Infantile haemangioma
IH; strawberry haemangioma; juvenile haemangioma; capillary haemangioma of infancy
Infantile haemangioma is the commonest vascular tumour of infancy, affecting approximately 5% of infants (10% of pre-term, white female infants). Unlike vascular malformations, IHs follow a characteristic biphasic course — a rapid proliferative phase over the first 4–6 months, followed by gradual involution over 1–7 years, with residual fibrofatty tissue or telangiectasia. They are GLUT1-positive on immunohistochemistry — distinguishing them from all vascular malformations and from congenital haemangiomas (RICH, NICH, PICH). Treatment with oral propranolol revolutionised management in 2008 and is first-line for problematic lesions (functional impairment, ulceration, large segmental, life-threatening). PHACES syndrome should be considered for large facial segmental IHs.
Natural history
- Premonitory phase — telangiectasia or pale anaemic patch at birth in 30–50%.
- Proliferative phase — rapid growth from ~ 2 weeks to 4–6 months; majority of growth complete by 5 months.
- Plateau phase — 6–12 months.
- Involution phase — slow regression over 1–7 years (rule of thumb: 50% by age 5, 70% by 7, 90% by 9).
- Residual change — telangiectasia, atrophic skin, fibrofatty tissue, anetoderma — in ~ 50% of lesions.
Clinical classification
- Superficial ("strawberry") — bright red lobular surface plaque.
- Deep — blue-grey subcutaneous nodule with normal or telangiectatic overlying skin.
- Mixed — both components.
- Segmental — distributed in a recognisable developmental territory; higher complication risk; associated with PHACES (facial), LUMBAR (lumbosacral) syndromes.
- Multifocal — > 5 skin lesions warrants hepatic ultrasound to exclude hepatic haemangiomatosis.
PHACES and LUMBAR syndromes
- PHACES — Posterior fossa malformations, large facial segmental Haemangioma, Arterial anomalies (cerebral), Cardiac anomalies + Coarctation of aorta, Eye abnormalities, Sternal cleft / Supraumbilical raphe.
- LUMBAR — Lower-body Haemangioma, Urogenital anomalies + Ulceration, Myelopathy, Bony deformities, Anorectal malformations, Renal anomalies.
- Large facial segmental IH (> 5 cm) — arrange MRI brain + neck + heart echo + ophthalmology review.
- Lumbosacral midline IH (> 2.5 cm) — arrange spinal MRI to exclude occult spinal dysraphism.
When to treat
- Functional impairment — periocular (visual obstruction, amblyopia), airway (subglottic), feeding interference (perioral), auditory canal.
- Ulceration — pain, bleeding, infection; especially napkin / perineal area.
- High-risk anatomical sites — facial (central / cosmetic), large segmental, "beard" distribution (airway risk).
- Anticipated permanent deformity — nose, lip, ear cartilage at risk.
- Life-threatening — high-output cardiac failure (rare), Kasabach-Merritt (different — see KHE).
- Many IH require no treatment — active surveillance and parental education.
Management
- Oral propranolol — first-line for problematic IH; start by 5 months. Standard dosing 1–3 mg/kg/day in two divided doses; baseline ECG / HR / BP / glucose monitoring. Treat for 6–12 months minimum.
- Topical timolol 0.5% gel — for small superficial IH, particularly periocular and other functionally sensitive areas.
- Oral corticosteroids — historic first-line; now reserved for cases where propranolol contraindicated.
- Pulsed-dye laser — for residual telangiectasia in involution; ulcerated IH.
- Surgery — for residual fibrofatty / cosmetic remodelling after involution, usually at school age.
- Specialist vascular-anomaly MDT input for complex / syndromic cases.
- Parental education and reassurance — most lesions involute without treatment.
References
- Léauté-Labrèze C et al. Propranolol for severe infantile haemangiomas. N Engl J Med; 2015.
- Krowchuk DP et al. Clinical practice guideline for the management of infantile hemangiomas (AAP). Pediatrics; 2019.
- Frieden IJ et al. PHACE syndrome — clinical course. Arch Dermatol; 2010.
Spot a correction?
If any clinical statement, citation or link on this page needs updating, please email admin@skinoncology.net with the page name, the proposed correction and the supporting source.