In a 4‑month‑old infant with a large scalp hemangioma, which specialist should be consulted for referral?

Referral for Large Scalp Hemangioma in a 4-Month-Old

A 4-month-old infant with a large scalp hemangioma should be referred to a pediatric dermatologist or a multidisciplinary vascular anomalies center for evaluation and management with oral propranolol. 1, 2

Primary Specialist Referral

Refer to a pediatric dermatologist as the primary specialist, since they are specifically trained to initiate and supervise propranolol therapy for infantile hemangiomas. 3 The British Society for Paediatric Dermatology guidelines explicitly state that propranolol dosing regimens should be determined by the supervising dermatologist or paediatrician. 3

Alternatively, referral to a multidisciplinary vascular anomalies center is recommended when complications are likely or the threshold for intervention is uncertain. 1, 2 These centers provide coordinated care across multiple specialties.

Why This Referral Matters at 4 Months

At 4 months of age, this infant is in the rapid proliferative phase of hemangioma growth (typically first 3-6 months of life). 4 Large scalp hemangiomas warrant early specialist evaluation because:

• Scalp location increases risk for disfigurement, particularly if the lesion distorts anatomical landmarks. 3
• Segmental facial/scalp hemangiomas require screening for PHACES syndrome (posterior fossa malformations, arterial anomalies, cardiac defects, eye abnormalities). 3, 1, 5
• Early propranolol initiation during proliferative phase is most effective at preventing growth and complications. 1

Additional Specialists to Consider

Pediatric Plastic Surgeon

Consider referral to a pediatric plastic surgeon for large cutaneous vascular lesions, particularly if there is concern about future disfigurement or need for reconstruction. 3 The Pediatrics guidelines specifically list "large cutaneous pigmented or vascular lesions (eg, nevi, port wine stains, arteriovenous malformations)" as appropriate referrals to pediatric plastic surgery. 3

Pediatric Cardiologist

If segmental scalp hemangioma is present, the infant requires ECHO and ECG interpreted by a pediatric cardiologist before starting full-dose propranolol, as part of PHACES syndrome screening. 3

Pediatric Neurologist

Brain MRI/MRA should ideally be performed before starting full-dose propranolol in patients with segmental hemangiomas of the head and neck. 3 If arterial stenosis or agenesis is found, discuss propranolol treatment and dosing with a pediatric neurologist. 3

Critical Pitfalls to Avoid

• Do not delay referral waiting for spontaneous involution—while 90% of hemangiomas involute by age 4 years, large facial/scalp lesions causing disfigurement require early intervention during the proliferative phase. 1, 2
• Do not refer to general surgery or adult dermatology—infantile hemangiomas require pediatric subspecialty expertise for propranolol initiation with appropriate cardiovascular monitoring. 3, 1
• Do not miss PHACES syndrome screening—segmental scalp hemangiomas mandate cardiac and neurologic evaluation before full-dose propranolol. 3, 5

Immediate Actions Before Referral

• Document the lesion with clinical photographs to establish baseline appearance. 3
• Assess for functional impairment: Does the lesion cause bleeding, ulceration, or pain? 1
• Screen for multiple hemangiomas: If ≥5 cutaneous hemangiomas are present, obtain abdominal ultrasound to screen for hepatic involvement and check thyroid function. 1, 2, 5
• Determine if segmental: Segmental (large, plaque-like) versus focal (localized, round) morphology affects workup requirements. 3, 5