KidsMD Health Topics

Hemangioma

  • Overview

    When you saw that your baby had a birthmark, you may have been concerned. But rest assured that birthmarks are very common in infants—and most of them are pretty harmless.

    Your doctor probably told you that your child’s birthmark was called a hemangioma, which leads to more questions. At Children’s Hospital Boston, we’ve got answers for you.

    • An infantile hemangioma is a benign vascular tumor that usually appears as a red birthmark anywhere on your baby’s body within one to two weeks of birth.
       
    • Most infantile hemangiomas don’t cause problems and go away without treatment.
       
    • They grow rapidly for the first few months of life. About the time your baby turns one, the hemangioma may begin to shrink and fade until your child is between five and seven years old.

    How Children’s approaches hemangioma

    Children’s has the largest Vascular Anomalies Center in the world. So if your child’s hemangioma does need treatment, you’re in the right place. Here at the VAC, we have a team of 25 physicians—representing 16 medical and surgical specialties—who are experts in the field of vascular anomalies. This team approach ensures that your child’s treatment plan is carefully developed and coordinated with the expertise of our specialists in vascular anomalies and in other medical areas throughout the hospital.

    We’re also the worldwide referral center for new cases of vascular anomalies like hemangiomas. The large volume of patients seen and reviewed each year contributes to our team's expertise and familiarity with the latest treatment options for your child.

    Dealing emotionally with your child’s birthmark

    If your child has a prominent birthmark during early infancy, you may experience a range of emotions, from disappointment to fear. Read about ways to cope with emotions you may experience, such as panic, sadness, a sense of isolation and guilt or self-blame.

    Hemangioma: Reviewed by Arin K. Greene, MD, MMSc.
    © Children’s Hospital Boston, 2010


  • In-Depth

    Seeing a hemangioma on your baby’s skin can be scary, but most of these benign tumors go away on their own without any treatment.

    So try not to worry. Hemangiomas are quite common. And if your baby does require treatment, the doctors at Children’s Hospital Boston are experts in the care and treatment of infantile hemangiomas.

    How common are hemangiomas? 

    Hemangiomas are the most common benign tumor in infants. Between four and ten percent of Caucasian infants are born with at least one hemangioma.

    Hemangiomas are three to five times more common in females (especially fair-skinned girls) than in males, and occur more frequently in Caucasian infants than in Asian infants. They are rare in African-American infants. Premature infants are more likely to have hemangiomas.

    Where do hemangiomas occur?

    About 60 percent of hemangiomas occur in babies’ head and neck area. About 25 percent occur in the trunk and 15 percent occur in the arms or legs.

    About 80 percent of hemangiomas grow as a single tumor, and about 20 percent occur in multiple areas.

    While hemangiomas primarily grow within the skin, they do sometimes develop in an internal organ, including the liver and gastrointestinal tract.

    Should we talk to a vascular anomalies specialist? 

    Since most hemangiomas go away on their own without any treatment, the majority of children do not need to see a specialist in vascular anomalies. Your child’s pediatrician will monitor the lesion, provide support and reassurance, and contact a specialist if and when appropriate.

    You should take your child to see a vascular anomalies specialist if any of the following conditions apply:

    • Your doctor isn’t sure about the diagnosis.
    • Your child’s hemangioma develops a scab.
    • Your child’s hemangioma is on her face.
    • The hemangioma is large, growing rapidly or in a spot (near the eye, for example) where it could cause complications.
    • Your child has multiple hemangiomas — this can be a sign that your child has a hemangioma in an internal organ, such as the liver or gastrointestinal tract, which could require treatment.
    • Your child has a hemangioma along the spine — this can be a sign that your child has a malformed spine.

    Causes

    What causes hemangiomas?

    Researchers led by Joyce Bischoff, PhD, in Children's Vascular Biology Program, recently discovered that hemangiomas originate from stem cells. This discovery has led to more research into how we can use medications to stop the growth of tangled masses of blood vessels that make up a hemangioma.

    Hemangiomas are not hereditary, and no known food, medication or activity during pregnancy can cause a hemangioma.

    When do hemangiomas occur?

    The average age when hemangioma appears is two weeks old. Sometimes your doctor will notice a hemangioma just after your baby is born while she’s still in the hospital.

    Your doctor may not notice a deep hemangioma until your baby is three to four months old, because these hemangiomas don’t leave the typical red mark on your baby’s skin. They never develop in adults.

    Signs and symptoms

    What does a hemangioma look like?

    There are a few different kinds and they have different appearances.

    Superficial hemangioma: This most common type of hemangioma has a raised bright-red patch, sometimes with a textured surface. Usually, the last traces of color have faded by the time your child reaches age seven.

