How to Deal with Infantile Hemangiomas

Infantile hemangiomas, often simply called “strawberry marks” due to their characteristic appearance, are the most common benign vascular tumors of infancy. While they can be a source of anxiety for parents, understanding their natural course, potential complications, and available treatment options is crucial for effective management. This comprehensive guide will equip you with the knowledge and actionable strategies needed to navigate the journey of dealing with infantile hemangiomas, ensuring the best possible outcome for your child.

Understanding Infantile Hemangiomas: The Basics

Before delving into management, it’s essential to grasp what infantile hemangiomas are and how they behave. These growths are a proliferation of endothelial cells, the cells that line blood vessels. They are not present at birth in most cases but typically appear within the first few weeks of life, undergoing a characteristic three-phase natural history:

• Proliferative Phase (0-12 months): This is the period of rapid growth. Hemangiomas can grow significantly in size and become more prominent, often appearing bright red and raised. The most intense growth usually occurs between 3 and 5 months of age.

• Involution Phase (12 months – 5-10 years): After the proliferative phase, the hemangioma begins to shrink and fade. This process, known as involution, is gradual and can take several years. The color typically changes from bright red to dull red, then purple, and eventually to a grayish-white or yellowish hue as the vascular tissue is replaced by fatty and fibrous tissue.

• Involuted Phase (Beyond 5-10 years): By this stage, the hemangioma has typically resolved, though some residual skin changes, such as telangiectasias (small, dilated blood vessels), atrophy (thinning of the skin), or textural changes, may remain.

It’s important to remember that every hemangioma is unique, and its growth and involution pattern can vary. While most hemangiomas are superficial (on the surface of the skin), some can be deep (subcutaneous) or mixed (both superficial and deep). Their location also plays a significant role in their potential impact and management.

When to Seek Professional Guidance: Identifying Potential Concerns

While the vast majority of infantile hemangiomas are harmless and resolve on their own without intervention, certain characteristics warrant prompt medical evaluation. Recognizing these “red flags” is the first step towards ensuring your child receives appropriate care.

Location, Location, Location: Critical Areas for Concern

The anatomical site of a hemangioma is often the most important determinant of its potential for complications. Hemangiomas in certain locations can interfere with vital functions or lead to significant disfigurement if left untreated.

• Periorbital (Around the Eye): Hemangiomas near the eye can obstruct vision, leading to amblyopia (lazy eye), a permanent vision impairment if not corrected early. Even partial obstruction or pressure on the globe can affect visual development. Example: A hemangioma on the eyelid growing to cover the pupil. This requires immediate ophthalmological consultation.

• Perioral (Around the Mouth): Hemangiomas around the mouth, especially on the lips, can interfere with feeding, lead to ulceration due to constant friction, or cause cosmetic distortion. Example: A hemangioma on the lower lip causing difficulty latching during breastfeeding or leading to recurrent bleeding when the baby eats.

• Nasal Tip (Nose): Often referred to as “Pinocchio nose” hemangiomas, these can cause significant disfigurement and may not involute completely, leaving residual tissue. They also have a higher risk of ulceration due to their exposed location. Example: A hemangioma growing on the tip of the nose, causing a bulbous deformity.

• Airway (Larynx/Trachea): Though rare, hemangiomas in the airway can be life-threatening. Symptoms might include noisy breathing (stridor), hoarseness, or difficulty breathing, especially when crying or agitated. Example: A baby developing a harsh, high-pitched breathing sound that worsens with activity. This is a medical emergency.

• Perineal/Diaper Area: These hemangiomas are highly prone to ulceration due to moisture, friction from diapers, and exposure to urine and stool. Ulceration can be extremely painful and lead to infection. Example: A hemangioma in the groin area becoming open, raw, and painful, making diaper changes difficult.

• Large Segmental Hemangiomas: These are typically larger, flatter, and involve a broader area of the body, often following a dermatomal distribution. They can be associated with underlying structural anomalies, such as PHACE syndrome (Posterior fossa malformations, Hemangioma, Arterial anomalies, Cardiac defects, Eye anomalies) or LUMBAR syndrome (Lower body hemangioma and other cutaneous anomalies, Urogenital anomalies, Myelopathy, Bony defects, Anorectal malformations, Renal anomalies). Example: A large, flat hemangioma covering one side of the chest and arm, prompting a workup for associated syndromes.

• Ulcerated Hemangiomas: Any hemangioma that breaks open and forms an ulcer is painful and at risk of infection. This is the most common complication of hemangiomas. Example: A hemangioma on the neck developing an open sore that is red, swollen, and weeping pus.

