Are there any residual effects after involution of a scalp hemangioma?

Residual Effects After Involution of Scalp Hemangiomas

Yes, residual skin changes frequently occur after involution of scalp hemangiomas, with approximately 50-70% of infantile hemangiomas leaving behind telangiectasias, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, or scarring. 1, 2

Natural History and Involution Timeline

Infantile hemangiomas follow a predictable life cycle:

• Most appear by 4 weeks of age
• Rapid growth occurs between 5-7 weeks of age
• 80% of growth is completed by 3 months
• Growth typically stops by 5-12 months of age
• Involution begins between 6-12 months, appearing as color change from red to milky-white/gray
• 90% of involution is complete by 4 years of age 1, 2

Common Residual Effects

After involution, the following residual changes may persist:

1. Telangiectasias - dilated superficial blood vessels
2. Fibrofatty tissue - residual bulk or contour deformity
3. Redundant skin - excess loose skin
4. Atrophy - thinning of the skin
5. Dyspigmentation - color changes in the skin
6. Scarring - particularly in areas that previously ulcerated 1

Factors Influencing Residual Changes

The likelihood and severity of residual changes depend on:

• Size and depth of the original hemangioma
• Location on the scalp
• Complications during growth phase (ulceration, bleeding)
• Prior treatments received 2

Management of Residual Changes

By 4 years of age, it's usually possible to determine whether residual changes will persist and require intervention 1. Management options include:

1. Laser Therapy

• Pulsed dye laser (PDL) is highly effective for residual telangiectasias and flat areas
• Potential complications include atrophic scarring and hypopigmentation, particularly in darker skin types 1

2. Surgical Management

• Indicated for significant fibrofatty residuum or redundant skin
• Optimal timing is typically around 3-4 years of age, before the child develops significant self-awareness but after maximum involution has occurred
• Surgical approaches include:
  • Elliptical excision with primary closure
  • Rotational flap closure for larger defects
  • Partial resection with natural contour restoration 1, 3, 4

3. Observation

• Appropriate for minor residual changes that don't cause functional or significant cosmetic concerns

Decision-Making Algorithm for Residual Changes

1. Assess at age 4 years when 90% of involution is complete
2. Evaluate residual changes:
   • Minimal changes → observation
   • Telangiectasias only → consider PDL
   • Significant fibrofatty tissue or redundant skin → consider surgical correction
3. Consider impact on quality of life:
   • Functional impairment
   • Psychological impact (especially before school entry)
   • Location visibility
4. Consult appropriate specialist:
   • Dermatologist for laser therapy
   • Plastic surgeon or dermatologic surgeon for excision

Important Considerations

• Surgical correction of residual changes often yields excellent cosmetic outcomes when performed by experienced surgeons 3, 4
• For scalp hemangiomas specifically, alopecia is a common residual finding that may require surgical correction 4
• Suture lines should be placed along natural skin lines or anatomical borders for optimal cosmetic results 3
• Early intervention during the proliferative phase (with propranolol or other treatments) may reduce the likelihood of significant residual changes 1

By understanding the natural history and potential residual effects of scalp hemangiomas, clinicians can provide appropriate guidance to parents and make timely referrals for intervention when necessary.