    Deep hemangioma: These hemangiomas appear bruise-like or bluish in color. They’re often not diagnosed until swelling becomes apparent —when your child is around two to four months old.

    Congenital hemangioma: These hemangiomas are large at birth and are purplish with prominent veins; they also may be encircled by a pale halo. There are two kinds of hemangiomas that are present at birth.

    • Non-involuting congenital hemangioma (NICH) — This kind of hemangioma appears fully formed and does not shrink over time like most other hemangiomas.
    • Rapidly involuting congenital hemangiomas (RICH) — This kind of hemangioma appears fully formed and then shrinks over the course of the first year of your baby’s life.

    Complications

    What are the possible complications of hemangiomas?

    While most hemangiomas grow and shrink without causing your child much trouble, complications with hemangiomas can happen.

    They include the common:

    • As the skin stretches around your child’s hemangioma, it can develop a wound and/or scab.

    And the rare:

    • A hemangioma around your child’s eye or throat can cause problems with vital functions such as vision or breathing.
    • A large facial hemangioma can be disfiguring.
    • A hemangioma in an internal organ can cause internal bleeding or heart failure (this is exceedingly rare).

    Long-term outlook

    What is the long-term outlook for my child?

    There are very few long-term risks of hemangiomas. Most hemangiomas go away on their own without any treatment.

    If your child’s hemangioma does need treatment, our doctors can use a variety of methods to reduce the threat of further complications. For more information on treatment methods, see the Treatment & Care section.

    About half of all hemangiomas will leave behind some extra skin, blood vessels and fatty tissue after they shrink. A doctor can help with these cosmetic issues, which you may want to address before your child begins school.

    Can a hemangioma start growing again after it has shrunk?

    No — once they’ve shrunk, hemangiomas never come back.

    FAQ

    Q: What is a hemangioma?
    A:
    It’s a benign (not cancerous) vascular tumor that grows quickly during the first few months of your child’s life and then slowly begins to shrink and fade when your child is about one year old.

    Q: How common are hemangiomas?
    A:
    They’re pretty common. Between four and ten percent of Caucasian infants are born with at least one hemangioma.

    Hemangiomas are three to five times more common in females (especially fair-skinned girls) than in males, and occur more frequently in Caucasian infants than in Asian infants. They are rare in African-American infants. Premature infants are more likely to have hemangiomas.

    Q: What does a hemangioma look like?
    A:
    There are a few different kinds and they have different appearances.

    Superficial hemangioma: Raised bright-red patch, sometimes with a textured surface. Usually, the last traces of color have faded by the time your child reaches age 7.

    Deep hemangioma: Appear bruise-like or bluish in color. These types of hemangiomas often aren’t diagnosed until swelling becomes apparent —when your child is around 2 to 4 months old.

    Congenital hemangioma: These are large at birth, round or oval and are purplish with prominent veins and may be encircled by a pale halo.

    Q: What do we do about it?
    A:
    Most hemangiomas go away on their own without any treatment. We recommend that a primary care physician monitor your child’s lesion, provide support and reassurance and contact a vascular anomalies specialist if the situation warrants.

    You should take your child to see a vascular anomalies specialist if any of the following conditions apply:

    • Your doctor isn’t sure about the diagnosis.
    • Your child’s hemangioma develops a scab.
    • Your child’s hemangioma is on the face.
    • Your child’s hemangioma is large, growing rapidly or in a spot (near the eye, for example) where it could cause complications.
    • Your child has multiple hemangiomas — this can be a sign that your child has a hemangioma in an internal organ, such as the liver or gastrointestinal tract, which could require treatment.
    • Your child has a hemangioma along the spine — this can be a sign that your child has a malformed spine.

    Q: Will my child’s hemangioma require treatment?
    A:
    Not usually. Most hemangiomas grow and shrink on their own and don’t require formal treatment.

    If your child’s hemangioma does require treatment, Children’s is home to the world’s largest Vascular Anomalies Center — which means we’ve got the expertise and experience to make sure your baby returns to good health as quickly as possible.

    Q: What if my child’s hemangioma does need treatment?
    A:
    Our doctors use corticosteroids and other methods to slow the growth of the hemangioma and help to shrink it. For more information on treatment methods, see the Treatment & Care section.

    Q: Can a hemangioma start growing again after it has shrunk?
    A:
    No — once they’ve shrunk, hemangiomas never come back.

    Q: Will my child’s hemangioma completely go away?
    A:
    Not usually. While your child’s hemangioma will shrink, about half of these tumors leave behind excess skin, fat or blood vessels — there may also be some discoloration of the skin around the lesion.

    Q: How long will it take to completely shrink?
    A:
    This varies, but most hemangiomas have finished shrinking by the time your child is between five and seven years old.

