How should a newborn with a cheek infantile hemangioma be managed?

Management of Neonatal Hemangioma on the Cheek

Most neonatal cheek hemangiomas require only active observation without treatment, but early specialist referral is warranted for large facial lesions (>4 cm), segmental patterns, or lesions causing functional impairment or risk of permanent disfigurement. 1, 2

Initial Assessment and Risk Stratification

Determine if immediate intervention is needed by evaluating for the following high-risk features:

• Life-threatening complications: respiratory distress, heart failure 1, 2
• Functional impairment: visual obstruction (especially periocular lesions causing ptosis, amblyopia, or astigmatism), feeding difficulties if perioral 1
• Active complications: ulceration, bleeding, or significant pain 1
• High-risk anatomic features: segmental facial hemangiomas, large lesions >4 cm, or lesions with significant risk of permanent facial disfigurement 2, 3

Facial hemangiomas are inherently more complicated than non-facial lesions and warrant closer monitoring, as they carry higher risk of complications and permanent cosmetic sequelae. 1

Management Algorithm

For Uncomplicated Cheek Hemangiomas

Observation with regular monitoring is appropriate for small, asymptomatic lesions without functional impairment or high-risk features. 4, 3

• Most infantile hemangiomas appear by 4 weeks of age, reach 80% of final size by 3 months, and stop enlarging by 5 months 1, 5
• Natural involution is complete by 4 years in most cases, with 90% involuting spontaneously without treatment 2, 3
• Close follow-up in the first weeks of life is crucial to identify lesions requiring early intervention 5
• Up to 70% leave residual skin changes (telangiectasia, fibrofatty tissue, redundant skin, atrophy, dyspigmentation, scarring) even after involution 1

For Hemangiomas Requiring Treatment

Oral propranolol is the first-line treatment for infantile hemangiomas requiring intervention. 1, 2

Propranolol Protocol:

• Dose: 2 mg/kg/day divided into three doses 1, 2, 3
• Initiation: Must be started in a clinical setting with cardiovascular monitoring every hour for the first 2 hours 1, 2
• Inpatient initiation required for infants <8 weeks old, postconceptional age <48 weeks, or presence of cardiovascular risk factors 1, 2
• Duration: Minimum 6 months of therapy recommended, with treatment ideally started as early as possible to prevent complications 5
• Efficacy: Rapid reduction in hemangioma size with progressive improvement over at least 3 months; failure rate approximately 1.6% 2

Alternative Medical Therapies:

Systemic corticosteroids are second-line when propranolol cannot be used or is ineffective:

• Prednisolone or prednisone 2-3 mg/kg/day as single morning dose 1, 2
• Several months of therapy often needed, more successful when initiated during proliferative phase 1, 2

Intralesional steroid injections can be effective for small, bulky, well-localized lesions 1

Surgical Management Timing

Delay elective surgical resection until after infancy to allow for natural involution and achieve better outcomes. 1, 4

• Resection during infancy carries higher risks of anesthetic morbidity, blood loss, and iatrogenic injury 4, 3
• Optimal surgical timing is before 4 years of age, as most hemangiomas do not improve significantly after this age 4, 2
• For circular facial lesions, circular excision with purse-string closure can minimize scar length and distortion 4

Special Considerations for Facial Hemangiomas

Evaluate for structural anomalies in patients requiring intervention 1

Imaging is generally not necessary for typical presentations, but ultrasonography is the preferred initial modality if diagnosis is uncertain or anatomic abnormalities are suspected. 1, 2

Screen for associated conditions in specific scenarios:

• Multiple cutaneous hemangiomas (≥5) require hepatic screening with ultrasonography 2
• Multifocal or diffuse hemangiomas require thyroid hormone screening, as tumors can inactivate thyroid hormone 2, 3

When to Refer

Refer to a specialist or multidisciplinary vascular anomalies center when:

• Complications are likely or already present 2, 3
• Threshold for intervention is uncertain 2, 3
• Large facial lesions (>4 cm) or segmental patterns are present 2
• Periocular location requiring ophthalmology evaluation to prevent visual complications 2, 3

Common Pitfalls to Avoid

Do not confuse infantile hemangiomas with other vascular lesions: Congenital hemangiomas are fully grown at birth and behave differently; vascular malformations (port wine stains) are structural anomalies, not tumors. 1

Do not assume all hemangiomas will resolve without consequence: While most involute spontaneously, facial location carries higher complication risk and potential for permanent disfigurement requiring early intervention. 1

Do not delay treatment for high-risk lesions: Early pharmacotherapy with propranolol can prevent complications like ulceration and minimize permanent disfigurement, particularly for segmental facial lesions. 2, 5