Dr Lizanne Noronha, Dr Lea Solman

A birthmark is a mark on the skin that is there at birth or appears shortly afterwards. Birthmarks can be a huge source of anxiety for parents, especially if they are obvious and affect a baby’s appearance. While most birthmarks are harmless and don’t need treatment, it’s important to recognise which ones need further investigation and treatment.

In this article, we’re looking at one of the most common birthmarks we see in paediatrics. Often named after summer berries (strawberry, raspberry etc) because of their characteristic appearance, infantile haemangiomas affect 1 in 10 babies. They can appear anywhere on the body. They’re more common in girls, premature babies and multiple pregnancies.

What is an infantile haemangioma?

A haemangioma is a collection of tiny blood vessels that form a lump under the skin. Importantly, haemangiomas are NOT there at birth but tend to appear in the first few weeks of life. Parents sometimes notice a pink or pale area before the haemangioma appears.

How to describe a haemangioma?

• A haemangioma may be superficial (on the skin, red/ pink in colour) or deep (under the skin, blue/ purple in colour) or a mixture of both

• It can be focal (a well-defined lump with a clear border) or segmental (flatter, wider with a more irregular texture and border)

How does a haemangioma normally behave?

Haemangiomas usually grow rapidly in the first few months of life, then stop growing at around 6 months of age. Around 1 year of age, they begin to involute (shrink and become paler in colour) and by 5 years of age, 50% will have disappeared. By 10 years, almost all haemangiomas will have involuted. 

Families often worry that a haemangioma could bleed heavily. Haemangiomas may bleed if knocked (very common when babies start crawling and walking) but they are unlikely to cause significant bleeding as the vessels contained within them are tiny. 

Applying firm pressure to the area with a clean gauze or towel should stop the bleeding. Putting Vaseline on the surface of the haemangioma each day helps to keep the surface of it moist and prevent cracks and bleeding.

When to consider referral

Most haemangiomas don’t need any intervention and can just be left alone – but there are some cases which will need discussion with a Dermatology specialist centre:

Haemangiomas causing functional problems

Haemangiomas around the eyes can grow very quickly and affect vision. Children who have them usually require treatment and an Ophthalmology review. Haemangiomas around the nose and mouth can cause feeding or breathing difficulties. 

Haemangiomas affecting the neck can extend inwards and compromise the airway. These should always be referred and managed with the input of the ear, nose and throat (ENT) team.

Ulcerated haemangiomas or those at risk of ulceration

These can be really painful and need special management with specific dressings and regular pain relief. It is important to treat them quickly as they can scar if left untreated. Haemangiomas in the genital area are at high risk of infection and ulceration due to constant exposure to nappy contents and trauma from frequent nappy changes. 

Multiple haemangiomas

While it is not uncommon to have more than one infantile haemangioma, it is rare to have multiple.

This is called ‘Haemangiomatosis’ and may be cutaneous (only affecting the skin) or visceral (affecting internal organs). If a baby has multiple haemangiomas on the skin, they may need further investigation to look for internal lesions e.g. a liver ultrasound. 

In very rare cases, large visceral haemangiomas (usually in the liver or GI tract) can cause shunting of the systemic circulation resulting in high output heart failure. 

Risk of scarring and disfigurement 

Most haemangiomas resolve with minimal or no scarring. Larger, more complex lesions are the ones more likely to scar or cause disfigurement. Clearly, large birthmarks on the face or body can cause a lot of distress for parents and may have a long term psychological effect on the child themselves. It is always worth referring children with obvious haemangiomas in visible areas such as the face and hands. Starting treatment early gives a better cosmetic result in the long term.

Uncertainty

If you are not sure whether a birthmark is a haemangioma, it’s worth getting an expert opinion. An experienced dermatologist will often confirm a diagnosis just on appearance, but sometimes an ultrasound or specialist imaging is needed.

Suspicion of a segmental haemangioma syndrome

Segmental haemangiomas may be associated with two syndromes. These should not be missed as they require further investigation and treatment and there are potential longer term implications for the child and family. 

In a baby with a segmental haemangioma affecting the eye area, consider PHACES:

Posterior fossa abnormalities

Haemangioma

Arterial abnormalities

Cardiac abnormalities

Eye problems

Sternal anomalies

These babies need investigative work-up with MRI head/MRA head and neck, ECG, echo and Ophthalmology review

In a baby with a segmental haemangioma affecting the lower back, consider LUMBAR

Lower body haemangioma

Uro-genital anomalies

Myelopathy

Bony deformities

Ano-rectal malformations

Renal anomalies

These babies will need MRI spine with contrast, renal ultrasound and sometimes neurosurgical intervention and follow up

Treatment options

• If a haemangioma needs treatment, we normally use beta-blockers. Starting treatment earlier rather than later is associated with a better cosmetic result. 
• It’s a good idea to arrange medical photography before starting treatment as this gives a clear record of response to treatment. 
• The choice of treatment depends on the size and location of the haemangioma.
• Smaller haemangiomas can be treated with Timolol drops directly onto the skin. Larger, more complex lesions need oral treatment, usually with Propranolol. Treatment should be started under the guidance of an experienced department and parents should be counselled about the risks of potential side effects. 
• Patients in high risk groups (premature babies, low birth weight infants and those that had neonatal hypoglycaemia) should have the first dose of beta blocker treatment in hospital. 
• Most children will need at least 6 months of treatment and should be regularly followed up while on treatment.

Families often ask about laser treatment and/ or surgery. Laser treatment can be considered if an involuted haemangioma has left disfigurement or scarring that is causing distress – but it is not normally considered until a child has reached school age. 

Surgery is usually not recommended as it carries significant risk of complications and scarring. 

Take home messages

• Most infantile haemangiomas don’t require any treatment and will involute by 5 years of age
• Haemangiomas are not present at birth but usually appear in the first few weeks of life. If a lesion is fully present at birth, a different diagnosis should be considered
• Always consider early referral for segmental haemangiomas, those causing a functional problem and those likely to cause distress or disfigurement if left untreated
• Starting treatment early in babies with larger, complex haemangiomas gives a better cosmetic result

Resources

Changing Faces – this is a charity that provides support to anyone with a scar, mark or condition that affects their appearance 

Great Ormond Street Hospital Dermatology department has a variety of information leaflets for parents, families and health professionals 

Authors: Dr Lizanne Noronha, paediatric registrar; Dr Lea Solman, dermatology consultant at Great Ormond Street Hospital