    Q: What can we do about the excess skin, tissue and blood vessels?
    A:
    The excess skin and fat can be surgically removed. Pulsed-dye laser therapy effectively eliminates the extra blood vessels.

    Q: What makes Children’s different?
    A:
    We’re home to the first and largest Vascular Anomalies Center in the world.

    When doctors in other states or other countries need help diagnosing or treating children with vascular anomalies, including hemangiomas, they often come to us.

    Questions to ask your doctor

    It can be difficult to remember all the questions that you want to ask your child’s doctor at the appointment, and many parents find it helpful to jot them down. Here are some to get you started:

    • What kind of birthmark does my child have?
    • Could it be serious?
    • Is there anything we should watch for?
    • What treatments are available for removing the birthmark, if appropriate?
    Stem cells suggest a better therapy for hemangiomas

    Researchers in Children's Vascular Biology Program discovered that hemangiomas originate from stem cells. Steroids can interfere with these cells, blocking their ability to stimulate blood vessel growth. Bischoff's lab is now searching for other agents that could stop the proliferation of hemangioma stem cells and prevent them from forming unwanted blood vessels.

  • Tests

    When you make an appointment at Children’s Hospital Boston, we start with a complete medical history and a thorough physical exam. Your doctor may be able to diagnose your baby’s hemangioma simply by looking at it.

    If it’s unclear, your child will have one or more of the following imaging tests:

    • ultrasound (also called ultrasonography) — An ultrasound also shows the size of the hemangioma and allows your doctor to see how much blood is flowing through it.
    • magnetic resonance imaging (MRI) — This high-resolution scan shows how large your child’s hemangioma is, as well as its relationship to nearby muscles, nerves, bones and other blood vessels.

    If these tests prove inconclusive — or if there is any suspicion of cancer — your doctor will perform a biopsy. A biopsy is a surgical procedure where a doctor removes a small tissue sample.

    Examining the tumor's cellular appearance under a microscope allows the physician to determine definitively whether your child has a hemangioma or another type of lesion.

    If your child has had a biopsy done elsewhere, we can use it instead of performing another biopsy.

    It’s important to get an accurate diagnosis because some vascular anomalies look like hemangiomas but may be vascular malformations or other types of vascular tumors.

  • Finding out that your child has a hemangioma can be upsetting. But you can rest assured that your child is in good hands here at Boston Children's Hospital. Our physicians are bright, compassionate and committed to focusing on the whole child, not just his or her condition — that's one reason we're frequently ranked as a top pediatric hospital in the United States.

    And should your child's hemangioma need treatment, Children's is home to the world's first and largest Vascular Anomalies Center — which means we've got the expertise and experience to make sure your baby returns to good health as quickly as possible.

    How are hemangiomas treated?

    Most hemangiomas don't require any treatment (other than observation) because they go away on their own.

    In some children, loose skin, discoloration or tiny, dilated blood vessels may remain after the hemangioma has shrunk. When this occurs, an operation or laser therapy can improve your child's appearance; often treatment is done before your child starts school.

    How do I care for my child's hemangioma at home?

    While most hemangiomas don't require formal treatment, there are some things you can do. Because the skin is stretching during the growth phase of the hemangioma, the lesion can be prone to ulceration and bleeding.

    • Keep your child's skin around the lesion moist with a hydrated petroleum gel.
    • If your child's lesion does begin to bleed, wash the wound gently twice a day with soap and water.
    • You can also apply a topical antibiotic to reduce the risk of infection.

    If the affected area is large, you'll need to dress your baby's wound several times a day.

    Although an ulcerated lesion may look unsightly and be painful for your baby, remember that it will eventually heal – most within two weeks.

    Are there hemangiomas that require treatment from a doctor?

    Yes. If your child's hemangioma is obstructing vital functions like breathing or vision, your doctor will treat it. We'll also treat a hemangioma if the skin around it begins to bleed (or gets infected), or if the lesion distorts your child's facial features. We use medications and surgical procedures to treat these kinds of hemangiomas.

    Corticosteroids

    Researchers from Children's have found that steroids can act on hemangioma stem cells, interfering with their ability to stimulate new blood vessel growth, which allows the hemangiomas to grow.

    • If your child has a small hemangioma near his nose or eye — or if the hemangioma threatens important facial structures like the eyelid or lip — your doctor will probably recommend an injection of a corticosteroid into the lesion.
    • If the problematic hemangioma is larger, your doctor will likely recommend that your child take an oral steroid called prednisolone every day until the tumor has stopped growing (when your child is 10 to 12 months old).

    We've been using corticosteroids to treat hemangiomas for more than 40 years — they're very safe and effective in nearly every child we treat.

    You can usually see some or all of the following signs that the hemangioma is responding in less than a week.

