Diagnosis: Infantile Hemangioma
This is an infantile hemangioma (IH), and given its large size (golf ball-sized) in the axillary region of a 4-year-old, you should evaluate for residual changes and consider surgical or laser intervention if disfigurement persists, as 90% of involution is complete by age 4 years. 1
Clinical Context and Natural History
At 4 years of age, this child is at the end of the typical involution phase for infantile hemangiomas. 1 The key question is whether this represents:
- Active residual hemangioma tissue requiring intervention
- Involuted hemangioma with residual skin changes (telangiectasias, redundant skin, fibrofatty tissue)
By age 4, it is usually possible to determine whether residual changes will persist, and if concerning, consultation for laser or surgical management should be pursued. 1
Immediate Assessment Steps
Document the following specific features: 2, 3
- Growth pattern: Is the lesion still growing, stable, or involuting?
- Color characteristics: Bright red suggests active proliferation; milky-white or gray indicates involution 1
- Texture: Firm and raised versus soft and flat
- Skin changes: Telangiectasias, redundant skin, ulceration
- Functional impact: Does it limit arm movement or cause discomfort?
Diagnostic Imaging (If Needed)
Most infantile hemangiomas are diagnosed clinically without imaging. 4 However, imaging is indicated for:
- Atypical features that raise diagnostic uncertainty
- Deep extension that cannot be assessed by physical examination
- Large size (≥4 cm) 4
- First-line: Ultrasound with duplex Doppler to confirm vascular nature and distinguish from venous malformations based on arterial and venous waveforms
- MRI with and without IV contrast if ultrasound is inconclusive or to define complete extent before surgical planning 2
Treatment Algorithm
For Active/Residual Hemangioma Tissue:
At age 4, pharmacologic therapy (propranolol) is generally not the primary approach, as the proliferative phase has passed. 1 Instead:
Surgical excision is the preferred option when: 1
- The lesion causes functional impairment or significant disfigurement
- Residual tissue is well-localized
- The child is 3-5 years of age (optimal surgical window) 1
Benefits of surgery at this age: 1
- The lesion has completed most involution, making it smaller and primarily adipose tissue rather than vascular
- The operation is safer with less blood loss
- Resultant scar may be smaller
- Minimizes stigma and impact on self-esteem before school age
For Residual Skin Changes Only:
Pulsed dye laser (PDL) therapy can treat: 1
- Persistent telangiectasias post-involution
- Superficial erythema
- Textural irregularities
Surgical revision for: 1
- Redundant skin
- Significant fibrofatty residuum
- Scarring that causes functional or cosmetic concerns
Critical Pitfalls to Avoid
Do not reassure the family that "it will just go away" at this age. 4 By 4 years, 90% of involution is complete, and what remains is unlikely to improve significantly. 1
Do not delay intervention if disfigurement is present. The window between ages 3-5 years is optimal for surgical correction, balancing anesthetic safety with psychosocial benefit before school entry. 1
Do not assume this is a venous malformation without proper assessment. Venous malformations are present at birth, grow proportionally with the child, and do not involute—distinctly different from infantile hemangiomas. 3
Referral Recommendation
Refer to a hemangioma specialist or multidisciplinary vascular anomalies center for: 1
- Definitive assessment of residual tissue versus skin changes
- Surgical planning if intervention is indicated
- Laser therapy consultation for superficial changes
- Shared decision-making with the family regarding timing and type of intervention
Telemedicine consultation with photographs can expedite evaluation if in-person specialist access is limited. 1