Hemangiomas are the most common vascular anomaly and the most common tumor of childhood and infancy.
Hemangiomas are abnormally dense collections of dilated small blood vessels (or capillaries). Although not necessarily present at birth, they do typically appear in the first two weeks of life. They are classified as non-cancerous blood vessel tumors that may occur anywhere in the body, including the skin or organs.
Deeper hemangiomas may not be apparent until two to three months of age. There may be a faint discoloration or barely visible spot at birth in approximately 30 percent to 40 percent of patients. Most hemangiomas (80 percent) appear as a single lesion on the body. Less commonly (20 percent), they may appear in multiple locations. There are more female patients with hemangiomas than there are males (approximately 3:1).
Hemangiomas often appear on the infant’s head and neck area or other areas that are easily noticed. This can be quite disconcerting to parents as they are frequently asked if their baby was injured or has a tumor.
In rare instances, these lesions may occur in locations that interfere with normal function. Depending on the size, hemangiomas may interfere with breathing, feeding or even urination. For example, hemangiomas involving the eyelid can interfere with development of normal vision and must be treated as quickly as possible.
Hemangiomas are often diagnosed by patient history and physical examination. When there is a deep lesion, magnetic resonance imaging (MRI) may be performed to determine the extent of the problem and any involvement of internal organs. Rarely, hemangiomas are associated with unusual syndromes or conditions. A thorough exam and additional tests may be required to detect the presence of these syndromes.
Hemangiomas Over Time
The growth of hemangiomas is unpredictable. During the first six to nine months of infancy, hemangiomas tend to grow rapidly. The hemangioma may become more noticeable during this phase. It will appear bright red and take on a slightly raised, or bumpy, configuration. However, if the hemangioma lies deep under the skin, the skin itself may appear bluish and only slightly raised.
It is also difficult to predict whether a hemangioma will shrink over time. After the initial growth phase, hemangiomas will then enter a shrinking phase. Shrinking occurs gradually and is sometimes not completed until the child is 10 years of age. During this time the color of the hemangioma (also commonly referred to as a birthmark) will fade to a dull purple or grey and will feel soft to the touch. Sometimes, the remaining skin overlying may not appear normal and, in fact, may feel and look like crepe paper. If there was an ulceration over the lesion, then there may be an associated scar. If present on the scalp or other hair bearing areas on the body, there may be permanent hair loss in these areas.
Hemangioma Before and After Shrinking (Involution)
There is no reliable way to predict the rate at which a particular hemangioma will shrink. But as a general rule, in approximately half of patients, the shrinking process is complete by five years of age, and by seven years of age in 70 percent of patients. Some congenital forms (those present at birth) will shrink more rapidly (rapidly involuting congenital hemagiomas), and others may not shrink at all (non-involuting congenital hemangiomas).
Most hemangiomas will regress or shrink on their own without intervention. For many lesions, patience and time may be the best treatment. However, for those lesions interfering with function or lesions that may interfere with a normal childhood, we may recommend removal.
Early Treatment is Important
In the past, many pediatricians recommended waiting to treat hemangiomas, but we have learned that early treatment provides significant advantages. During the first few months of life, the growing hemangioma acts like a balloon under the skin to expand both the affected and nearby normal skin. In many instances, early intervention allows the surgeon to remove the affected skin and then use the excess normal skin to close with tension, thus decreasing the size of the scar.
Surgeons may use laser treatment for color changes, surgery to remove redundant skin or liposuction to remove the fatty tissue under the skin. Makeup is also a good alternative to conceal any minor imperfections.
Hemangioma Before and After Case
For serious cases where the hemangioma poses an immediate risk to life or compromises important functions such as eyesight, the use of systemic corticosteroids may be considered. This medication may be given by mouth, through an IV or injected directly into the hemangioma and surrounding tissues. Corticosteroids can speed the involution phase or prevent further growth of the hemangioma. All interventions have risks and benefits; using corticosteroids is no different. The benefits of this treatment must be weighed against the potential risks, and a discussion must be initiated with the child’s parents and the treating physicians to determine the best course of action.
In some instances, arterial embolization (blocking the feeding blood vessels) may be possible. This will “choke” the hemangioma and cause it to shrink. However, not all patients are candidates for this therapy, and there is no certainty that the hemangioma will shrink. The procedure is performed by an interventional radiologist.
Hemangioma Before and After Case
The most common complication of hemangiomas is bleeding. Bleeding occurs because the skin overlying the hemangioma is much thinner and more friable than normal. If this skin dries out and cracks or is scratched, then the area may bleed or become ulcerated (breakdown of skin). Bleeding can be stopped very effectively with direct and continuous hand pressure over the hemangioma for five to 15 minutes. If bleeding is uncontrolled with hand pressure, then the child should be seen by a physician in a local emergency department. Ulcerations can be painful and very uncomfortable. They can also become infected.
Prevention is the preferred treatment for bleeding. Whether ulcerated or not, we recommend keeping the hemangioma clean with soap and water and moisturized at all times with any fragrance-free, mild moisturizing cream or even simple petroleum jelly. Trimming nails will also lessen the likelihood of inadvertently scratching the lesion. If irritated by clothing or a diaper seam, the hemangioma may be covered with a light gauze dressing to protect it from being rubbed and irritated.
Often, hemangiomas occur on the face or trunk. When present on the face, a hemangioma can cause considerable social stress for the parents and sometimes the child. Openly discussing these issues with each other and the medical team will alleviate much distress.