Infantile hemangiomas, often called “strawberry birthmarks,” are the most common type of vascular tumor seen in infancy. These benign growths are made of extra blood vessels and appear in about 4 to 5% of all infants, typically emerging in the first few weeks of life rather than being present at birth. They are non-cancerous and usually resolve completely on their own over time. Parents need to understand the expected course of the birthmark and recognize specific instances when medical intervention is necessary.
Understanding Infantile Hemangiomas
An infantile hemangioma is a mass formed by a collection of rapidly growing endothelial cells, which are the lining cells of blood vessels. A superficial hemangioma appears as a bright red, raised lump with a textured surface, similar to a strawberry. A deeper hemangioma may present as a bluish-purple swelling beneath the skin. These birthmarks follow a predictable, three-phase natural history that spans several years.
The initial period is the proliferative phase, characterized by rapid growth, which is most intense during the first three to six months of life. This is when the birthmark becomes most noticeable and reaches its maximum size. Following this expansion, the hemangioma enters a plateau phase where its size remains stable for a period of months.
The final and longest phase is involution, where the growth begins to shrink, soften, and change color from a bright red to a duller grey or purple. Involution is a slow process that can take many years, with most hemangiomas showing significant regression by five to seven years of age. Some may leave behind residual skin changes, such as loose skin or fine blood vessels.
Critical Indicators for Medical Evaluation
While the natural course is generally favorable, certain characteristics require prompt medical attention to prevent complications. A primary concern involves growths located near vital structures that could lead to functional impairment. Hemangiomas on or near the eyelid may obstruct vision, potentially leading to permanent visual loss if not treated early.
Growths situated around the mouth, nose, or throat may interfere with feeding or breathing. A hemangioma located in the “beard area” of the lower face and neck raises the possibility of an internal growth in the airway, requiring immediate evaluation. Any birthmark causing difficulty with an infant’s ability to see, eat, or breathe should be seen by a specialist.
Another indication for evaluation is ulceration, where the skin surface breaks down to form an open sore. Ulcerated hemangiomas are common in high-friction areas, such as the diaper region, around the lips, or in skin folds. These sores are painful for the infant and create an increased risk of infection and scarring.
Atypical growth patterns also necessitate a medical assessment, particularly if the hemangioma is large or covers a broad, continuous area (segmental hemangioma). These large lesions, especially on the face or head, may be associated with underlying structural anomalies, sometimes referred to as PHACE syndrome. Additionally, an infant presenting with five or more separate hemangiomas may require an ultrasound to check for internal hemangiomas, most commonly in the liver.
Management and Treatment Approaches
For uncomplicated infantile hemangiomas, a “watchful waiting” approach is recommended, allowing the birthmark to follow its natural involution course. Active treatment is reserved for hemangiomas that pose a risk of functional impairment, ulceration, disfigurement, or internal complications. The goal of intervention is typically to halt the proliferative phase early and accelerate the shrinking process.
The standard first-line treatment for high-risk hemangiomas is oral propranolol, a beta-blocker medication. Propranolol works by narrowing the blood vessels within the hemangioma and inhibiting the growth of new blood vessel cells. This leads to rapid softening and color fading, often noticeable within the first 24 to 48 hours of starting the medication.
For small, superficial lesions, topical treatments, such as timolol gel, may be used as an alternative. These local treatments can effectively reduce the size and color of the birthmark on the skin surface. If a hemangioma leaves behind residual skin changes like stretched skin or excess tissue after regression, procedures such as laser therapy or surgical removal may be considered later in childhood to improve the cosmetic result.