February 8, 2018 | Categories: Health Care
Infantile hemangiomas are growths formed by collections of extra blood vessels in the skin. Perhaps the most common vascular birthmark, hemangiomas are common in infants. Anywhere from 5 percent to 10 percent of infants will have an infantile hemangioma, and sometimes they have more than one. Their specific cause is unknown, but they tend to be more common in girls, premature babies, and in twins and triplets.
Hemangiomas usually present as bright red bumps or patches or bluish lumps anywhere on the surface of the skin, says Richard J. Antaya, MD, professor of Dermatology, Pediatrics and Nursing and director, Pediatric Dermatology at Yale Medicine. They tend to grow quickly and go away very slowly.
Hemangiomas are noted about 30 percent of the time at birth as a little spot that’s red. Otherwise they first appear in babies from the ages of 2 weeks to 2 months, growing fairly rapidly for the first month or so then continuing to grow up to about five or six months old. When they are growing it’s called proliferation.
About 80 percent of hemangiomas stop growing by about 5 months, Dr. Antaya says. After hitting this plateau phase, they stay unchanged for several months, and then begin to slowly disappear over time (called involution). By the time children reach 10 years of age, hemangiomas are usually all gone.
Most of the time, hemangiomas are harmless. But in about 10 percent to 20 percent of cases, the growths will ulcerate or form sores, which can be extremely painful for babies. Ulcerations can appear anywhere, but high-risk sites include the lips, the neck, the diaper area, the lower back, and folds such as the armpit. Hemangiomas in the diaper area have about a 50 percent chance of developing an ulcer.
About 60 percent of infantile hemangiomas will leave some sort of mark behind. Once a baby with an infantile hemangioma gets an ulcer, it’s sure to leave a scar – If it is on a cosmetically sensitive area, such as the face, a scar left behind after the hemangioma shrinks may become a lifelong problem. The high-risk areas are the lip, nose, ear, cheek, forehead or eyelid.
Hemangiomas near the eye may compromise an infant’s vision either by closing the eyelid completely, or by putting pressure on the eye and blurring vision. According to Dr. Antaya, any baby who has a hemangioma on or near the eye should be evaluated by a pediatric ophthalmologist, who will perform a special examination to make sure that the baby’s visual acuity is okay.
And while it’s a good idea to bring any hemangioma to your doctor’s attention, particularly large hemangiomas on the face, head and/or neck are especially concerning. Rarely infants with large infantile hemangiomas in these locations can have multiple other birth defects. This is called PHACE syndrome. PHACE is an acronym that stands for: Posterior fossa (refers to possible abnormal structures in the brain, especially the cerebellum), Hemangioma, Arterial (refers to possible abnormal arteries in the brain, neck, eye or heart), Cardiac (refers to possible heart abnormalities), Eyes (refers to possible eye abnormalities). If a baby has a large hemangioma on the lower back, it could be a sign of associated spinal cord abnormalities. Even if the condition looks like it’s not causing the baby any problems, it should be promptly evaluated by a doctor with expertise in these conditions.
Usually a doctor needs only to see the skin marks to diagnose infantile hemangioma. The condition has a fairly straightforward appearance and pattern of growth and coloration, with the ones near the surface of the skin evolving from red little patches to bright red papules or bumps. Hemangiomas lacking the bright red color and/or with a purplish or bluish hue probably originate deeper below the skin.
While most diagnoses can be made in the doctor’s office, some hemangiomas in deeper tissues require further evaluation through ultrasound with Doppler or magnetic resonance imaging (MRI). The Pediatric Vascular Anomalies Clinic (PVAC) in Yale Medicine’s Pediatric Dermatology section employs handheld Doppler technology to detect increased blood flow in hemangiomas, resulting in early detection, diagnosis and treatment in some cases.
It’s Yale Medicine’s practice that, if an infant comes in with multiple hemangiomas on the skin’s surface and is younger than 6 months of age, the doctors will ultrasound the liver to make sure that the baby doesn’t have liver (or other internal) hemangiomas. (While internal hemangiomas are quite rare, they most commonly appear on the liver.)
Over the years, treatment for infantile hemangioma has generally followed a “watch and wait” approach. For most hemangiomas that’s still okay. But for more medically or cosmetically concerning cases – such as mid-facial hemangiomas, ones that appear on free edges or are ulcerated, ones that are near the eye or very large ones – doctors now treat them with a class of drugs called beta blockers.
The most widely used beta blocker is the oral medicine propranolol, which can be started when the baby is just a few weeks old and is usually taken for one year. Propranolol has been shown in clinical studies to result in a complete resolution of these hemangiomas in 60 percent of cases. Another potent beta blocker, timolol, which only comes as an eye drop, can be used “off-label” and be applied topically to the skin surface of certain types of hemangiomas to help them shrink. Ideally, this topical medication can shrink them enough so that the infant doesn’t require oral beta blockers.
Another treatment option is pulsed dye laser treatment. It works well for superficial hemangiomas, and is used to heal ulcerating hemangiomas and for the residual red vessels that are left behind after the hemangioma resolves. Once hemangiomas disappear, they can leave a scar or some saggy skin. The pulsed dye laser works well to get rid of that color after the fact. The Pediatric Vascular Anomalies Clinic (PVAC) in Yale Medicine’s Pediatric Dermatology section employs pulsed dye laser in conjunction with beta blockers to enhance the resolution of certain hemangiomas.
Many parents blame themselves for their infant’s hemangioma, but the truth is there are no known links between the condition and maternal diet, genetics, environmental factors or parental behavior.
For almost 20 years, Yale Medicine’s weekly Pediatric Vascular Anomalies Clinic (PVAC) has been caring for infants and children with hemangiomas and vascular anomalies and educating their parents, caregivers and primary medical providers. (For more helpful information on infantile hemangiomas from Yale’s PVAC point your browser to ) In close association with Yale Medicine’s Multidisciplinary Vascular Anomalies Center, dedicated to the care and management of patients of all ages with vascular lesions, patients have direct access to the best surgeons, radiologists and support staff. The PVAC offers inpatient and outpatient treatment – from laser treatments in the office to surgeries performed under general anesthesia at Yale’s Pediatric Surgical Center. The doctors take the time to explain every part of the process to parents. “We are equipped to diagnose and treat nearly all vascular lesions at our center,” Dr. Antaya says. After patients return home, Yale Medicine doctors continue to work with their local pediatricians and dermatologists to ensure a smooth and seamless transition.
This article was originally written for Yale’s School of Medicine website in 2016.
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