Differentiating Congenital Hemangioma from Capillary Malformation
Congenital hemangiomas are fully formed, raised vascular tumors present at birth that either rapidly involute (RICH) or remain stable (NICH), while capillary malformations are flat, pink-to-red lesions that grow proportionally with the child and never regress. 1
Key Clinical Distinguishing Features
Timing of Appearance
- Congenital hemangiomas: Fully formed and visible at birth, having completed their entire proliferative phase in utero 1, 2
- Capillary malformations: Present at birth but may become more clinically apparent over time due to progressive ectasia 1
Physical Characteristics
Congenital Hemangiomas:
- Raised, tumor-like lesions with well-defined borders 3
- Single, oval-shaped, nonpulsatile appearance 3
- May be warm to touch with visible draining veins 3
- Can have phlebolites (calcifications) 3, 4
- Size does NOT increase after birth (critical distinguishing feature) 3
Capillary Malformations:
- Flat lesions (most important differentiating feature) 1
- Port wine stains: darker red-purple with well-defined borders that darken over time 1
- Nevus flammeus simplex ("salmon patch"): pink-red with ill-defined borders 1
- Present in up to 43% of the general population 1
Natural History Patterns
Congenital Hemangiomas
- RICH (Rapidly Involuting): Begin involution at mean age 1.7 months, complete regression by mean 10.4 months (most within first year) 2, 3
- NICH (Non-Involuting): Remain stable without growth or involution, though 10% may show atypical postnatal growth after years of stability 1, 5
- Do NOT exhibit postnatal proliferation phase 1, 2
Capillary Malformations
- Never involute spontaneously 6
- Grow proportionally with body growth throughout life 6
- Tend to darken and become more prominent with age (especially port wine stains) 1
Diagnostic Imaging Features
Ultrasound with Doppler (First-Line Study)
Congenital Hemangiomas:
- Heterogeneous appearance (72% of NICH, 62.5% of RICH) 4
- Visible vessels within the lesion (72% of NICH, 62.5% of RICH) 4
- Calcifications present (17% of NICH, 37.5% of RICH) 4
- Arterial and venous waveforms demonstrating high flow 7
Capillary Malformations:
- Low-flow or no-flow lesions on Doppler 6
- Lack the heterogeneous appearance and calcifications seen in congenital hemangiomas 4
Advanced Imaging (MRI/CT)
- Congenital hemangiomas show fat stranding (29.4% of cases), well-defined limits, and enhancement patterns 4
- May be needed if ultrasound is inconclusive or for surgical planning 7
Immunohistochemical Differentiation
Critical molecular marker:
- Congenital hemangiomas are GLUT1-negative on immunohistochemistry 1, 2, 8
- This distinguishes them from infantile hemangiomas (which are GLUT1-positive) 1, 8
- Biopsy is rarely needed but definitive when performed 3, 8
Common Diagnostic Pitfalls
Avoid These Errors:
- Do not confuse deep congenital hemangiomas with capillary malformations based on color alone—depth can make hemangiomas appear bluish 1
- Do not assume all flat lesions are malformations—some involuting hemangiomas may flatten during regression 2
- Midline lumbosacral capillary malformations require spinal imaging to exclude dysraphism, unlike congenital hemangiomas 1
- Some congenital hemangiomas may have overlapping features with vascular malformations (warm lesions, dysplastic veins), requiring careful follow-up 3
Clinical Decision Algorithm
Assess elevation: If raised/tumor-like → likely congenital hemangioma; if flat → likely capillary malformation 1
Confirm timing: If fully formed at birth with no postnatal growth → congenital hemangioma; if growing with child → capillary malformation 1, 6
Observe over 1-2 months:
Obtain ultrasound with Doppler if diagnosis uncertain: Look for heterogeneity, visible vessels, calcifications, and flow patterns 7, 4
Follow for 12 months minimum: This remains the most discriminating element for definitive diagnosis 3