Infantile Hemangiomas: Definition and Treatment
Infantile hemangiomas (IHs) are benign vascular tumors characterized by abnormal proliferation of endothelial cells that occur in up to 5% of infants, making them the most common benign tumors of infancy. 1
Definition and Classification
Infantile hemangiomas have distinct characteristics:
- Typically develop during the first weeks or months of life
- Follow a natural history of rapid growth followed by gradual involution
- Can be identified by immunohistochemical staining with erythrocyte-type glucose transporter protein
Classification by Depth:
- Superficial: Red with little subcutaneous component (formerly "strawberry" hemangiomas)
- Deep: Blue and located below skin surface (formerly "cavernous" hemangiomas)
- Combined (mixed): Both superficial and deep components
Classification by Anatomic Appearance:
- Localized: Well-defined focal lesions
- Segmental: Involving an anatomic region, often plaque-like and >5cm
- Indeterminate: Neither clearly localized nor segmental
- Multifocal: Multiple discrete IHs at different sites 1
Natural History
IHs follow a predictable pattern:
- Appear by 4 weeks of age
- Most rapid growth occurs between 1-3 months
- Growth typically stops by 5 months
- Involution phase usually completes by 4 years of age
- Up to 70% leave residual skin changes (telangiectasia, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, scarring) 1
Treatment Approach
For most small, innocuous IHs, observation without treatment is appropriate as they will self-resolve. However, treatment is indicated for IHs that are life-threatening, cause functional impairment, pain, bleeding, or risk permanent disfigurement. 1
Risk Stratification:
High-risk IHs that may require intervention include:
- Facial IHs (risk of permanent scarring/disfigurement)
- Periorbital IHs (risk of visual impairment)
- Airway IHs (respiratory compromise)
- Large facial IHs (potential underlying vascular abnormalities)
- IHs at risk for ulceration (lip, perineum)
- Hepatic IHs
Treatment Options:
Pharmacologic Treatment:
- First-line: Propranolol at 2-3 mg/kg/day for at least 6 months, often until 12 months of age. This has largely replaced other treatments since 2008. 1
- Topical timolol for small, thin, superficial IHs
- Oral corticosteroids (prednisolone/prednisone 2-3 mg/kg/day) if propranolol cannot be used
- Intralesional steroid injections for small, localized IHs
Laser Treatment:
- Useful for early non-proliferating superficial lesions
- Treating ulceration
- Managing residual telangiectasia after involution 1
Surgical Management:
- Generally delayed until after infancy to allow for involution
- Indicated for residual deformities after involution
- Techniques vary based on location (circular excision with purse-string closure for facial lesions)
- Early surgery may be considered for specific anatomic locations with functional concerns 1, 2
Special Anatomic Considerations
- Eyelid IHs: Can cause astigmatism, strabismus, or amblyopia; early ophthalmology evaluation
- Airway IHs: May present with biphasic stridor and barky cough; requires endoscopy
- Liver IHs: Most common visceral location; screening ultrasound for infants with multiple cutaneous IHs
- Lip and perineal IHs: Higher risk of ulceration; early intervention may prevent complications 1
Monitoring and Follow-up
- Frequent evaluations during growth phase (1-5 months)
- Monitor for complications (ulceration, bleeding, functional impairment)
- Consider referral to hemangioma specialist for high-risk lesions
- Long-term follow-up may be needed as some patients require late intervention for recurrences 1, 2
Common Pitfalls
- Delaying referral for high-risk IHs during critical growth phase (1-3 months)
- Assuming all IHs will resolve without sequelae (up to 70% leave permanent skin changes)
- Misdiagnosing other vascular anomalies as IHs (congenital hemangiomas are distinct entities)
- Failing to screen for associated anomalies with large segmental IHs
- Overlooking potential thyroid dysfunction in infants with significant multifocal or diffuse hemangiomas 1