Infantile hemangiomas

An infantile hemangioma (hem-an-gee-o-ma), or "strawberry mark," is a very common type of birthmark made of blood vessels. Most hemangiomas are not visible at birth. When they do appear, they may first show up as a small bruise, scratch or tiny red bump.

When and where do infantile hemangiomas appear?

Most hemangiomas are not visible at birth, but they often begin to appear during the first four to six weeks of a child's life. All skin hemangiomas will be visible by six months of age.They may occur anywhere on the skin surface, but they are most common on the scalp, face and neck. Many first appear as a small bruise, scratch or a tiny red bump. But unlike other types of birthmarks, they will grow and change quickly during your child's first few months.

What do hemangiomas look like?

Hemangiomas can occur anywhere on the skin, including, rarely, in the organs of the body. Most often, hemangiomas grow on the skin of the head or neck.

There are three general types of infantile hemangiomas:

Superficial hemangiomas, which occur on the outer layers of the skin, are typically bright red to purple in color.
Deep hemangiomas, which grow under the skin in the fat, may be blue, purple or even skin color (if they are deep enough under
the skin surface).
Mixed hemangiomas are the most common type of hemangioma. These hemangiomas have both superficial and deep components.

Shape, size, and growth rate

Most hemangiomas are round or oval in shape, but larger lesions may follow the shape of the affected body part.
The size of hemangiomas varies. Some are very small (1 mm), while others are very large (20 cm or larger).
Every hemangioma differs in how fast it grows and how long it grows before it stops.

What causes an infantile hemangioma?

The cause of infantile hemangioma is unknown. However, we do know some things about them. For example:

They are more common in girls than boys.
They are more often seen in Caucasian children.
They are seen more frequently in babies born very small or born several weeks before their due date. We have not yet identified what may put these infants at risk. Research continues at Children's to find the causes of hemangiomas so we can begin to prevent these lesions and control their growth.

Are infantile hemangiomas dangerous?

Although most infantile hemangiomas are not anything to worry about, approximately 12 percent of these are complex enough to warrant a visit with a specialist who is familiar with birthmarks and vascular anomalies and knows what to look for. If your child develops any marks or lumps, it's best to have them checked by a pediatrician who will let you know whether you should see a specialist.

Will my baby's hemangioma grow?

Infantile hemangiomas grow rapidly for the first few weeks or months. They then enter a rest phase by about 8 months of age. And they usually begin to shrink (involution phase) around 1 year of age. As the lesion shrinks, the color may change from red to purple and gray. It may take several years for the hemangioma to go away completely. Larger lesions take a longer time to go away and have a greater chance of scarring.

The table below provides a bit of information about hemangiomas, along with some image examples.

Phase		Approximate Age		What's happening?	Examples
Growth		Newborn to 14 months (average 8 months)		Hemangioma is growing rapidly (puffing out), and the color is bright red.
Resting		8- to 4 months		No change in size, and the skin becomes less shiny
Shrinking (Involution)		1 to 5 years		Lesion shrinks, and the color changes to purple and gray. It may even fade completely

What problems or complications can infantile hemangiomas cause?

Most hemangiomas will go through the growth and involution phases without causing any problems. However, about 25 percent of hemangiomas will have a complication. Your doctor will help you determine if your child's hemangioma may be likely to have a complication based on the size, location and speed of growth. Possible complications include:

Interference with organ function
As a hemangioma grows, it can interfere with organ function. Most often, this interference relates to vision. If a hemangioma around the eye grows rapidly, it may block the infant's vision, which can cause irreversible loss of sight. If your child has a hemangioma on the eyelid, watch it closely and have a pediatrician check it as well. Other areas that may need urgent treatment are the diaper area and around the mouth.

Ulceration
The skin over the hemangioma can break down until the skin appears raw or shiny, and it might even develop a scab or crust. Ulcerations can be very painful for your child, which can lead to irritability, poor feeding and difficulty sleeping. Ulceration also increases the risk of infection and scarring. Hemangiomas that are located around the mouth, nose, ear or the skin under the diaper carry a higher risk of ulceration. Ulcerations heal slowly, so your child's doctor may recommend treatment to speed this process and to prevent infection and scarring.

Bleeding
The skin over the hemangioma protects it from bleeding easily. If a hemangioma is cut or injured, it can bleed or develop a crust or scab. The blood vessels that make up hemangiomas are not normal. When hemangiomas bleed, they tend to bleed rapidly, but only for a short time. You should be able to stop the bleeding by applying gentle, direct pressure to the wound for 15 minutes. If bleeding returns or does not stop with pressure, you should contact your child's doctor.

