Hemangioma

A hemangioma is a type of benign (non-cancerous) tumor in infants. This abnormal cluster of small blood vessels appears on or under the skin, typically within one to three weeks after birth.

Often, there is no mark or only a faint birthmark on the skin that brightens in color and increases in size over the baby’s first two to four months of life (proliferative phase).

The area then stabilizes in size and color and then starts to fade and shrink (involution phase). Most hemangiomas are gone by 3 to 5 years of age. Some may cause residual areas of extra skin or small blood vessels called telangiectasias.

Most infantile hemangiomas cause no complications and go away without treatment. Between 4 to 10 percent of Caucasian infants are born with at least one hemangioma, and they are three to five time more common in females (especially fair-skinned ones) than males.

Premature infants are more likely to have a hemangioma, and they occur more frequently in Caucasian infants than Asian infants, and are rare in African-Americans.

Infantile hemangioma

There are three types of infantile hemangiomas, categorized by appearance and behavior:

Superficial hemangioma (“strawberry mark”)

• Most common type of hemangioma
• Raised bright-red patch, sometimes with a textured surface
• Can be focal (in one place) or diffuse (over a larger area)

Deep hemangioma

• Appear bruise-like or bluish in color
• Often diagnosed when swelling becomes apparent, usually around age 2 to 4 months

Combination

Lesions are deep under the skin with a cutaneous or superficial stain.

Multiple hemangiomas

Also called multifocal hemangiomas, these lesions appear on the skin, and if there are greater than five hemangiomas, they can have an increased risk for internal organ involvement. Multiple hemangiomas most commonly affect the liver. Children may have a few skin lesions to several hundred.

PHACE syndrome

Children with PHACE have a large hemangioma combined with other abnormalities.

Airway hemangiomas (subglottic or diffuse hemangioma)

A subglottic hemangioma is a large mass of blood vessels in the airway, typically below the vocal chords. They often grow for six to 12 months and then start to slowly shrink. It is a serious condition because the mass can obstruct the airway and affect a child’s ability to breathe.

Hemangiomas appear as a red birthmark within one to three weeks after birth. During the first six months of life, they may grow in size and protrude from the skin, and many eventually fade and disappear. Some hemangiomas present as deep lesions under the skin and may not be noted until later.

Skin hemangiomas may appear anywhere on a baby’s body. Common locations include:

• Face
• Chest
• Scalp
• Back

The size and color of your child’s hemangioma depends on what type it is.

Hemangiomas are rarely hereditary. There are no known food, medication, or activity during pregnancy that causes a baby to develop a hemangioma.

Researchers led by Joyce Bischoff, PhD, at Boston Children’s Vascular Biology Program, have discovered that hemangiomas originate from stem cells. This research might lead the way for more medication management options in the future.

Your visit will start with a complete medical history and a thorough physical exam. In most cases, the physician will be able to diagnose your child’s hemangioma simply by looking at it and reviewing the clinical history with the parent or caregiver.

If more information is needed to confirm your child’s diagnosis, the physician may request an ultrasound. An ultrasound is an imaging test that uses sound wave technology to examine the size of the hemangioma and allows your doctor to see how much blood is flowing through it.

In rare cases, the physician may need more information to confirm a diagnosis of more complicated hemangiomas. In this case, the physician may order a:

• MRI (magnetic resonance imaging): High-resolution scan that shows how large your child’s hemangioma is, as well as its relationship to nearby muscles, nerves, bones and other blood vessels.
• Biopsy: Surgical procedure that removes a small tissue sample for further testing of its cells under a microscope

Most hemangiomas go away by age 3 to 5 and do not require any treatment. Your child’s physician will recommend treatment if the hemangioma:

• Obstructs vital functions like breathing or vision due to its location
• Becomes infected or starts to bleed
• Distorts a child’s facial or other body features
• Is associated with other conditions that may be harmful to the infant

Treatment typically starts with medication management, which can slow the growth of a hemangioma and even shrink it. Your child’s physician may recommend surgery or laser therapy when medically necessary.

Propranolol for hemangioma

Propranolol is the first-line therapy for hemangioma in children, which means medical experts agree it is the most effective first step in treatment.

Propranolol, an oral medication, is a beta-blocker commonly used to treat cardiac issues such as high blood pressure. In infants and children with hemangiomas, propranolol inhibits and constricts the growth of blood vessels associated with the tumor and decreases factors that are causing its growth.

Medication management for hemangioma

Your child’s physician may recommend other drug therapies in combination with propranolol or as an alternative. These include:

• Selective beta-blocker therapy: These drugs may have fewer side effects and are currently under investigation
• Topical beta-blocker therapy, such as timolol: Used if the hemangioma is smaller in size
• Combination therapy: Children with more complicated lesions may benefit from two treatments, such as combining propranolol with corticosteroid or timolol

Surgery for hemangioma

Surgery is less common today with the development of advanced medications to shrink hemangiomas. Your child’s physician may recommend surgery if:

• The hemangioma interferes with a vital structure and surgery is necessary to remove the hemangioma
• The child has an ulcerated hemangioma
• The hemangioma has involuted but there are residual effects, such as changes to the skin that need to be corrected

Laser therapy for hemangioma

Laser therapy can:

• Improve the appearance of skin after a hemangioma has shrunk if telangiectasias are present
• Decrease pain in patients with ulcerated lesions

While most hemangiomas do not require formal treatment, there are steps you can take at home to help healing.

Because the skin is stretching during the growth phase, hemangiomas in certain areas (lip, GU area) can be prone to ulceration and bleeding.

• Keep the skin around the lesion moist with a fragrance-free ointment, such as Aquaphor.
• Gently wash a bleeding lesion daily with soap and water.
• Apply a topical antibiotic to reduce the risk of infection and dress the wound several times a day.
• Please call your physician if there are any signs of ulceration as your physician will direct the most appropriate management.

At Boston Children’s Hospital we treat children with hemangiomas in our Vascular Anomalies Center, considered a premier center in the world for vascular anomalies. We offer:

• Comprehensive team approach: At the Vascular Anomalies Center, patients and their families benefit from a comprehensive team of specialists working together to develop a treatment plan customized for your child. Our clinic brings together the expertise of many fields, including dermatology, hematology/oncology, interventional radiology (minimally invasive treatments), diagnostic radiology, and surgery (plastic surgery and general pediatric surgery).
• Unmatched expertise: Our team includes recognized experts in hemangioma care known for their ability to treat the full range of cases, from basic to multiple and more complex hemangiomas that may be associated with other conditions.
• Expert, on-site diagnosis: Patients and their families look to our team for second opinions and diagnosis of severe hemangiomas. When needed, we can perform ultrasound testing within our clinic during your appointment to provide fast answers and more convenience.
• Customized, leading treatments: We offer systemic medical management of hemangiomas using the latest and most advanced drug therapies available today. Many members of our team have been working with these medications since they were first prescribed for hemangiomas. Our team excels in customized or combined therapy plans to provide the most effective treatment possible.

At Boston Children’s Hospital, our vascular anomalies team is known for its expertise in diagnosing and treating the most severe and complex hemangiomas in infants and children.

Many members of our team have been working with propranolol and the latest medications used today since they were first studied in hemangioma patients. We continue to study the safety and effectiveness of the newest drugs and combination therapies, including:

• Propranolol
• Selective beta-blockers
• Topical beta-blockers, such as timolol
• Combination therapies using propranolol with steroids and topical agents such as timolol