A hemangioma is a benign tumor made up of an abnormal overgrowth of the endothelial cells that line blood vessels. Infantile hemangiomas are the most common type and are the focus of this article. They are not typically present at birth but appear within the first few weeks of life.

The most unique and defining characteristic of an infantile hemangioma is its predictable life cycle, which occurs in two main phases:

1. The Proliferative Phase: This is a period of rapid growth that typically occurs during the first three to five months of life. The hemangioma grows quickly in size and volume.
2. The Involuting Phase: After the initial growth phase, the hemangioma stabilizes and then begins a long, slow process of shrinking and fading. This involution phase can take anywhere from three to ten years to complete.

A helpful analogy is to think of the development of blood vessels in a newborn as the laying down of a quiet network of small “garden hoses.”

• In an infantile hemangioma, it is as if a faulty “construction signal” is sent out in one specific spot shortly after birth.
• This signal tells the hose-building cells to work overtime, rapidly building a dense, tangled, and disorganized clump of extra hoses. This is the proliferative phase.
• After a few months, this faulty signal shuts off, and a new “demolition and remodeling” signal begins. Over the next several years, a slow-working crew comes in and gradually dismantles the tangled clump of extra hoses, clearing the area. This is the long involuting phase.

There are several different types of infantile hemangiomas, based on their location in the skin:

• Superficial Hemangioma: This is the classic “strawberry mark.” It is located on the surface of the skin and appears as a bright red, raised lesion.
• Deep Hemangioma: This type is located deeper under the skin. It may appear as a bluish or skin-colored swelling with a rubbery feel.
• Mixed Hemangioma: This type has both a superficial, bright red component and a deeper, bluish component.

In my experience, many parents are concerned when they notice a bright red bump on their baby’s skin usually, it turns out to be a common infantile hemangioma.

The exact cause of why infantile hemangiomas form is unknown. They are not caused by anything the mother did or did not do during pregnancy. The leading theory suggests that they may be related to placental tissue. It is thought that some cells from the placenta may embolize, or travel, to the fetal skin during development. After birth, these placental cells are then triggered to proliferate and form the blood vessel-rich tumor. This theory helps to explain why hemangiomas are not present at birth but appear and grow rapidly in the early postnatal period.

In my experience, I often explain to parents that hemangiomas are not caused by anything the mother did during pregnancy and are usually spontaneous.

An infantile hemangioma is a benign tumor that a baby develops shortly after birth. It is not contagious and is not an inherited condition in the traditional sense. It is a sporadic developmental anomaly.

While any baby can develop a hemangioma, several factors are associated with an increased risk:

• Prematurity and Low Birth Weight: This is a significant risk factor.
• Gender: They are more common in girls than in boys, at a ratio of about 3 to 1.
• Race: They are most common in Caucasian infants.
• Complications of Pregnancy: Certain placental abnormalities or procedures performed during pregnancy, like chorionic villus sampling, have been linked to a higher incidence.

In my experience, hemangiomas usually develop within the first few weeks of life, especially in premature babies or those with low birth weight.

The signs of an infantile hemangioma follow its predictable life cycle.

• Appearance: Often, there is nothing visible at birth, or there may be a pale patch of skin or a small red dot. In the first few weeks of life, this precursor lesion begins to grow into a red, raised bump.
• Growth: The hemangioma will undergo a period of rapid growth for the first 3 to 5 months of life.
• Involution: After the growth phase, the hemangioma will stabilize and then begin to slowly fade and shrink. The bright red color may soften to a purplish or grayish color, and the tumor will become softer and flatter. This process takes many years. By age 5, about 50% have involuted, and by age 10, over 90% have resolved.

When is a Hemangioma a Problem?

Most infantile hemangiomas are a purely cosmetic issue. However, a small percentage can be “high-risk” and cause medical complications due to their size or location.

• Ulceration: The skin over a large, rapidly growing hemangioma can break down, creating a painful, open sore that is at risk for bleeding and infection. This is most common for hemangiomas located in the diaper area.
• Vision Obstruction: A hemangioma on or around the eyelid can be a vision-threatening emergency. If it grows large enough to block the pupil or put pressure on the eyeball, it can cause permanent vision loss (amblyopia) or astigmatism. Any hemangioma near the eye requires urgent evaluation by a pediatric ophthalmologist.
• Airway Obstruction: Hemangiomas located in the “beard distribution” (on the chin, jawline, and neck) can sometimes be associated with a hemangioma in the airway. If this internal hemangioma grows, it can cause noisy breathing (stridor) and can become a life-threatening airway obstruction.
• PHACE Syndrome: This is a rare syndrome where a large, segmental hemangioma on the face is associated with underlying developmental abnormalities of the brain, heart, major arteries, and eyes.

