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Haemangioma – infantile

  • RCH Infantile haemangioma pre referral guideline

    Most infantile haemangiomas do not require treatment. However some infants require investigations and/or treatment. Consider urgent referral to a specialist with expertise in this field if there are any of the following red flags:

    Type of haemangioma Potential associated problems
    Large head or neck haemangioma brain abnormalities, eye abnormalities, stroke, congenital heart disease, airway haemangioma, permanent deformity  
    Eyelid/peri-orbital haemangioma permanent visual deficit  
    Nose or lip haemangioma permanent scarring or deformity, feeding difficulties  
    Face neck upper chest haemangioma cosmetic issues, permanent residual changes at site, scarring, atrophy, telangiectasias and redundant skin  
    Large haemangioma on lower back or anogenital area urogenital and spine abnormalities  
    Large haemangioma involving nipple area in females significant cosmetic sequelae in both childhood and adulthood  
    Napkin area haemangioma painful ulceration that is difficult to heal
    Five or more haemangiomas large liver haemangioma with resulting cardiac failure and possible hypothyroidism. If child is unwell or under three months of age, liver ultrasound is warranted.  

     Initial work up by local doctor

    • Educate the family on what an infantile haemangioma is and the natural evolution, the management plan
    • Provide The Royal Children's Hospital (RCH) Infantile Haemangioma fact sheet
    • Liver ultrasound if there are five or more haemangiomas in infant under three months of age
    • Consider differentials; vascular malformations (e.g. port wine stain capillary malformation, venous malformation, lymphatic malformation), pyogenic granuloma, tufted angioma, sarcoma, myofibroma, neuroblastoma, leukaemia cutis.
      • Refer for urgent paediatric dermatology specialist opinion if uncertain diagnosis or atypical history or atypical clinical features for infantile haemangioma.

    Recommended pre-referral treatment by local doctor

    • Most children do not require treatment for their haemangioma.
    • For small and flat haemangiomas on the face
      • Topical Timolol Maleate 0.5% gel forming drops, one drop applied to the haemangioma with a finger twice a day is reasonable.
      • If this successfully prevents further growth, and gives early fading, it can usually be ceased after 4–6 months treatment.
      • Topical timolol is less effective than oral beta blocker and is not adequate for larger troublesome haemangiomas
    • For haemangiomas requiring treatment (e.g. red flags above), treatment should be started early to reduce the possibility and severity of complications. Consider urgent referral.
    • If oral beta blocker (atenolol or propranolol) is commenced locally by a doctor with experience in this area, detailed guidelines have been published.

    Referral information needed for any referral to the RCH

    • Mark with reason for urgency
    • Age of onset
    • Location of haemangioma
    • Size of haemangioma
    • Does the haemangioma cover a large anatomic region in a geographic pattern (i.e. is it a segmental lesion)? 
    • Is it still growing?
    • Is there ulceration or bleeding?
    • Number of haemangiomas
    • Ultrasound results (if previously performed)

    Contact information

    Clinical advice

    • Department of Dermatology (03) 9345 5522 and page the on call Dermatology Registrar or derm.dept@rch.org.au
    • Department of Plastic and Maxillofacial (03) 9345 5522 and page the on call Surgical Fellow or plastic.surgery@rch.org.au
    • RCH Emergency Department (03) 9345 5522

    Booking enquiries and appointment rescheduling

    • Specialist clinics: (03) 9345 5522

    Admission enquiries

    • After hours/Switchboard: (03) 9345 5522

    Other

    • Seriously unwell child: 000
    • RCH Medicines Information pharmacy line: (03) 9345 5208. Monday to Friday 08.30am–5.30pm

    General Practitioner resources and links

    Parent resources and links

    References

    1. Rodriguez Bandera A, Sebaratnam D, Wargon O, Wong L. “Infantile hemangioma. Part 1:Epidemiology, pathogenesis, clinical presentation and assessment”. J Am Acad Dermatology 2021; 85:1379-92.
    2. Sebaratnam D, Rodriguez Bandera A, Wong L, Wargon O. “Infantile hemangioma. Part 2: Management”. J Am Acad Dermatology 2021; 85:1395 – 1404.
    3. Smithson S et al. “Consensus statement for the treatment of infantile haemangiomas with propranolol”. Austral J of Dermatology 2017;58: 155-159.
    4. RCH Kids Health Information Fact Sheet: Infantile Haemangioma
    5. RCH Kids Health Information Fact Sheet: Treatment of haemangiomas with beta blockers
    6. DermNet NZ, Infantile haemangioma: Definition and pathogenesis: Definition https://dermnetnz.org/topics/infantile-haemangioma-definition-and-pathogenesis
    7. DermNet NZ, Infantile haemangioma: Complications and treatment. https://dermnetnz.org/topics/infantile-haemangioma-complications-and-treatment
    8. Dermnet NZ, PELVIS SYNDROME. PELVIS syndrome | DermNet NZ
    9. Plastic and Maxillofacial Surgery, The Royal Children’s Hospital. Haemangioma of infancy. https://www.rch.org.au/plastic/department_sections/Haemangioma/


    Dermatology Department, The Royal Children’s Hospital. Management of an Infantile Haemangioma.

    Author
    Departments of Dermatology, Plastic and Maxillofacial Surgery, General Medicine and the Education Hub of The Royal Children’s Hospital.

    Guideline first published
    September 2022

    Guideline reviewed
    September 2022