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
5 or more haemangiomas	large liver haemangioma with resulting cardiac failure and possible hypothyroidism. If child is unwell or under 3 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 RCH Infantile Haemangioma Fact sheet
Liver ultrasound if there are 5 or more haemangiomas in infant under 3 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 to 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. [link to current propranolol guidelines in AJD and change to atenolol if we change the guidelines]

Referral information needed for any referral to 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 & 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 0830am-530pm

General Practitioner resources and links

Referring clinician information

Referral form

RCH Specialist Clinics

https://www.dermcoll.edu.au/atoz/infantile-haemangiomas/

DermNet NZ, Infantile haemangioma: Definition and pathogenesis.

DermNet NZ, Infantile haemangioma: Complications and treatment.

Plastic and Maxillofacial Surgery, The Royal Children’s Hospital. Haemangioma of infancy.

Infant Birthmarks - Community HealthPathways Melbourne

Parent resources and links

RCH Kids Health Information Fact Sheet: Infantile Haemangioma

RCH Kids Health Information Fact Sheet: Treatment of haemangiomas with beta blockers

References

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.

Sebaratnam D, Rodriguez Bandera A, Wong L, Wargon O. “Infantile hemangioma. Part 2: Management”. J Am Acad Dermatology 2021; 85:1395 – 1404.

Smithson S et al. “Consensus statement for the treatment of infantile haemangiomas with propranolol”. Austral J of Dermatology 2017;58: 155-159.

RCH Kids Health Information Fact Sheet: Infantile Haemangioma

RCH Kids Health Information Fact Sheet: Treatment of haemangiomas with beta blockers

DermNet NZ, Infantile haemangioma: Definition and pathogenesis: Definition https://dermnetnz.org/topics/infantile-haemangioma-definition-and-pathogenesis

DermNet NZ, Infantile haemangioma: Complications and treatment. https://dermnetnz.org/topics/infantile-haemangioma-complications-and-treatment

Dermnet NZ, PELVIS SYNDROME. PELVIS syndrome | DermNet NZ

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