Rapid Growth and Multiple Hemangiomas

• Rapid Growth: If a hemangioma is growing unusually fast, particularly if it’s in a critical location, it needs prompt evaluation.

• Multiple Hemangiomas: The presence of five or more cutaneous hemangiomas may warrant an ultrasound of the liver to rule out hepatic hemangiomas, which can sometimes lead to complications like high-output heart failure. Example: A baby with several small hemangiomas scattered across their body, leading the pediatrician to recommend a liver ultrasound.

Navigating Treatment Options: A Tailored Approach

The decision to treat an infantile hemangioma, and the choice of treatment, is highly individualized. It depends on several factors, including the hemangioma’s location, size, growth pattern, presence of complications, and potential for long-term disfigurement. The goal of treatment is to prevent complications, minimize residual skin changes, and improve cosmetic outcomes.

Watchful Waiting: The Power of Observation

For many hemangiomas, especially small, uncomplicated ones in non-critical areas, the most appropriate approach is “watchful waiting.” This involves closely monitoring the hemangioma’s growth and involution, with regular follow-up appointments with your pediatrician or a specialist.

• When it’s appropriate: Small, superficial hemangiomas away from vital structures, deep hemangiomas that are not causing functional impairment, and hemangiomas that have already begun to involute.

• What it involves: Regular measurements, photographic documentation, and parental observation for any changes in size, color, or the development of ulceration. Example: A small, pea-sized hemangioma on a baby’s back that is tracked monthly with photos to ensure it’s not growing rapidly or causing any issues.

Medical Management: First-Line Treatments

For hemangiomas requiring intervention, medical therapies are typically the first line of treatment. These aim to halt growth and accelerate involution.

Propranolol: The Game-Changer

Oral propranolol has revolutionized the treatment of problematic infantile hemangiomas. It is a beta-blocker that works by constricting blood vessels, decreasing blood flow to the hemangioma, and promoting apoptosis (programmed cell death) of the endothelial cells.

• How it’s administered: Typically given orally, two or three times a day, often mixed with a small amount of breast milk or formula. The dosage is weight-based and gradually increased.

• Indications: Propranolol is indicated for proliferating hemangiomas that are:

  • Life-threatening (e.g., airway involvement).

  • Function-threatening (e.g., periorbital affecting vision, perioral affecting feeding).

  • Ulcerated and refractory to wound care.

  • Causing significant disfigurement, especially on the face.

  • Large segmental hemangiomas.

• Potential side effects: While generally well-tolerated, side effects can include:

  • Bradycardia (slow heart rate): Usually mild and clinically insignificant, but monitored at the start of treatment.

  • Hypotension (low blood pressure): Rare with appropriate dosing.

  • Hypoglycemia (low blood sugar): More common in younger infants or during periods of poor feeding. Parents are often advised to give doses with feeds.

  • Bronchospasm: Worsening of asthma-like symptoms, rare in infants without pre-existing respiratory issues.

  • Sleep disturbances, irritability, cold extremities.

• Monitoring: Treatment initiation often involves a brief hospital stay for baseline vital signs and observation. Subsequent monitoring is typically done outpatient, with regular checks of heart rate, blood pressure, and blood sugar. Example: A 3-month-old with a rapidly growing hemangioma on the eyelid causing partial vision obstruction is started on oral propranolol, with parents monitoring for lethargy or difficulty feeding, and regular follow-up with the ophthalmologist and pediatrician.

Topical Beta-Blockers (Timolol): For Superficial Lesions

Topical timolol maleate solution (often in gel-forming eye drop formulation) is a good option for small, superficial, non-ulcerated hemangiomas. It works similarly to oral propranolol but has minimal systemic absorption, leading to fewer side effects.

• How it’s administered: Applied directly to the hemangioma, typically twice a day.

• Indications: Small, thin, superficial hemangiomas that are not rapidly growing or causing functional impairment. Example: A small, bright red hemangioma on a baby’s cheek that is not growing very fast is treated with topical timolol by applying a small drop with a clean finger twice a day.

• Potential side effects: Generally minimal, but can include local irritation, mild redness, or rarely, systemic absorption leading to mild bradycardia.

Corticosteroids: A Less Common Option

Systemic corticosteroids (oral or injected) were once the mainstay of hemangioma treatment but have largely been replaced by propranolol due to more significant side effects (e.g., growth retardation, Cushingoid features, immunosuppression). They are now rarely used, primarily in cases where propranolol is contraindicated or ineffective. Intralesional corticosteroids (injected directly into the hemangioma) can be used for very specific, localized lesions, like small periorbital hemangiomas.

• Indications: Reserved for very specific, often refractory cases.

• Potential side effects: Systemic corticosteroids carry a wide range of side effects. Intralesional injections carry risks of skin atrophy, pigment changes, and very rarely, embolization to the retinal artery.

