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Dermatology
Infantile Hemangiomas
Built from Dermatology, 5th Edition
What’s inside
14 sections · 155 slides
Overview
What an infantile hemangioma is, and how this deck is organized
- What is an infantile hemangioma?
- How this deck is organized
- Key features
Classification and History
How doctors learned to separate hemangiomas from other vascular birthmarks
- Older names for infantile hemangioma
- The 1982 biologic classification
- Three groups of vascular birthmarks
- Biologic classification of vascular birthmarks
- Infantile hemangioma vs vascular malformation
- Differences between infantile hemangiomas and vascular malformations
Epidemiology
Who develops an infantile hemangioma, and known risk factors
- How common is infantile hemangioma?
- Risk factors for developing an IH
- Family history
Pathogenesis
What drives abnormal vessel growth inside an infantile hemangioma
- Where hemangioma vessels come from
- A placenta-like cell signature
- The role of low oxygen (hypoxia)
- Signaling pathways driving growth
- Normal cells make a “decoy” receptor, VEGFR-1, that soaks up VEGF and limits growth signaling.
- Other growth pathways
- Growth vs shrinkage: what changes
- Markers of proliferating and involuting hemangiomas
Clinical Presentation
How an infantile hemangioma looks, from first sign to full lesion
- Early warning signs (precursor lesions)
- IH precursors are the very first, faint hints of a hemangioma before it thickens.
- Ulceration as a first sign
- Where hemangiomas occur
- Segmental IHs can mimic a flat capillary malformation (“port-wine” birthmark) early on.
- Superficial hemangiomas sit in the upper layer of skin (the dermis).
- More examples of segmental superficial IH — broad, plaque-like patches rather than a single focal bump.
- This superficial IH closely mimics a capillary malformation (a flat vascular birthmark) at first glance.
- Deep and mixed hemangiomas
- A: a skin-colored deep hemangioma on the scalp, with fine vessels and patchy hair loss over it.
- A further example of a deep hemangioma: a warm, ill-defined, blue-purple mass with little surface change.
- 50-60%
- Focal vs segmental patterns
- Researchers mapped facial segmental hemangiomas onto four zones, S1 to S4.
- Segmental patches: the early field
- “Biker glove” describes a segmental hemangioma on a limb that spares the fingertips — like a fingerless glove.
Natural History
How an IH grows, plateaus, and shrinks over years
- Early proliferation
- The growth phase in detail
- When does growth peak?
- This figure lays out the whole natural history side by side: infantile hemangioma vs congenital hemangioma.
- IH with minimal or arrested growth (IH-MAG)
- IH-MAG shows visible fine and coarse vessels (telangiectasias) over pale skin.
- More IH-MAG examples: visible fine and coarse vessels over pale skin, with focal crusting.
- This IH-MAG shows blotchy (reticulated) redness with scattered fine vessels over a pale background.
- Involution: how shrinkage begins
- This IH is caught mid-involution: color has patchily lightened, and the surface is softening.
- How much shrinks, and by when?
- What is left behind (residua)
- A: a hemangioma with an open ulcer. B: the same patient 20 years later — mild pale patch and a small circular scar where it had ulcerated.
- A mushroom-shaped (exophytic, pedunculated) IH during involution.
- Left: residual fine visible vessels (telangiectasias) after a segmental IH resolved.
- This example shows atrophy (thinning) and loose fibrofatty tissue after an IH shrank.
Complications
Ulceration, disfigurement, and interference with function
- Who is at risk of complications?
- Ulceration: the most common complication
- Ulceration: timing and warning signs
- A: an early ulcerated superficial IH on the buttock — the vascular nature may not be obvious at first.
- A mixed hemangioma with an open ulcer — a common complication of larger, deeper lesions.
- An ulcerated IH on the arm, showing the raw, painful surface typical of this complication.
- An early, superficial ulcerated IH on the buttock — the vascular component underneath can be subtle.
- Complications from size or location
- Periocular (near-the-eye) hemangiomas
- A: a superficial segmental IH and B: a deep IH, both obstructing the line of sight over the eye.
- Nasal tip and lip hemangiomas
- A: nasal tip hemangioma — mixed or deep lesions here can distort the underlying cartilage.
- A lip hemangioma crossing the vermilion border — the sharp color line at the edge of the lip.
- Another lip IH — a cosmetically sensitive site that is prone to painful ulceration.
