Infantile Hemangiomas - HealthPlexus.net

DERMATOLOGY
Infantile Hemangiomas:
What They Are, When To Worry And
What To Do
ABSTRACT
Infantile hemangiomas (IH) are the most common tumor of infancy and have been estimated to
occur in 4% of infants. While IH are typically absent at birth, they become noticeable within the
first few weeks of life. Approximately one third of IH present shortly after birth, another third
present in the first month and the remainder develop within the first six months of life.
KEYWORDS: infantile hemangiomas, tumor, lesions, vascular patches.
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What Infantile Hemangiomas Are (and what they
aren’t)
Infantile hemangiomas (IH) are the most common
tumor of infancy and have been estimated
to occur in 4% of infants. 1 While IH are typically
absent at birth, they become noticeable within the
first few weeks of life. 2 Approximately one third
of IH present shortly after birth, another third
present in the first month and the remainder
develop within the first six months of life. 1,2,3 In
some instances, IH can be preceded by precursor
lesions including vascular patches and blanched
areas which may present at birth. 3,4
Ulcerated hemangioma
Caroline Weisser, BHSc, Faculty of Medicine University of Ottawa, Ottawa, Ontario.
Joseph M Lam MD, Clinical Assistant Professor, Departments of Paediatrics and Dermatology, University of British Columbia, Vancouver, BC.

Infantile Hemangiomas
During typical development,
IH undergo a period of rapid
proliferation during the first three
months and then slowly involute
once the maximum size has been
reached, usually after one year
(Figure 1). Involution will take
many years with 50% of IH being
completely involuted by 5 years
of age. 3 IH are quite distinct from
true neoplasms as they tend
to grow in volume rather than
diameter. 3 While some IH regress
completely, the IH that resolve
after 6 years are more likely to leave
residual cutaneous changes such as
telangectasias, atrophic wrinkling,
and scarring among other sideeffects.
3 The pathogenesis behind
IH is not well documented, however
recent studies have indicated
genetic mutations in pro-angiogenic
growth factors and hypoxia as
possible causes, and endothelial
progenitor cells as the original cells. 1
It is important to note that other
vascular lesions can be mistaken
for IH, and these include congenital
hemangiomas (Figure 2), portwine
stains (Figure 3), kaposiform
Figure 1: Natural history of infantile hemangiomas
Size
Proliferative
Phase 2
Growth
Arrest
Early Involutive
Phase
Nascence
Proliferative
Phase 1
Late Involutive
Phase
4 weeks
6 months
1 year
2-5 years
6-10 years
Age
37 Journal of Current Clinical Care Volume 3, Issue 4, 2013

Infantile Hemangiomas
Figure 2: Congenital hemangioma
Figure 3: Port-wine stain
Figure 4: Tufted angioma
hemangioendotheliomas, tufted
angiomas (Figure 4) and pyogenic
granulomas (Figure 5). 3
Generally, IH tend to occur
more in females, Caucasians, low
birth weight babies, premature
infants and multiple gestation pregnancies.
1 In the early 1990’s, the
International Society for the Study
of Vascular Anomalies (ISSVA)
developed a classification system
that distinguished vascular tumours
from vascular malformations, hence
resolving erroneous communication.
5 While vascular tumours usually
regress or may persist, vascular
malformations never regress and
tend to persist throughout life. 5
Differentiating between these two
anomalies is essential to not only
distinguish their clinical, radiological
and pathological features, but
their approach toward management
is quite different as well. 5
What infantile hemangiomas to
worry about
While most IH resolve without
complications, some have alarming
features that need to be addressed
and followed. 1 Approximately
24% of IH have complications
that require interventions, with
ulceration being most common. 1,2
Other important features to
note are that some may result
in permanent disfigurement
or functional impairment. For
Figure 5: Pyogenic granuloma
Figure 6: Periorbital hemangioma
Figure 7: “Beard distribution” hemangioma
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Infantile Hemangiomas
instance, periorbital lesions (Figure
6) may lead to visual compromise
through astigmatism, amblyopia
and optic atrophy. Laryngeal and
tongue lesions can lead to airway
obstruction and cause swallowing
The timing of therapy is critical in
severe IH as they are best treated
early in the proliferative phase to
prevent inferior outcomes.
or respiratory impairment, and
clues to airway involvement are
associated hemangiomas in a
“beard distribution” (Figure 7).
Nasal-tip lesions can result in
cosmetic disfigurement (Figure
8). 6 A lumbosacral location is
associated with underlying spinal
cord tethering and myelopathy,
as well as other structural
abnormalities (Figure 9). 1,6 Also,
multiple (>5) IH are a marker
of hepatic hemangiomas and
hemangiomatosis (Figure 10). 1,7
How to treat infantile hemangiomas
Although most patients with IH
do not require intervention, the
decision to treat is made on an
individual basis. 2 Usual therapy for
IH involves active observation, but
systemic treatment can be required
to avoid scarring, permanent
disfigurement or life threatening
complications. 2 Until 2008, the
first-line therapy for IH was
corticosteroids (systemic, topical or
intralesional), however they were
associated with high-incidence
side effects, including secondary
hypertension (40%), cushingoid
features (40%) and growth
suppression (67%). 1,8 Over the last
few years, the non-selective betablocker
propranolol has become
the first-line therapeutic choice.
Its superior safety and efficacy has
been documented in a number of
studies. 2,9-15 Its mechanism of action
is not fully elucidated. However, it
is believed to induce early colour
change through vasoconstriction,
to inhibit the growth phase through
blocking endothelial growth factors
Figure 8: Nasal tip hemangioma Figure 9: Lumbosacral hemangioma Figure 10: Neonatal hemangiomatosis
39 Journal of Current Clinical Care Volume 3, Issue 4, 2013