Other Therapies: When Specialized Approaches are Needed

For specific types of hemangiomas or in cases where medical therapies are not sufficient, other specialized treatments may be considered.

Pulsed Dye Laser (PDL): For Residual Lesions or Ulceration

PDL targets the blood vessels within the hemangioma. It’s not typically used for rapidly proliferating hemangiomas as a primary treatment, but it can be very effective for:

• Ulcerated hemangiomas: PDL can promote healing of ulcers by reducing inflammation and promoting re-epithelialization.

• Residual telangiectasias: After involution, some hemangiomas may leave behind tiny, dilated blood vessels that give a reddish tint to the skin. PDL can improve this residual redness.

• Thin, superficial hemangiomas: In very selected cases, it can be used for thin, superficial lesions.

• What it involves: Multiple treatment sessions are typically required. Example: A fully involuted hemangioma on the forehead leaves behind some fine red lines. The child undergoes a few sessions of PDL to fade these lines and improve the skin’s appearance.

Surgery: For Specific Indications

Surgery is generally reserved for hemangiomas that:

• Fail to respond to medical therapy.

• Cause significant functional impairment or disfigurement that cannot be resolved by medical means.

• Leave significant residual tissue after involution (fibrofatty residuum).

• Have very specific characteristics, such as pedunculated (stalk-like) lesions.

• Are complicated by infection or uncontrolled bleeding.

• Types of surgical procedures: Can range from simple excision to more complex reconstructive procedures. Timing of surgery is crucial; it’s often performed after the proliferative phase or even after involution to allow for maximum natural regression. Example: A hemangioma on the earlobe that has completely involuted but left a significant baggy, soft tissue mass is surgically excised to restore the normal contour of the earlobe.

Embolization: For High-Flow Lesions or Pre-Surgical Management

Embolization is a procedure where substances are injected into the blood vessels supplying the hemangioma to block blood flow. It’s typically reserved for very large, high-flow hemangiomas that are causing significant complications (e.g., high-output cardiac failure) or as a pre-surgical measure to reduce blood loss during excision of very vascular lesions.

• Indications: Reserved for complex, high-risk cases.

• What it involves: Performed by an interventional radiologist. Example: A very large hemangioma in the liver causing strain on the baby’s heart. Embolization is performed to reduce the blood flow to the hemangioma and alleviate the cardiac stress.

Managing Complications: Proactive Care

Even with careful monitoring, complications can arise. Knowing how to address them promptly can prevent further issues and discomfort for your child.

Ulceration: The Most Common Challenge

Ulceration is the breakdown of the skin surface over the hemangioma, leading to an open sore. It’s painful and prone to infection.

• Signs of ulceration: Redness, swelling, a break in the skin, bleeding, pain (baby may cry when the area is touched or during diaper changes), and sometimes discharge.

• Management:

  • Pain control: Acetaminophen or ibuprofen can help manage pain.

  • Wound care:

    • Gentle cleaning: Cleanse the ulcer daily with mild soap and water or saline.

    • Non-adherent dressings: Apply a non-adherent dressing (e.g., petroleum jelly gauze, hydrogel dressings) to keep the wound moist and prevent it from sticking to clothing or diapers.

    • Frequent diaper changes: For perineal lesions, change diapers frequently and use barrier creams around the ulcer to protect healthy skin.

    • Topical antibiotics: May be prescribed if signs of infection are present.

    • Oral antibiotics: For more significant infections.

  • Propranolol: Starting or increasing propranolol can help accelerate healing of ulcerated hemangiomas by reducing inflammation and promoting blood vessel regression. Example: A hemangioma on a baby’s arm develops an open sore. The parents are instructed to clean it gently, apply a non-stick dressing, and are given a prescription for a topical antibiotic cream. The pediatrician also considers starting oral propranolol to speed up healing.

Bleeding: Usually Minor, Sometimes More Significant

Hemangiomas are made of blood vessels, so they can bleed, especially if traumatized or ulcerated.

• Management of minor bleeding:
  • Apply direct pressure: Use a clean cloth or gauze and apply firm, continuous pressure for 5-10 minutes.

  • Elevate the affected area: If possible, elevate the part of the body with the bleeding hemangioma.

  • Ice pack: A cold compress can help constrict blood vessels.

• When to seek medical attention: If bleeding is profuse, persistent, or if the child shows signs of significant blood loss (e.g., lethargy, paleness). Example: A child scratches their hemangioma, causing it to bleed. The parent applies pressure with a clean cloth for 5 minutes, and the bleeding stops. No further action is needed.

Infection: A Risk with Ulceration

Any open wound, including an ulcerated hemangioma, is susceptible to infection.

