Haemangioma of infancy (strawberry birthmark)

  • What is a haemangioma?

    Haemangiomas are the most common tumours that occur in babies.  They are found in about 5% of infants.

    Most often a haemangioma is not present at birth, or is seen as a small red mark or a pale patch on the skin.  They start to grow within a few days of birth and can grow very rapidly in the first few months of life.  They reach a maximum size anywhere from about four months to twelve months of age, before they start to gradually go away (known as ‘involution’).  It takes several years for a haemangioma to become flat.  Parents are often told that haemangiomas will be ‘gone’ by the age of five, but the reality is that the appearance often continues to improve for many years after that.  Sometimes they go away completely, but more often they leave behind a mark or scar on the skin.

    Most often haemangiomas are on the surface of the skin but sometimes they can be under the skin or even deeper.  If they are not on the surface they grow at the same rate, but they may not become obvious until a few months of age when they reach a size large enough to be visible.  They go away over time just like the ones on the surface do, but if the surface skin is not involved there may be no mark left behind.

    What causes haemangiomas?

    We do not know what causes haemangiomas.  They are more common in children with a low birth weight (from prematurity or otherwise) and slightly more common in girls than in boys.  Haemangiomas are not caused by anything that a mother has done or not done during pregnancy.  Haemangiomas do not generally run in families but, because they are so common, some families have 2 or 3 or even more children with a haemangioma.

    What problems can occur with haemangiomas?

    The most common complication of haemangioma is ulceration.  The skin on the surface of a haemangioma is less strong than normal skin and can break down.  This is especially common in haemangiomas in the nappy area.  When an ulcer happens on a haemangioma, it is painful and can be slow to heal.  Specialised dressings by nurses experienced in the management of ulcerated haemangiomas can speed up healing.  Sometimes the doctor may suggest surgery to remove an ulcerated haemangioma.   

    If a haemangioma is close to the eye, it can affect the vision by pressing on the eye or blocking vision and specialist assessment should be sought. 

    Depending on their location, haemangiomas can cause other problems such as ear or lip deformities, or airway obstruction.  Very large haemangiomas around the face can potentially cause permanent scars and problems with appearance and therefore may need early treatment.

    Will my child bleed from his or her haemangioma?

    Parents are often worried about whether a haemangioma will bleed.  Haemangiomas contain large numbers of blood vessels and, if injured, will bleed more than normal skin. However, the bleeding is easily controlled by pressure and like bleeding elsewhere on the body will stop in a short time if continuous pressure is applied. It is very rare for bleeding from a haemangioma to be a major problem.

    What treatments are available for haemangiomas?

    Most true haemangiomas (not vascular malformations, see above) will reach a certain size and then shrink away and do not require treatment.  Sometimes when they go away, they leave some changes in the skin such as thinning or redness or scarring. This may be treated with laser or surgery to improve the final appearance.  If required, this is usually done prior to going to school.

    Some haemangiomas do reach a size that requires early treatment.  This is especially so if they threaten to damage a vital organ such as the eye.  We would always consider treatment for haemangiomas around the eye, nose, lips, ears, airway, or nappy area. We would also consider treatment for haemangiomas at other areas of the face, or for larger lesions elsewhere on the skin, or for any ulcerated haemangioma (see above). The most common treatment today is the drug propranolol.  This is a drug which has been used for many years to treat high blood pressure and migraine. Since 2008, it has been shown to also be an effective treatment for haemangioma.  Propranolol treatment needs to be supervised by an experienced paediatrician or dermatologist.  It is generally taken by mouth and needs to be continued for several months, or sometimes a year or more.  Propranolol should therefore only be started if the doctor and parent have both agreed that treatment is required and are committed to the full course. 

    For small, superficial haemangiomas, there may be an option of applying Timolol, a drug closely related to propranolol, to the skin of the haemangioma.  Laser is sometimes used to treat haemangioma as part of a comprehensive treatment plan.  Surgical excision of haemangiomas in the early phase is possible but only occasionally required. 

    Are there other types of haemangioma?

    Although the typical haemangioma of infancy is by far the most common type, there are some other tumours which are quite similar.

    The most common of these is the ‘congenital haemangioma’.  Unlike haemangioma of infancy, these are fully formed at birth.  Some get much smaller in the first few months of life (Rapidly Involuting Congenital Haemangioma or RICH), whereas others stay the same size through childhood (Non-Involution Congenital Haemangioma or NICH).  Congenital haemangiomas do not respond to propranolol, but luckily most do not need early treatment.

    Pyogenic Granuloma (or ‘lobular haemangioma’) is a small growth of blood vessels on the skin which looks similar to a haemangioma.  They usually occur in older children most often on the face or the hands.  They are quite fragile and bleed easily.  They can be removed by surgery or ‘curettage’ and laser. The name ‘haemangioma’ has traditionally been used for a lot of different lesions which are not haemangiomas of infancy or congenital haemangiomas. Many doctors still use the outdated terms.  This can be quite confusing for parents.  Most often they will be referring to one of the other conditions described on this website.