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Is Your Child Sick?TM

Hemangioma

by Joseph Morelli, M.D.
Associate Professor of Dermatology and Pediatrics
University of Colorado School of Medicine

What is a hemangioma?

A hemangioma is a benign tumor of the blood vessels ("capillary endothelium"). Some hemangiomas occur as birthmarks, often spontaneously improving.

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What causes hemangiomas?

The cause of hemangiomas is unknown.

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Who gets hemangiomas?

Hemangiomas are a very common benign tumor of infancy. Hemangiomas occur in up to 10% of the population, most commonly in females and in premature infants.

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How do hemangiomas cause disease?

Because they are tumors, hemangiomas have a mass effect, meaning they take up space or room, which is caused by the growth of the tumor.

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What are the common findings of hemangiomas?

Only 20% of hemangiomas are present at birth. The other 80% occur during the first two months of life, usually within the first month. They appear as white-gray blue flat spots, swollen "spider veins" (telangiectasias), or raised bumps. Then, they undergo a rapid growth phase, lasting from six to nine months, in which they grow faster than the child's rate of growth. After this time, the growth of the hemangioma slows and approximates the growth rate of the child. The stable growth phase lasts until 12 to 18 months of age at which time the hemangioma begins to undergo "involution." During the involution phase, the tumor shrinks on its own, without the need for treatment. Maximum shrinkage occurs in 50% of children by age 5, in 70% of children by age 7, and in 90% of children by age 9.

Parents should know that hemangiomas do not always completely disappear; in some cases, the affected skin does not return to its normal appearance.

Some hemangiomas leave recognizable marks following shrinkage of the tumor. These include decreased skin color; spider veins; excess lax skin; fibrous fatty deposits; and scarring, if the skin has broken down over the hemangioma.

Hemangiomas can appear as three different forms. The first type is the superficial bright red form, formerly known as the strawberry mark. The second type is the deep blue nodule, formerly known as a cavernous hemangioma. The third type is a combination of the superficial and the deep forms, which is called a mixed hemangioma. Commonly, the terms "superficial," "deep," and "mixed" are used to describe the three different types of hemangiomas.

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How are hemangiomas diagnosed?

Hemangiomas usually are diagnosed based on an examination and the history of the lesion. Occasionally, magnetic resonance imaging is performed to determine the depth of involvement of the tumor; however, this procedure is rarely necessary or helpful.

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What are the complications of hemangiomas?

Most hemangiomas are uncomplicated and do not require treatment. Complications of hemangiomas include ulceration (a breakdown of the overlying skin), infection, interference with a vital function, and, even, high output cardiac failure. Initially, the Kasabach-Merritt syndrome, which is a bleeding disorder, was thought to occur with hemangiomas; however, now, it is thought to occur with hemangioendotheliomas, which are a much less common and more aggressive tumor. Ulceration is the most common complication of hemangiomas. Ulcerated hemangiomas occur most commonly on the lip and in the diaper areas. If a lesion is ulcerated, it is at risk for infection. Staphylococcus aureus is the most common bacteria in infected hemangiomas. Vision, breathing, eating, urination, and bowel movements may all be obstructed by large, rapidly growing hemangiomas.

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How are hemangiomas treated?

Most hemangiomas do not require treatment. Ulcerated hemangiomas are best treated with a specific type of laser. This leads to rapid healing of the open area. Infection is treated with specific antibiotics for Staphylococcus aureus. Large, rapidly growing hemangiomas, or hemangiomas that interfere with a vital function, are treated with systemic therapy. (Systemic therapy is treatment that affects the whole body, as opposed to localized treatment, and can be given either by mouth or intravenous injection.) Prednisone is the initial treatment of choice. It usually is given for two weeks. If after two weeks of therapy the tumor growth has been slowed, treatment is then tapered over the next four weeks. If there is no initial effect of therapy, the dose of prednisone is maintained for another two weeks. The patient should be seen every two weeks during therapy. Occasionally, after therapy is stopped, there will be some rebound growth of the tumor. If this growth is substantial, therapy should be restarted. Interferon-alfa also has been used to treat hemangiomas. The use of interferon-alfa should be reserved for hemangiomas that do not respond to prednisone therapy.

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How are hemangiomas prevented?

Currently, hemangiomas cannot be prevented.

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What research is being performed?

The research most applicable to hemangiomas is being performed in the area of inhibiting the formation of new blood vessels (anti-angiogenesis). Since hemangiomas are vascular tumors, any therapy that inhibits blood vessel formations should impede hemangioma growth. At this time, agents that inhibit blood vessel formation have not yet been used for hemangioma therapy.

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Are there links to other information?

A support group for families with children with hemangiomas is available at: The National Organization of Vascular Anomalies, P.O. Box 0358, Findlay, OH 45839-0358, phone number: (419) 425-1593, e-mail: hemangnews@msn.com and on the web at www.novanews.org.

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References

Rasmussen JE. Vascular birthmarks in children. Dermatology Nursing 10:169-177, 1998.

Frieden IJ. Which hemangiomas to treat-and how? Arch Dermatol 133:1593-1595, 1997.

Morelli JG. Hemangiomas and vascular malformations. Pediatric Annals 25:91-96, 1996.

About the Author

Joseph received his undergraduate degree from the University of Pennsylvania, graduating Summa cum Laude with honors in biophysics. He completed his medical school training in 1981 from the Harvard University School of Medicine.

He is board certified in pediatrics and dermatology and completed his residencies in the same specialties. Joseph is a Pediatric Dermatologist with major interest in birthmarks and vascular lesions.

He spends most of his free time coaching Little League Baseball and Midget Football!

Copyright 2012 Joseph Morelli, M.D., All Rights Reserved