What does a hemangioma look like?

Appearance of Hemangiomas: Clinical Characteristics and Diagnosis

Infantile hemangiomas (IHs) are classified based on soft-tissue depth and anatomic appearance, with superficial IHs appearing bright red with little subcutaneous component (formerly called "strawberry" hemangiomas), deep IHs appearing blue and located below the skin surface (formerly called "cavernous" hemangiomas), and combined (mixed) IHs having both superficial and deep components. 1

Types of Hemangiomas Based on Appearance

Superficial Infantile Hemangiomas

• Appear as bright red, protuberant lesions with a bosselated or smooth surface and sharp demarcation 2
• Dermoscopically show polymorphous vascular structures without obvious red linear vessels 3
• Typically develop in the first few weeks of life, starting as areas of pallor or faint red patches before becoming more prominent 2

Deep Infantile Hemangiomas

• Appear bluish and dome-shaped 2
• Located below the skin surface with minimal cutaneous involvement 1
• Dermoscopically show polymorphous vascular structures with red linear and red dilated vessels 3

Combined (Mixed) Infantile Hemangiomas

• Contain both superficial and deep components 1
• May present with both red superficial and blue deeper components 1

Anatomic Classification

• Localized: Well-defined focal lesions appearing to arise from a central point 1
• Segmental: Involving an anatomic region, often plaque-like and measuring >5 cm in diameter 1
• Indeterminate (undetermined): Neither clearly localized nor segmental (often called partial segmental) 1
• Multifocal: Multiple discrete IHs at disparate sites 1

Natural History and Growth Pattern

• Most IHs are not present at birth but appear in the first few weeks of life 2
• Undergo rapid growth in the first 3-6 months of life 2
• Growth typically slows by 9-12 months of age 2
• Involution begins around 1 year of age with approximately 50% showing complete involution by age 5,70% by age 7, and 95% by 10-12 years of age 2

Diagnostic Considerations

When to Consider Imaging

• Ultrasonography is the initial imaging modality of choice when the diagnosis is uncertain 1, 4
• Imaging is particularly useful for:
  • Superficial lesions with atypical features 1
  • Deep lesions difficult to assess physically 1
  • Central or segmental location in the face/ears, breast, or midline lumbosacral region 1
  • Lesions ≥4 cm 1
  • Presence of ≥5 hemangiomas 1
  • Suspected airway involvement 1

Distinguishing from Other Vascular Anomalies

• IHs must be distinguished from vascular malformations, which are congenital lesions that do not involute and grow proportionally with the patient 1
• Port wine stains (capillary malformations) are flat, darker red-purple lesions with well-defined borders 1
• Nevus flammeus simplex ("salmon patch") is a flat, pink or red capillary malformation with ill-defined borders 1
• Congenital hemangiomas differ from IHs as they are fully formed at birth and either rapidly involute or do not involute at all 1

Special Considerations

• Midline lumbosacral infantile hemangiomas may be associated with underlying spinal dysraphism 1
• Segmental hemangiomas in the lumbosacral region may be part of LUMBAR syndrome (lower body hemangioma, urogenital abnormalities, myelopathy, bony defects, anorectal malformations, arterial anomalies, and renal anomalies) 1
• Facial segmental hemangiomas may be associated with PHACE syndrome (posterior fossa malformations, hemangioma, arterial anomalies, cardiac defects, eye abnormalities) 1

Management Approach

• Most uncomplicated IHs require no treatment and will involute naturally 2, 5
• Treatment is indicated for life-threatening conditions, functional impairment, pain, bleeding, or risk of permanent disfigurement 4
• Oral propranolol is the first-line treatment for complicated IHs 4, 2
• Topical timolol may be considered for superficial IHs 2

By understanding the typical appearance and natural history of hemangiomas, clinicians can better differentiate them from other vascular anomalies and determine appropriate management strategies.