What is an Hemangioma?  

An Hemangioma is a benign tumour affecting the celules that cover the walls of the vascular system (endothelium). These vascular anomalies consist of a proliferation of the endothelial cells, which create a mass that is fed and drained by newly created vascular channels.

How many people is affected? 

Hemangioma represents the benign tumour more commonly found on newborns. Between 5% and 10% of children under one year are affected. This anomaly is more common between girls (3 to 5 times more common), specially when the skin is very pale. It is indeed more common to see them on children of caucasian heritage.  

The incidence of hemangiomas is also more common amogst early-borns, when weight is between 1kg and 1,8kg (proportion of children affected in this case can be as high as 25%).

What are the causes of Hemangioma?  

The exact cause of an hemangioma is not yet known. However there is a hypothesis that there is a certain genetic predisposition. In any case, there is certainty that they are not heriditary, even if they are found in antecedents of about 10% of the cases. 

There is no known linkage with any aliments or drugs which may be ingested during pregnancy, or with any activity carried out during this period. There is nothing that can be done during pregnancy to prevent them. 

Current research is focused on the relevance of skin pigmentation, the role of estrogens, and a potential genetic predisposition. 

When do they first appear?  

About 10% of the hemangioma are visible at the moment of birth, as a small red spot. In most other cases, they appear during the first 15 days after birth. 

They are really noticeable at the second or third month, after achieving a certain volume. It is important to know that an hemangioma never appears in adulthood. 

How do they evolve over time?  

The hemangioma usual develops rapidly during a period going between 6 to 12 months of life, sometimes even up until 18 months: it is the growing phase, referred to as proliferation phase.  After this, it will regresse spontanously and naturally, however in a much slower fashion, over a period that can last between 4 and 7 years. During this period, referred to as involution, the hemangioma becomes less and less red, its colour turning towards grey and its texture becoming less sponge-like. 

The involution is complete in 50% of the cases when the child is at age of 5, and in 70% of the cases when the child is aged 7. This regression is always completed at age of 10, or 12 at the latest. Once the hemangioma disapears, it does not regrow.

Do they leave any sequels?  

In some cases hemangiomas leave sequels, in others they don’t. Once its involution finishes, depending on its former extension and kind, there may be scars left (small vessels dilated). The subcutaneous hemangioma or mixed ones may leave a thinner and lose skin with wrinkles. 

What parts of the body can be affected?  

Nevermind its morphology, an hemangioma can affect any part of the body. In 60% of the cases they are located on the head or neck areas. In 25% of the cases they are on the upper part of the body, and 15% on arms or legs. The large majority of hemangiomas (80%) are isolated. Only 20% of them are localised in more than one part of the body.

Even if they are external to the vascular system, they may develop on internal organs. This includes liver, lungs, digestive system or even on the brain.  

How do you recognize an Hemangioma?  

The external aspect of an hemangioma varies according to its type (cutaneous, tuberous, subcoutaneous or mixed) and state of its evolution (growing phase, involution phase or complete regression).                                                                                                                                 

• The cutaneous hemangioma is superficial in nature. It has a slick red aspect which becomes quickly protruding, ressembling a strawberry. This is often how it looks particularly when it is located on the nose or close to the lips. When it begins its involution, the bright red color takes a beige or greyish tinge. Usually, they completely dissapear before the age of 7.
• The subcoutaneous hemangioma is located deeper on the skin, and it is more difficult to recognize. It presents itself as a bluish or dew swelling, which can be often confused with a simple bruise. It grows and becomes more visible at age of 2 or 4 months, presenting a firm, rubbery consistency and appearance.

• The hemangioma mixte has a double component. The red and tuberous part is the first to show up, and the subcutaneous part develops later turning the first a bit bluish. The superficial component regresses before the deeper subcutaneous area.

When should I consult with a specialist?  