Clinically, I monitor for complications like ulceration, bleeding, or interference with vision or breathing, depending on the hemangioma’s location.

The diagnosis of a typical infantile hemangioma is made clinically. This means a pediatrician or a pediatric dermatologist can confidently diagnose the condition based on two key factors:

1. The characteristic physical appearance of the “strawberry mark.”
2. The classic history of appearing a few weeks after birth and then undergoing a period of rapid growth.

For most common hemangiomas, no tests are needed. The diagnosis is made by visual inspection.

When is Imaging Needed?

If a hemangioma is very large, deep, or located in a high-risk area like the “beard” distribution, a doctor may order an MRI scan. The MRI can show how deep the hemangioma goes and can be used to screen for any of the associated internal abnormalities seen in syndromes like PHACE. An ultrasound may also be used.

A biopsy is almost never needed to diagnose an infantile hemangioma.

In my experience, I consider ultrasound or MRI in atypical cases, especially for segmental or internal hemangiomas to assess depth and involvement.

The treatment plan for an infantile hemangioma is highly individualized and is best managed by a pediatric dermatologist or a specialist at a vascular anomalies center.

1. Observation (“Watchful Waiting”)

For the vast majority of infantile hemangiomas, the recommended treatment is no treatment at all.

• Because most hemangiomas are small, harmless, and will go away completely on their own, the most appropriate course of action is simply active observation.
• Your doctor will monitor the hemangioma to make sure it is following the expected pattern of growth and involution.

2. When is Treatment Needed?

Medical treatment is reserved for the small percentage of hemangiomas that are considered “high-risk” those that are causing or threatening to cause a medical complication. The goals of treatment are to stop the growth of the hemangioma, shrink it, and prevent any complications like scarring, disfigurement, or functional impairment.

3. Medical Therapy

The treatment of problematic infantile hemangiomas was revolutionized by the discovery that beta-blocker medications are highly effective at shrinking them. This is now the first-line treatment.

• Oral Propranolol: This is the gold standard medical therapy. Propranolol is a common beta-blocker medication that is taken by mouth as a liquid. It works to rapidly halt the growth of the hemangioma and then causes it to shrink and fade much faster than it would on its own. Treatment is usually continued for several months.
• Topical Timolol: Timolol is another beta-blocker that comes in the form of an eye drop. It can be applied directly to the surface of small, thin, superficial hemangiomas.

4. Other Treatments

• Laser Therapy: A pulsed dye laser can be very effective at treating the early, flat precursor lesions of a hemangioma or for treating any residual redness or small blood vessels that remain after a hemangioma has involuted. Laser therapy is also used to help heal ulcerated hemangiomas.
• Surgery: Surgery to remove a hemangioma is rarely performed during its growth phase. It is typically reserved for removing the residual scar tissue or stretched skin that can be left behind after a very large hemangioma has involuted in a cosmetically sensitive area.
• Corticosteroids: In the past, high-dose oral or injected steroids were the mainstay of treatment. Due to their significant side effects, they have now been largely replaced by the safer and more effective beta-blocker therapy.

Clinically, I initiate treatment early in hemangiomas that risk disfigurement or functional issues topical timolol, systemic therapy, or laser treatment may be appropriate.

Seeing a bright red, rapidly growing “strawberry mark” on your infant can be a source of significant parental anxiety. It is essential to be reassured that infantile hemangiomas are the most common benign tumor of infancy and are not a form of cancer. The journey of a hemangioma is a predictable one, with a natural life cycle of rapid growth followed by a long, slow period of fading away. The vast majority are harmless and require no treatment other than patience. For the small number of hemangiomas that pose a risk to a child’s health or development, we now have safe and remarkably effective medical therapies, like propranolol, that can rapidly shrink the lesion and prevent complications. In my experience, most hemangiomas resolve without intervention, but regular monitoring helps catch complications early and ease parental anxiety.

The American Academy of Dermatology (AAD). (n.d.). Hemangioma: Overview. Retrieved from https://www.aad.org/public/diseases/a-z/hemangioma-overview

The American Academy of Pediatrics (AAP). (n.d.). Hemangiomas: About Strawberry Baby Birthmarks. Retrieved from https://www.healthychildren.org/English/health-issues/conditions/skin/Pages/Hemangiomas.aspx

The National Organization for Rare Disorders (NORD). (2023). Infantile Hemangioma. Retrieved from https://rarediseases.org/rare-diseases/infantile-hemangioma/