Hemangioma of Infancy
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An 8-month-old girl presented with a small but growing, strawberry-colored tumor over the left side of her neck at the angle of the jaw. The mass had been present at birth, measuring approximately 0.5 × 1.0 cm at the time. The parents were concerned about the tumors growth and appearance, and their primary care physician reassured them that it was a benign hemangioma and explained that the usual course is an initial increasing in size and a subsequent regression.
The girl had been born prematurely at 32 weeks’ gestation after premature contractions and prolonged rupture of membranes. No maternal fever, tachycardia, chorioamnionitis, or other complications had occurred. The girl had stayed in neonatal intensive care for 6 weeks because of feeding issues, and she had been transiently on nasal continuous positive airway pressure therapy, from which she was weaned to room air after 3 days of life. She was discharged at 38 weeks’ gestation.
During a follow-up visit at 2 months of age, the parents were anxious about the tumor’s rapid growth, and the girl was referred to pediatric dermatology. After evaluating the girl and noting the hemangioma’s location and rapidly increasing size, the dermatologist started her on propranolol 0.25 mg once daily. Still, the hemangioma continued to grow persistently, reaching 5 × 6 cm; the propranolol dose was increased to 0.5 mg twice daily, after which growth stabilized but with no significant reduction in size.
When the child had reached approximately 6 months of age, she had begun to scratch the hemangioma and rub it against toys and other items, resulting in severe ulceration of the lesion. After referral to pediatric dermatology, she was scheduled for surgical excision of the hematoma in order to prevent complications such as bleeding and secondary infection. She tolerated the procedure well, with no surgical complications, and afterwards was completely asymptomatic.
A hemangioma of infancy is a benign, self-involuting tumor of endothelial cells that usually appears during the first weeks to months of life. It is one of the most common birthmarks among newborns.
Superficial hemangiomas are benign endothelial tumors at the superficial layers of skin; they typically are bright red and lie flat against the skin. Deep hemangiomas develop in the lower skin layers and may appear smooth across the skin’s surface but develop a blue or gray color. Deep hemangiomas may not be detectable until a child is several weeks or months of age. Once detected, a deep hemangioma can feel firm or rubbery to the touch. Mixed hemangiomas, which extend along all skin layers, exhibit characteristics of superficial and deep hemangiomas, can be red or blue, and can appear as flat or raised lesions.
Hemangiomas are found in up to 10% of children by the age of 1 year and are more common in girls and premature infants. Their cause is unknown. In very rare instances, they may run in families, but they generally are not inherited.
Hemangiomas usually involute over time: 30% resolve by 3 years of age, 50% by 5 years of age, and 80% to 90% by 9 years of age. More than half of hemangiomas heal with excellent cosmetic results without treatment. Nevertheless, some hemangiomas require treatment, such as when a vital organ (eg, eye, ear, trachea) is involved; when bleeding, ulceration, crusting, or infection is present; or when their rapid growth leads to deformity of surrounding tissues. Hemangiomas in certain areas, particularly the face (especially the nose and lips), body folds, and groin, have a higher risk of complications.
Hemangiomas may be treated with medically or surgically. Cortisone may be given orally or injected into the hemangioma. Oral propranolol is now the treatment of choice for most infantile capillary hemangiomas.1 Infected and open hemangiomas may be treated with a short course of antibiotics and daily wound cleansing. Interferon alfa-2b therapy is limited to the most severe and potentially life-threatening hemangiomas, since it has serious potential adverse effects.2 Pulsed-dye laser therapy best treats the superficial blood vessels and usually is reserved for superficial hemangiomas. In rare instances, hemangiomas may be surgically removed, especially when they are unlikely to resolve spontaneously or lead to significant tissue distortion.
1. Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. Propranolol for severe hemangiomas of infancy. N Engl J Med. 2008;358(24):2649-2651.
2. Tamayo L, Ortiz DM, Orozco-Covarrubias L, et al. Therapeutic efficacy of interferon alfa-2b in infants with life-threatening giant hemangiomas. Arch Dermatol. 1997;133(12):1567-1571.