Hemangioma can present a large variety of forms and sizes. The majority are small and dissapear naturally over time. It is convenient in any case to check with a dermatologist who, if needed, will prescribe a consultation with a specialist in vascular anomalies. 

A child must be examined by an specialist if the diagnostic isn’t certain, or if the hemangioma is growing very rapidly or evolves in a way that a wound may appear. Also, if the hemangioma is located in the facial area, or in the genitals or close to the anus, it is convenient to check with a specialist. 

If the hemangioma is diffused or present in multiple areas it must be closely followed by specialists, because there may be a chance that other hemangiomas are present internally affecting vital organs. Such cases could be grave and require treatment. 

If you are looking for a doctor specialized in vascular anomalies, check our section “Finding a Doctor” for some suggestions. 

What are the possible complications?  

Only one hemangioma in ten generates complications. Ulceration is the most common one: ulceres may bleed, get infections or eventually develop a necrosis. Ulcerations can also be very painful and are most often present when hemangioma affects the mouth, genitals or anal area. The treatment is through local antibiotic creams, frequent cleaning and daily dressings. In some instances, stronger treatments are required, including oral medication, surgery or laser. 

If ulcers are correctly treated, they usually heal in a few weeks, and don’t reappear although they may leave a scar. In any case if an ulcer appears, a specialist must be contacted for diagnostic and follow up.

In some cases, depending on the location of the hemangioma and their size, they may obstruct  the respiratory tract, trouble vision field or difficult feeding: they require inmediate attention by specialists. For instance, if they affect the upper eyelid, despite their size, a specialist should be contacted at once, for they may affect vision permanently. Similarly, if the hemangioma is present around the beard area of the chin a doctor should be contacted inmediately.

If the hemangioma affects the head they may originate deformations on the facial area. Therefore, to avoid as much as possible the damage of tissue as well as potential psycological effect of the esthetic impact, these case also require a treatment.

In rare instance, hemangioma affecting internal organs may occasionate an internal bleeding or a cardiac arrest if they would create an elevated blood drain. In these cases a very close follow up is required with regular checks. Only about 1% of total hemangioma cases lead to complications that can endanger life.  

How do specialists diagnose it?  

Most of the times, the diagnostic is done through a clinic exam of the child which is weighted with the medical antecedents of the family. Sometimes, in order to confirm the diagnostic some tests are required, like a color-Doppler ecography, an MRI or a scanner. These are all radiologic test of non-invasive nature.  

One challenge is that certain vascular anomalies may ressemble an hemangioma, while they are in fact a vascular malformation. In that case, they require very different treatment.

In some instances, there may also be a risk of a cancer to present symthoms which may appear those of an hemangioma. In that case, once the vascular anomaly has been ruled out, a biopsia may be required. This is a test which consists in taking a sample of the tissue to have it analized in a laboratoire afterwards. It is very important to notice that in most cases of vascular malformations a biopsia is not indicated.  

What are the treatment options?

In most patients, hemangiomas do not require any treatment, given that they regress naturally as the child grows. Only those with complications require treatment, which must be done by a specialist. Until 2008, treatments with corticoids were the best choice to slow down the growth of these tumours and even make them shrink. These drugs can be administered in many ways, including oral, injections or local treatments, but they also have a number of side effects associated.

Since that time, the beta blockers (like the propanolol) have replaced them. The regression of the hemangioma is faster than when using corticoids. The propanolol is a drug often given as pills to treat arterial hypertension. It lowers blod tension and slows down the heart, which is a reason why a child who’s on propanolol to treat an hemangioma must be followed up by a cardiologist to ensure all complications are avoided.

Another treatment option in certain cases is the pulse dye laser, which is sometimes used to diminish the red coloration of certain scars left by an hemangioma. 

Surgery in children before 2 years old is only a last resource, and it is considered for certain hemangiomas affecting the eye lid, nose or lips. After the child is at least 4 years or older, surgery could treat certain sequels (like deformations, assymetries …). In most instances however, surgery is typically done after the 6 years of age when possible.