Infantile Hemangiomas
like VEGF and BFGF, and to hasten
resolution through induction of
apoptosis. 16,17 Infants started on
propranolol are closely monitored
for side effects, with the most
common being hypoglycemia,
hypotension, bradycardia and
bronchial hyperreactivity. 3 Another
non-selective beta-blocker, nadolol
has shown similar benefits to
propranolol, while exhibiting less
side effects. 3
The timing of therapy is
critical in severe IH as they
are best treated early in the
proliferative phase to prevent
inferior outcomes. 3 Patients who
are started on a beta-blocker
should extend their treatment up to
one year of age to prevent relapse
of IH. 3 Second-line treatments
include systemic corticosteroids,
alpha-interferon and vincristine. 7
Topical treatments such as the
use of timolol have been reported
to be effective in the treatment of
small superficial IH. 2,3 Very few IH
require surgical intervention but
cases are considered on a case-bycase
basis. 3
Vascular Anomaly Classification
Vascular Anomaly Classification
Vascular Tumour
• Usually regress or may persist
Single vessel type:
• Capillary
• Venous
• Lymphatic
• Arteriovenous
Combined/ complex malformations:
• Lymphaticovenous
• Capillary-venous
• Capillary-lymphaticovenous
• Capillary-arteriovenous
Vascular Malformation
• Never regress and tend to persist
throughout life
• Hemangioma
• Hemangioma of infancy
• Congenital hemangioma
• Rapidly involuting congenital hemangioma
• Noninvoluting congenital hemangioma
• Vascular neoplasm
• Kaposiform hemangioendothelioma
• Angiosarcoma
• Hemangiopericytoma
• Miscellaneous
• Tufted angioma
• Pyogenic granuloma
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Infantile Hemangiomas
SUMMARY OF KEY POINTS
Hemangiomas usually appear within the first month of
life and undergo a rapid proliferation phase followed by
an involution phase
Risk factors for hemangiomas include female gender,
prematurity, low birth-weight, Caucasian ethnicity and
multiple gestation pregnancies
In select hemangiomas, complications can ensue and
these include visual obstruction, airway compromise,
cosmetic disfigurement and extracutaneous involvement
In concerning hemangiomas, an emerging and effective
treatment option is oral beta-blocker therapy
Most hemangiomas can be managed by observation,
education and reassurance
The authors have no conflict of
interest to disclose.
This paper has not been previously
published or presented.
All photos courtesy of Dr. Lam.
References
1. Dickison P, Christou E, Wargon O. A prospective study
of infantile hemangiomas with a focus on incidence
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2. Maguiness SM, Frieden IJ. Management of difficult
infantile haemangiomas. Arch Dis Child.
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3. Neri I, Balestri R, Patrizi A. Hemangiomas: new
insight and medical treatment. Dermatol Ther. 2012;
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4. Drolet BA, Frieden IJ. Characteristics of infantile
hemangiomas as clues to pathogenesis: does hypoxia
connect the dots? Arch Dermatol. 2010; 146(11):1295-
9.
5. Introduction: ISSVA Classification. Cambridge University
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6. Iacobas I, Burrows PE, Frieden IJ, Liang MG, Mulliken
JB, Mancini AJ, et al. LUMBAR: Association between
cutaneous infantile hemangiomas of the lower body
and regional congenital anomalies. J Pediatr. 2010;
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7. Storch CH, Hoeger PH. Propranolol for infantile
hemangiomas: insights into the molecular
mechanisms of action. Br J Dermatol. 2010; 163:269-
274.
8. Phan TA, Adams S, Wargon O. Segmental
haemangiomas of infancy: a review of 14 cases.
Australasian Journal of Dermatology. 2006; 47:242–247.
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CLINICAL PEARLS
Beware of periorbital hemangiomas – even small ones can cause amblyopia, astigmatism, optic atrophy
Patients with greater than 5 hemangiomas are at risk for diffuse hemangiomatosis and hepatic hemangiomas
Other vascular lesions that can mimic hemangiomas – these generally do not respond to beta-blocker therapy
Since the majority of growth occurs in the first 12 weeks, early recognition and referral of problematic hemangiomas is essential.
41 Journal of Current Clinical Care Volume 3, Issue 4, 2013

Infantile Hemangiomas
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9. Rosbe KW, Suh KY, Meyer AK, et al. Propranolol in the
management of airway infantile hemangiomas. Arch
Otolaryngol Head Neck Surg. 2010;136:658–65.
10. Zaher H, Rasheed H, Hegazy RA, et al. Oral propranolol:
an effective, safe treatment for infantile hemangiomas.
Eur J Dermatol. 2011; 21:558–63.
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astigmatism using propranolol as first-line therapy for
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orbital infantile hemangioma. Arch Ophthalmol.
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hepatic hemangioma to propranolol resistant to highdose
methylprednisolone and interferon-a therapy.
Pediatr Blood Cancer. 2010; 55:1433–4.
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first-line treatment with propranolol of multifocal
infantile hepatic hemangioma with high-flow cardiac
overload. J Pediatr Gastroenterol Nutr. 2011; 53:693–5.
15. Truong MT, Chang KW, Berk DR, et al. Propranolol for
the treatment of a life-threatening subglottic and
mediastinal infantile hemangioma. J Pediatr 2010;
156:335–8.
16. Storch CH, Hoeger PH. Propranolol for infantile haemangiomas:
insights into the molecular mechanisms
of action. Br J Dermatol. 2010; 163(2):269-74.
17. Chakkittakandiyil A, Phillips R, Frieden IJ, Siegfried E,
Lara-Corrales I, Lam J, et al. Timolol Maleate 0.5% or
0.1% gel forming solution for infantile hemangiomas:
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Dermatology. 2012; 29:28-31.
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