Do hemangiomas hurt?

Most hemangiomas do not cause discomfort for your baby unless ulceration occurs. Ulcerations can be painful, even before you can see them. If you think your baby is experiencing pain, you should let your pediatrician know.

Will the hemangioma leave a scar?

The final appearance of a hemangioma varies from person to person and will depend on a number of things, including:

• The size
• The location
• Whether the hemangioma became ulcerated or infected

Some areas are more prone to scarring than others – like areas where skin doesn't stretch easily. Areas prone to scarring include:

• Nose
• Lip
• Forehead
• Ear 

Sometimes, extra skin remains in these areas once the hemangioma has shrunk. Once the hemangioma's shrinking phase (involution) is complete, a plastic surgeon can remove extra skin, if necessary. If there is any remaining discoloration, laser therapy may help.

How will a doctor diagnose my child?

Doctors usually make a diagnosis when a lesion appears. Occasionally, physicians will use a Doppler (sound device) to check the blood flow through a birthmark to help distinguish it from other vascular lesions. This technique is frequently used at Children's. It has an additional benefit of helping the doctor know which phase the hemangioma is in. A skin biopsy or an imaging study also can help make the diagnosis if the lesion is not typical in its appearance or in its behavior.

Can my baby have more than one hemangioma?

About 80 percent of patients have one skin hemangioma, but it is not uncommon for some infants to have more than one.

Do hemangiomas occur anywhere else besides on the skin?

It is very uncommon to have internal hemangiomas, but they may occur on internal organs. The risk of internal hemangiomas increases if your child has more than six skin hemangiomas. During your child's physical exam, the doctor might feel your child's liver and spleen to determine if the size is normal. The doctor also may order imaging studies if he or she thinks that your child has any risk of internal hemangiomas.

How are hemangiomas treated?

In general, infantile hemangiomas will shrink over time and most disappear completely on their own. Therefore, most will not require treatment. However, some hemangiomas do need treatment.
Whether to treat a hemangioma is determined by a number of factors, including:

• Age
• Size of the hemangioma
• Location of the hemangioma
• How rapidly the hemangioma is growing

Hemangiomas that are located in areas that can threaten health (airway or liver) or normal development (ear canal or on the eye) and those hemangiomas that are potentially disfiguring (face) are treated more quickly and aggressively than hemangiomas that pose less of a risk.

Treatment options for infantile hemangiomas include:

• Observation
• Oral systemic corticosteroids
• Surgical removal
• Laser therapy- Children's laser clinic
• Vincristine
• Propranolol
• Regranex (becaplermin) gel

Currently, the FDA has not approved the use of any medication for the treatment of infantile hemangiomas. Birthmark and vascular anomalies specialists at Children's are participating in ongoing research projects to find the safest and best treatments for hemangiomas.

Learn more about the best treatment options for your child.

Are my future children at risk?

Traditionally, hemangiomas haven't been considered to be an inherited condition; however, a recent study completed by our team of specialists has demonstrated a tendency for hemangiomas to run in families. Further studies need to be completed before the true risk of having a second infant with a hemangioma is known. Hemangiomas are very common, and in our experience, they do not tend to occur in the same location within families.

Are you conducting research on hemangiomas?

The Medical College of Wisconsin and Children's are conducting several studies on hemangiomas. For more information, contact Shawna Joachim, clinical research coordinator, at (414) 955-2817.

More facts about hemangiomas

• The cells that make up a hemangioma are most like the cells that line blood vessels. Under the microscope, a hemangioma looks like a cluster of tangled blood vessels.
• A hemangioma's cells multiply, which cause the hemangioma to grow or thicken. The lesion usually swells, rather than spreading on the skin surface.
• A hemangioma is a form of a tumor that will stop growing and go away with time, unlike cancer tumors.
• In the past, many types of red skin lesions were incorrectly called hemangiomas. This has produced a considerable amount of confusion in the medical field regarding their prognosis and treatment. Even today, many textbooks and scientific papers will use the term to describe other blood vessel tumors in older children and adults. The term hemangioma of infancy or infantile hemangioma often is used to refer to these lesions.
• Hemangiomas do not result from anything you did or did not do during the pregnancy.
• Hemangiomas are noncancerous and eventually shrink, but we can treat them if necessary.

Learn more

• Learn more about birthmarks and vascular anomalies and current hemangioma research at Children's.