- Other vulnerable sites
Extracutaneous Involvement
When a large hemangioma is a marker for problems beyond the skin
- Large head-and-neck IHs: a broader concern
- PHACE(S) syndrome: what the letters mean
- This figure lays out the major PHACE(S) features together: brain, hemangioma, arteries, heart, eyes, and midline skin.
- How common is PHACE(S)?
- Diagnostic criteria for PHACE(S) syndrome
- Definite vs possible PHACE(S)
- Vessel and heart changes in PHACE(S) can progress over time, not just stay static.
- Airway hemangiomas and the “beard” pattern
- A: the anatomic sites on the lower face and neck linked to airway hemangioma risk.
- Another example of an IH in a beard distribution — the pattern that prompts a check for airway involvement.
- Lumbosacral hemangiomas and spinal dysraphism
- A segmental lumbosacral hemangioma — this location puts the child at risk of LUMBAR syndrome (see next).
- A lumbosacral hemangioma found together with a tethered spinal cord — a direct example of the spinal-dysraphism link.
- LUMBAR syndrome: what the letters mean
- This figure lays out the major LUMBAR syndrome features together.
- Multifocal hemangiomas and internal organs
- This infant has many small superficial skin lesions in a scattered, miliary pattern, plus liver hemangiomas.
- Liver hemangiomas: when to screen
- A CT scan showing multiple hemangiomas scattered through the liver in a child with multifocal skin IHs.
- Another example of multifocal skin IHs together with liver hemangiomas, in a scattered miliary pattern.
- Rarer sites of internal involvement
- Hemangiomas and low thyroid hormone
Radiology and Pathology
Imaging and microscopic findings that confirm the diagnosis
- When is imaging needed?
- Imaging findings in infantile hemangiomas: MRI
- Imaging findings in infantile hemangiomas: Doppler and CT
- What a biopsy shows: proliferating IH
- What a biopsy shows: involuting/involuted IH
- This biopsy shows clusters of endothelial cells forming vessel channels, separated by fibrous walls (septae).
- Confirming the diagnosis by stain (immunohistochemistry)
Differential Diagnosis
Other conditions that can look like an infantile hemangioma
- Look-alikes of superficial hemangioma
- Look-alikes of deep hemangioma
- Key features of infantile and congenital hemangiomas
- Kasabach–Merritt phenomenon (KMP)
- This is kaposiform hemangioendothelioma, a rare vascular tumor distinct from IH, associated with Kasabach–Merritt phenomenon.
- Other tumors that can mimic a hemangioma
Treatment
Goals of care, and the therapies used for complicated IH
- Goals of IH management
- Reasons to consider systemic therapy for infantile hemangiomas
- Active non-intervention
- Managing an ulcerated hemangioma: wound care
- Managing an ulcerated hemangioma: specific therapy
- Pain control for ulcerated hemangiomas
- Topical beta-blockers
- A: an ulcerated superficial IH on the neck of a 10-week-old girl.
- Intralesional corticosteroids
- Systemic beta-blockers: the game-changer
- How propranolol works
- Propranolol: side effects to watch for
- Propranolol in PHACE(S) syndrome
- Administration of propranolol for infantile hemangiomas: counseling, risk assessment, dosing, and monitoring
- Administration of propranolol for infantile hemangiomas: counseling, risk assessment, dosing, and monitoring (continued)
- Propranolol dosing in practice
- Other beta-blockers besides propranolol
- Systemic corticosteroids
- Other systemic drugs: sirolimus and historical agents
- Laser and surgical therapy
- When is early surgery considered?
Congenital Hemangiomas
RICH and NICH: fully formed vascular tumors present at birth
- Congenital hemangiomas: a distinct family
- Rapidly involuting congenital hemangioma (RICH)
- A: a violet tumor with surface fine vessels on the arm of a newborn — classic RICH appearance.
- Another RICH example: A, a violet nodule with coarse vessels and a pale blanched rim in a newborn.
- Non-involuting congenital hemangioma (NICH)
- A and B: light blue-violet vascular plaques with coarse surface vessels and a pale rim, on the cheek and thigh.
- A NICH on the forehead of a school-aged child, showing a subtle pale rim.
- Another NICH in a school-aged child, fully formed at birth and remaining warm and firm to the touch.
- Diagnosing and treating congenital hemangiomas
- PICH: an intermediate form
Summary
The essential points to take away
- Takeaways: recognizing IH
- Takeaways: risk and syndromes
- Takeaways: treatment
References
The cited literature underlying this topic
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- Dermatology, 5th Edition (2-Volume Set)