What is a Hemangioma?
A hemangioma is a bright red or bluish birthmark made up of extra blood vessels that usually appears within the first few weeks after birth, grows rapidly for several months, and then slowly fades away on its own over several years. 1
How Hemangiomas Look and Behave
Appearance
- Superficial hemangiomas appear as bright red, raised bumps on the skin surface that may look like a strawberry 1, 2
- Deep hemangiomas appear as bluish, dome-shaped swellings under the skin 1, 3
- Some hemangiomas have both superficial and deep components 1
Growth Pattern
- Most hemangiomas are not present at birth but appear within the first 4 weeks of life, often starting as a pale area or faint red patch 3
- They grow most rapidly between 1 and 3 months of age, with 80% reaching their final size by 3 months 1, 2
- Growth typically stops by 5 months of age in most cases, though some continue growing until 9-12 months 1, 3
Natural Disappearance (Involution)
- After the growth phase stops, hemangiomas begin to slowly shrink and fade, usually starting around 1 year of age 3
- 90% will completely disappear by age 4 years 4, 5
- 50% disappear by age 5,70% by age 7, and 95% by age 10-12 years 3
- However, up to 70% leave behind permanent skin changes such as loose skin, scarring, discoloration, or visible blood vessels 1, 4
How Common Are They?
- Hemangiomas occur in 4-5% of all infants, making them the most common tumor of infancy 1
- They are more common in premature babies, white infants, and girls (affecting girls 1.4 to 3 times more often than boys) 1
When Treatment is Needed
Most hemangiomas (the majority) are harmless and require only observation without any treatment. 1, 5 However, treatment is necessary in certain situations:
Urgent Treatment Situations
- Life-threatening problems such as difficulty breathing or heart failure 4, 6
- Blocking vision or causing eye problems that could lead to permanent vision loss 4, 6
- Interfering with feeding or other essential functions 1, 4
- Active bleeding or severe pain that doesn't improve with basic care 4
- Open sores (ulceration) that are painful or won't heal 4, 6
Elective Treatment Situations
- Large facial hemangiomas (especially those larger than 4 cm or covering a large area) that could cause permanent disfigurement 4, 6
- Hemangiomas in cosmetically sensitive locations where scarring would be problematic 4
Treatment Options When Needed
Medication (First Choice)
- Oral propranolol (a beta-blocker medication) is the first-line treatment at a dose of 2-3 mg/kg per day, divided into three doses 1, 4
- This medication causes rapid shrinkage, often within 48 hours to weeks 4
- Treatment typically continues for at least 6 months, often until 12 months of age 1, 2
- The medication must be started in a medical setting with heart monitoring 1, 4
Other Options
- Topical timolol gel can be used for small, thin, superficial hemangiomas 1, 5
- Oral steroids are an alternative if propranolol cannot be used 1
- Surgery or laser treatment are usually reserved for treating leftover skin changes after the hemangioma has shrunk, not during the growth phase 1, 5
Important Timing Considerations
Early evaluation is critical—ideally by 1 month of age for any concerning hemangioma—because the window of opportunity to prevent permanent changes is narrow. 1 Since most growth occurs between 1-3 months of age, waiting too long to start treatment reduces its effectiveness 1, 4.
Special Situations Requiring Extra Attention
- Hemangiomas near the eye need immediate evaluation by a pediatric eye doctor to prevent vision problems 4, 5, 6
- Large facial hemangiomas (especially in a "beard distribution" on the lower face and neck) may indicate airway involvement requiring urgent evaluation 1, 6
- Five or more hemangiomas on the skin require an ultrasound to check for hemangiomas in the liver 4, 5, 6
- Hemangiomas on the lower back need an MRI to check for spinal cord problems 4