    • decreased growth rate
    • fading color
    • softening of the lesion

    What about propanolol? Or interferon?

    Propanolol is another medication that can potentially be used to treat hemangiomas; however, the effectiveness and risk of this drug is still being studied. At the present time, we feel that steroids are more effective and safer than propanolol.

    Interferon has also been used to slow the growth of blood vessels in a hemangioma. However, there is a very real risk of interferon causing neurological problems in children less than one year old, so we no longer use this drug.

    Surgery

    While the tumor is growing

    We don't generally recommend surgery for hemangiomas while they are growing rapidly during a child's first year of life. However, your doctor may want to remove the hemangioma in certain circumstances.

    After the tumor has shrunk

    Half of hemangiomas leave behind excess skin and tissue after they've shrunk, and your doctor may recommend an operation to improve your child's appearance, and work with you to determine the best time for this operation. Many parents like to do it before their child enters school.

    Will my child have a scar?

    Every surgical operation results in a scar of some size. However, John B. Mulliken, MD, co-director of the Boston Children's Hospital's Vascular Anomalies Center, has developed an innovative way to reduce scars resulting from surgical removals of hemangiomas.

    You can find more information about this technique in the Research & Innovation section.

    Laser therapy

    We don't recommend laser therapy for hemangiomas while your child is an infant. It can cause scarring and does not stop the tumor from growing.

    However, pulsed-dye laser therapy is helpful to eliminate excess blood vessels after the tumor has fully shrunk.

    Embolization

    In very rare cases, your doctor may recommend embolization, a procedure in which particles are injected into affected blood vessels to stop the blood flow. We may use embolization to treat kids with congestive heart failure from a large hemangioma.

    Coping & support

    We understand that you may have a lot of questions when your child is diagnosed with a hemangioma. We've tried to provide some answers to those questions in these pages, and we also have a number of other resources to help you and your family.

    Patient education: From the first office visit, our nurses will be on hand to walk you through your child's treatment and help answer any questions you may have — Does my child need treatment? What can we expect next? They will also reach out to you by phone, continuing the care and support you received while at Children's.

    Parent to parent: Want to talk with someone whose child has a hemangioma? We can often put you in touch with other families who can share with you their experience.

    On our For Patients and Families site, you can read all you need to know about:

    • getting to Children's
    • navigating the hospital experience
    • resources that are available for your family

    And here are a few helpful pages with more information about hemangiomas:

    • Our Vascular Anomalies Center has a page with links to organizations that offer support and education for parents who have a child with a vascular anomaly.
  • Research & Innovation

    At Children’s Hospital Boston, we’re known for our science-driven approach. In fact, we’re home to the world's most extensive pediatric hospital research enterprise, and we partner with elite health care and biotech organizations around the globe. But as specialists in innovative, family-centered care, our physicians never forget that your child is precious, and not just a patient.

    Stem cells suggest a better therapy for hemangiomas
    Hemangiomas consist of tangled masses of blood vessels. Researchers led by Joyce Bischoff, PhD, in Children's Vascular Biology Program, recently discovered that infantile hemangiomas originate from stem cells. The corticosteroids typically used to treat problematic hemangiomas interfere with these cells and how they work, information that may help their lab find new approaches to treating hemangiomas.

    Since endothelial cells are the major cell type in blood vessels, they were assumed to be steroids’ target. But in the New England Journal of Medicine, Shoshana Greenberger, MD, PhD, in Bischoff's lab, demonstrated that steroids act on the much rarer hemangioma stem cells, blocking their ability to stimulate blood vessel growth by shutting down production of vascular endothelial growth factor (VEGF-A), a well-known stimulator of angiogenesis.

    “We already have drugs targeting VEGF, so our findings open the way to finding a more specific, safer therapy for hemangioma,” says Greenberger.

    Bischoff's lab is now searching for other agents that would shut down cellular VEGF-A, stop the proliferation of hemangioma stem cells and prevent them from forming unwanted blood vessels.

    New surgical technique decreases facial scarring

    Every surgical operation results in a scar of some size. However, John B. Mulliken, MD, co-director of Children’s Vascular Anomalies Center, has developed an innovative way to reduce scars resulting from surgical removals of hemangiomas.

    Instead of using a traditional excision that leaves a linear scar, we often remove hemangiomas with a circular excision and something called a “purse-string suture.” This technique results in a scar that’s approximately one-third of the length of a scar from the traditional surgical method.

    New surgical technique

    Watch a short video where Mulliken talks about how he developed his new technique that can decrease facial scarring and its benefits. 

  • Vascular Anomalies Center

    Boston Children's Hospital

    300 Longwood Avenue
    Fegan Building, 3rd Floor
    Boston MA 02115

    617-355-5226

     

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