Infantile hemangiomas are common benign tumors that occur in childhood, and it is important for clinicians who work with children to be familiar with methods of identifying these lesions. Although the patient’s caretakers may be concerned about them, many infantile hemangiomas resolve without treatment and complications. When complications do arise, it is important for health care providers to know how to recognize them and to be aware of the treatment options available.

Infantile hemangiomas may appear as erythematous lesions or tumors on the body, but they are often seen on the head and neck.1,2 The diagnosis is based mainly on clinical findings.3,4 Infantile hemangiomas occur most often in female or white infants.2 Factors that may predispose infants to the development of hemangiomas are low birth weight and premature birth.4 In most cases, there is no past family history of infantile hemangiomas, although in rare cases, they are associated with a hereditary condition.3,5



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Phases and subtypes

There are three different phases observed in infantile hemangiomas. The proliferative phase can occur between 2 to 3 weeks and 5 to 9 months after birth. In this phase, the infantile hemangioma can grow very quickly and may be noncompressible.1,3 Within 5 months, 80% of the growth of the hemangioma is completed, and after approximately 9 months, most hemangiomas are fully developed.1,4 Next is the plateau phase, in which slight variation in the infantile hemangioma can be observed. The final stage, or involutional phase, occurs between age 1 year and 5 to 10 years. The infantile hemangioma becomes more compressible, and the original erythematous lesion may acquire a purple or gray tone.4 Infantile hemangiomas often regress; however, fibrofatty or scar tissue may remain.3,6 

The three clinical subtypes of infantile hemangiomas are superficial, deep, and mixed.2 Superficial hemangiomas are located in the upper portion of the dermis and can appear erythematous. Deep hemangiomas may appear as purple or flesh-colored protuberances and are located in the lower portion of the dermis or in subcutaneous tissue.3 Mixed hemangiomas may combine features of superficial and deep hemangiomas.1,4 Hemangiomas may also be described according to their distribution on the skin. Localized hemangiomas appear more focal, with a round shape, whereas segmented hemangiomas cover a large area and are more likely to ulcerate and cause complications.2,7

Quick facts about infantile hemangiomas

  • They often occur in female or white infants.
  • They frequently appear on the head and neck.
  • Infantile hemangiomas evolve through a proliferative phase, a plateau phase, and an involutional phase.3
  • Some types of infantile hemangiomas are cutaneous, periorbital, hepatic, lumbosacral, and airway.
  • Treatments for the complications of infantile hemangiomas include propranolol, corticosteroids, laser therapy, and surgery.

Complications

Most infantile hemangiomas do not cause complications or require therapy.3 If the hemangioma is potentially fatal, affects the patient’s ability to function, or is physically deforming, then therapy is warranted.4 Complications that may be observed in patients with infantile hemangiomas are ulcers, infections, bleeding, visceral issues, vision problems, and difficulty breathing.1,3

Ulcers are the most frequently observed complication of infantile hemangiomas.3 Ulcers can cause pain, difficulty eating, and infections. Locations where ulcers commonly develop from infantile hemangiomas are the lower lip, neck, genital and anal areas, and regions of the body where apposed skin surfaces may rub against each other.3,4 If an infection develops, a culture may be required, followed by the administration of appropriate antibiotics. Pulsed dye laser can also be used to treat ulcers that are a complication of infantile hemangiomas.1,3

Vision may also be affected; periorbital infantile hemangiomas most often lead to astigmatism.4 Amblyopia may occur, resulting in blindness, and exophthalmos can arise if an infantile hemangioma is located in the posterior region of the eye.3 An ophthalmologist should be consulted when a patient has a periorbital infantile hemangioma, and therapy should be considered if needed.1,3 A beta-blocker, such as oral propranolol, may be useful for treating periorbital hemangiomas associated with astigmatism, causing them to involute.4

Difficulty breathing may develop if an airway is obstructed by an infantile hemangioma. Respiratory difficulty may become apparent when the patient is aged between 6 and 12 weeks. An airway hemangioma may manifest as coughing or stridor.1 For patients with airway hemangiomas, it is necessary to consult an otolaryngologist, and a coordinated medical team should treat this condition.3

Hemangiomas may develop in the viscera. If a patient has five or more skin hemangiomas, then an ultrasound should be performed to check for hepatic and other visceral involvement. Heart failure may arise in patients with hepatic hemangiomas.1,3 Hemangiomas in the lumbosacral region may be associated with spinal dysraphism, and magnetic resonance imaging may be required in these cases.3 A patient may have multiple hemangiomas, although multiple hemangiomas on the skin are found in only approximately 30% of cases.1

Complications of infantile hemangiomas

  • Bleeding
  • Difficulty breathing
  • Infections
  • Ulcers
  • Visceral issues
  • Vision problems

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Treatment

In most cases, infantile hemangiomas do not require therapy unless they are causing complications. The choice of treatment may be based on the age of the patient, as well as the size, depth, and stage of the hemangioma.4,7 The treatments currently used for infantile hemangiomas are propranolol, off-label medications, laser therapy, and surgery.1,3 Oral propranolol is now approved by the US Food and Drug Administration as a treatment for infantile hemangiomas and may work more quickly than steroids.2,8 It is important to try to treat complicated infantile hemangiomas during the proliferative phase to prevent expansion and allow regression to take place.5 

