important to understand that the medication will not necessarily shrink the hemangioma, but it will help stop its growth during the “proliferative” phase within the first year of life. Thereafter, the hemangioma will continue to involute as it normally does. The medication can be started as early as one month of age when necessary. Alternatives to propranolol include oral steroids, steroid injections, or a chemotherapeutic agent (ie, vincristine) for aggressive and resilient types.

Before and after photos of child treated with propranolol for infantile hemangioma of face and chest.
Rapidly-convoluting congenital hemangioma of a child’s shoulder.

Surgery is reserved for hemangiomas that are causing symptoms (eg, ulceration or frequent bleeding) or functional obstruction such as those located over the eyelid or inside the airway. Sometimes, smaller hemangiomas may benefit from early excision to avoid social insecurity during childhood. The decision to pursue a surgical option should be largely guided by the surgeon, who will evaluate whether or not any particular hemangioma can be excised without causing significant secondary deformity.

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Is a hemangioma the same as a port wine stain?

There is a lot of misinformation in the world of vascular birthmarks. A study by our own practice revealed a rate of misdiagnosis more than 65 percent among patients referred. Hemangiomas are NOT the same as port wine stains. Hemangiomas are benign blood vessel tumors that have a fairly predictable life cycle as described above. Port wine stains are capillary malformations that are present at birth and persist throughout life. The importance of making the correct diagnosis cannot be emphasized enough. Treatment options are vastly different between these two conditions. Port wine stains are largely treated with pulsed-dye lasers. Depending on the size of the stain, several treatments over the course of a lifetime are necessary. Early treatment when the port wine stain is light is now recommended. Although certain hemangiomas may respond well to similar laser treatments, this is still not effective for large ones.

In addition, there are other considerations with port wine stains. Some of these are associated with overgrowth conditions when located over a limb. A child may demonstrate a limb length discrepancy as he or she grows. This is sometimes pronounced during puberty and may require treatment in the form of orthotics, if it significantly affects walking. In addition, port wine stains occurring over the face need to be scrutinized closely for associated problems, including glaucoma, migraines, and seizures. The combination of theses symptoms is known as Sturge Weber syndrome. Although rare, it is important to recognize this condition and have a multidisciplinary team in place to include a plastic surgeon, neurologist, and ophthalmologist.

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Last modified by Dr. Andre Panossian