• Signs of infection: Increased redness, swelling, warmth around the ulcer, pus or purulent discharge, foul odor, fever, and increased pain.

• Management: Prompt medical evaluation. Treatment usually involves oral or topical antibiotics, depending on the severity. Example: An ulcerated hemangioma becomes increasingly red and swollen, with a yellowish discharge. The doctor prescribes an oral antibiotic after examining the child.

Functional Impairment: A Priority for Intervention

Hemangiomas in critical locations can impair vital functions.

• Vision obstruction (Amblyopia): If a periorbital hemangioma blocks vision, aggressive treatment (usually propranolol) is crucial to prevent permanent vision loss. Regular ophthalmological follow-up is essential to monitor visual development. Example: An infant with a hemangioma on the upper eyelid is regularly assessed by an ophthalmologist who monitors for amblyopia and adjusts propranolol dosage as needed.

• Airway obstruction: Life-threatening. Requires immediate medical attention and often systemic therapy (propranolol) or, in severe cases, intubation and laser treatment or tracheostomy.

• Feeding difficulties: Perioral hemangiomas can make feeding challenging. Treatment with propranolol can help shrink the lesion, improving feeding ability.

• Pain: Ulcerated hemangiomas are very painful. Pain management is a priority, alongside treatment to promote healing.

Long-Term Outlook and Residual Changes: What to Expect

Even after complete involution, some hemangiomas may leave behind residual skin changes. Parents should be prepared for these possibilities and discuss them with their healthcare provider.

• Telangiectasias: Small, persistent red blood vessels that can be treated with pulsed dye laser.

• Atrophy/Textural changes: The skin over the involuted hemangioma may appear thinner, wrinkled, or have a different texture than the surrounding skin.

• Hypopigmentation/Hyperpigmentation: Lighter or darker patches of skin may remain.

• Fibrofatty residuum: Especially with larger or deeper hemangiomas, a soft, fatty, or fibrous lump may be left behind. This can sometimes be surgically excised if it’s cosmetically bothersome.

• Scarring: Particularly after ulceration or surgical intervention, scarring may occur.

It’s important to have realistic expectations. The goal is to minimize these residual changes as much as possible, but complete restoration to pristine skin is not always achievable. Open communication with your child’s dermatologist or specialist is key to managing these long-term outcomes.

Supporting Your Family: Emotional and Practical Tips

Dealing with an infantile hemangioma can be emotionally challenging for parents. It’s crucial to acknowledge these feelings and seek support.

Emotional Well-being: Coping with Anxiety and Stress

• Acknowledge your feelings: It’s normal to feel worried, anxious, or even guilty. Don’t suppress these emotions.

• Educate yourself: Knowledge is power. Understanding the hemangioma’s natural course and treatment options can reduce anxiety.

• Seek support: Talk to your partner, family, friends, or other parents who have gone through similar experiences. Online forums or support groups can also be valuable resources.

• Focus on the positive: Remind yourself that most hemangiomas resolve without major issues and that effective treatments are available.

• Practice self-care: Ensure you are getting enough rest, eating well, and engaging in activities that help you relax.

Practical Tips for Daily Management

• Gentle skin care: Keep the skin around the hemangioma clean and moisturized. Avoid harsh soaps or vigorous rubbing.

• Sun protection: Protect the hemangioma from sun exposure, especially if it’s ulcerated or thin. Use protective clothing or a broad-spectrum sunscreen (for infants over 6 months) if direct sun exposure is unavoidable.

• Monitor for changes: Regularly observe the hemangioma for any changes in size, color, texture, or signs of ulceration. Keep a growth chart or take weekly photos to track progress.

• Communicate with healthcare providers: Maintain open and honest communication with your pediatrician and any specialists involved in your child’s care. Ask questions and voice any concerns you have.

• Childproofing: If the hemangioma is in an area prone to trauma (e.g., forehead, knee), try to childproof your home to minimize accidental bumps or scrapes.

• Dressing considerations: For larger or ulcerated hemangiomas, choose loose-fitting clothing that won’t irritate the area.

Conclusion: A Journey of Care and Patience

Infantile hemangiomas, while often initially alarming, are generally benign and self-limiting. The journey of dealing with them involves a combination of careful observation, timely intervention when necessary, and comprehensive management of any complications that may arise. With the advent of effective treatments like propranolol, the outlook for children with problematic hemangiomas has significantly improved, minimizing the long-term impact on their health and appearance. By understanding the nature of these unique birthmarks, actively engaging with healthcare professionals, and providing a supportive environment for your child, you can confidently navigate this experience, ensuring the best possible outcome and a healthy, happy future.