Referral for Growing Scalp Hemangioma
A patient with a growing hemangioma of the scalp should be referred urgently to a hemangioma specialist, which may include pediatric dermatology, plastic surgery, pediatric surgery, or a multidisciplinary vascular anomalies center. 1
Understanding the Specialist Definition
The American Academy of Pediatrics explicitly recognizes that hemangioma management is not limited to one specialty—appropriate specialists may have expertise in dermatology, hematology-oncology, pediatrics, facial plastic and reconstructive surgery, ophthalmology, otolaryngology, pediatric surgery, or plastic surgery. 1
Key Qualifications of a Hemangioma Specialist
A qualified specialist should: 1
- Understand the time-sensitive nature of infantile hemangiomas during the growth phase and accommodate urgent evaluations
- Have experience with accurate risk stratification and potential complications
- Provide recommendations for observation, medical therapies, surgical procedures, and laser treatments
- Maintain thorough knowledge of current and emerging literature on infantile hemangiomas
Why Scalp Hemangiomas Require Urgent Referral
High-Risk Features of Scalp Location
Segmental facial or scalp hemangiomas are associated with PHACE syndrome (posterior fossa malformations, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities), making them high-risk lesions requiring immediate specialist evaluation. 2
Scalp hemangiomas frequently cause significant morbidity including: 3
- Alopecia (51.7% of cases requiring surgery)
- Ulceration (23.2% of cases requiring surgery)
- Bleeding complications
- Permanent disfigurement if untreated
Critical Timing Considerations
The most rapid hemangioma growth occurs between 5-7 weeks of age, with optimal referral timing at 1 month of age—far earlier than most patients are typically referred. 1, 2 The American Academy of Pediatrics provides a strong recommendation (Grade X) that high-risk hemangiomas should be evaluated by a specialist "as soon as possible." 1
A wait-and-see approach for growing lesions results in missed therapeutic windows and irreversible damage to dermis, subcutaneous tissues, and anatomic landmarks. 2 By the time significant growth is evident, permanent distortion may have already occurred. 1
Practical Referral Approach
When Immediate Specialist Access Is Limited
If in-person consultation cannot be arranged promptly: 1
- Use telemedicine (live interactive or store-and-forward photographs) for triage and initial evaluation
- Educate office staff to prioritize appointments for young infants with growing hemangiomas
- Consider photographic consultation to expedite decision-making
What the Specialist Will Provide
The specialist will assess: 1
- Risk stratification based on age, anatomic site, size, and growth pattern
- Need for oral propranolol (first-line treatment for problematic hemangiomas requiring systemic therapy) 4
- Potential for topical timolol for superficial lesions 4
- Timing and appropriateness of surgical intervention (typically reserved for residual changes after involution, though early excision may be beneficial for scalp lesions due to tissue laxity) 3
Common Pitfalls to Avoid
Do not reassure families that the lesion will simply "go away"—this long-held myth leads to delayed referrals and poor outcomes. 1 While 90% of hemangiomas complete involution by 4 years of age, many leave permanent skin changes that may be life-altering, especially thick lesions. 1, 4
Do not wait to see how large the lesion will become—predicting growth is extremely difficult even for experienced clinicians, and damage may occur during the observation period. 1 The heterogeneity of hemangiomas means that even on the same patient, one lesion may become problematic while others remain small. 1
Scalp hemangiomas specifically have a high likelihood of eventually requiring surgical intervention (in one series, many ultimately needed surgery), making early specialist involvement particularly important for treatment planning. 3