Beta-blockers, such as propranolol, are used to treat infantile hemangiomas and have been shown to stop expansion and result in regression of the lesions.1,5 Oral propranolol can lead to involutional changes in skin infantile hemangiomas and can alleviate stridor due to airway hemangiomas. In some cases, skin infantile hemangiomas may fully involute within 6 months of propranolol use.5 Propranolol may cause severe side effects, such as bradycardia and hypoglycemia.1,3 Therefore, it is best to administer propranolol when an infant feeds, and it is important for caregivers to be aware of indications of hypoglycemia in infants and know how to respond.3 A cardiology consult should be obtained and the patient’s electrocardiogram, vital signs, and serum glucose level should be evaluated before beta-blockers are administered to determine if they are appropriate for the patient.7 Topical beta-blockers can also be used for superficial cutaneous infantile hemangiomas. In particular, topical timolol appears to be helpful in resolving some small skin infantile hemangiomas by decreasing erythema and causing involution.5,8 Although timolol is recommended for some patients with cutaneous infantile hemangiomas, the safety of its use over time for this condition is still not fully known, and therefore caution is advised.5

Before oral propranolol, oral corticosteroids were commonly used to treat infantile hemangiomas. Corticosteroids help to prevent infantile hemangiomas from expanding but may not lead to full involutional changes.1,5 Corticosteroids also cause side effects, such as cushingoid characteristics, stunted growth, and immune system suppression, which may increase the risk for infections.3,7 Often, growth that is lost during corticosteroid treatment is regained once the corticosteroids are stopped.3 Intralesional corticosteroids have been used to treat infantile hemangiomas on the head and neck, and topical corticosteroids have been administered for localized superficial hemangiomas.6 

Vincristine has been used to treat infantile hemangiomas unresponsive to corticosteroid treatment.3,7 Propranolol is a more common drug of choice for infantile hemangiomas than vincristine; however, vincristine is preferred to interferon alfa.7 Side effects of vincristine are constipation, pain in the abdominal region, and foot drop due to toxic effects of the drug on the nervous system.1,3

Interferon alfa has been used to treat infantile hemangiomas; however, it has severe side effects, such as neurotoxicity and spastic diplegia.3,4 Recommendations in the literature regarding the use of interferon alfa for infantile hemangiomas are variable. Some authors recommend interferon alfa for infants older than 1 year with infantile hemangiomas that are potentially fatal or unresponsive to treatment and who receive close neurological monitoring, whereas others advise against the use of interferon alfa for infantile hemangiomas.1,3,4,7

Pulsed dye laser is the most frequently used laser for treating infantile hemangiomas, especially those that ulcerate.3,4,8 This laser therapy is used to treat superficial infantile hemangiomas, and multiple treatments may be required.4,7 Pulsed dye laser may diminish the pain caused by ulcerated infantile hemangiomas.3 However, scars, hypopigmented skin, and even ulcers may result from pulsed dye laser treatment.1,3,4

Surgery is a useful therapy for deep infantile hemangiomas and can remove excess fibrofatty tissue and scarring.1,4 A risk of surgery is bleeding; however, new techniques may prevent this complication.7 Surgery can also treat infantile hemangiomas if drug therapy is unsuccessful or the infantile hemangioma is potentially fatal or deforming. Surgery is used to treat airway and periorbital hemangiomas.3,7 

Conclusions

Infantile hemangiomas are benign lesions that commonly affect children and are generally diagnosed based on clinical findings. They are often found on the head and neck. Many of them resolve without treatment; however, complications may arise, including ulcers, infections, bleeding, visual problems, difficulty breathing, and visceral issues. Depending on the complication, propranolol, corticosteroids, vincristine, interferon alfa, laser therapy, and surgery may be therapeutic options.

Sarah Lund is a medical student at the University of Texas Medical School at Houston, and Maura Holcomb, MD, is a resident at the Baylor College of Medicine in Houston.

References

  1. Holland KE, Drolet BA. Infantile hemangioma. Pediatr Clin North Am. 2010;57(5):1069-1083. 
  2. Hartzell LD, Buckmiller LM. Current management of infantile hemangiomas and their common associated conditions. Otolaryngol Clin North Am. 2012;45(3):545-556. 
  3. Kwon EK, Seefeldt M, Drolet BA. Infantile hemangiomas. Am J Clin Dermatol. 2013;14(2):111-123.
  4. Callahan AB, Yoon MK. Infantile hemangiomas: a review. Saudi J Ophthalmol. 2012;26(3):283-291. 
  5. Lee KC, Bercovitch L. Update on infantile hemangiomas. Semin Perinatol. 2013;37(1):49-58.
  6. Craiglow BG, Antaya RJ. Management of infantile hemangiomas: current and potential pharmacotherapeutic approaches. Paediatr Drugs. 2013;15(2):133-138. 
  7. Fay A, Nguyen J, Waner M. Conceptual approach to the management of infantile hemangiomas. J Pediatr. 2010;157(6):881-888.
  8. Reddy KK. Management of infantile hemangiomas. J Cutan Aesthet Surg. 2014;7(2):85-86.

This article originally appeared on Clinical Advisor