A "red mark and bruising" on an infant's face

You are asked to evaluate a 3-month-old girl whose mother is concerned about "a red mark and bruising" on her baby's cheek that developed several weeks after birth. The course of development included blanching of the skin, followed by the appearance of fine telangiectases and then a red macule. The lesion's growth rate appears to be more rapid than that of the infant's. The child is otherwise healthy.

Diagnosis: Infantile hemangioma

Incidence and diagnosis

Hemangiomas are benign vascular tumors characterized by early proliferation followed by slow spontaneous involution. Estimates are that 30% of hemangiomas are present at birth, and 70% appear in the first several weeks of life. Complete involution occurs by the time the child is 5 years old in 50% of cases, and by age 9 in 90%. Hemangiomas that take longer to involute have a higher incidence of permanent cutaneous changes that include scar formation, telangiectasia, or redundant skin.

Early appearance, gradual change

The earliest sign of a hemangioma is blanching of the involved skin, which is often followed by fine telangiectases and then a red macule.

The hallmark of a hemangioma is rapid growth that typically outpaces the child's growth rate during the neonatal period. During involution, the hemangioma shrinks centrifugally from the center of the lesion. The superficial lesions become less red, taking on a duskier purple color, and finally regaining normal flesh tones (so-called graying). After involution, the hemangioma becomes softer and more compressible, with decreased tenderness. Involution can take four to eight years to complete.

Are imaging studies needed?

Imaging studies may include MRI to delineate the location and extent of both cutaneous and extracutaneous hemangiomas and to differentiate them from other high-flow vascular lesions. Ultrasonography is occasionally useful in differentiating hemangiomas from other deep dermal or subcutaneous structures, such as cysts or lymph nodes.

What can you tell the mother about treatment?

The best and most common approach in uncomplicated lesions is watchful waiting and parental education. The optimum cosmetic result often occurs when the hemangioma resolves without intervention. Referral to a pediatric dermatologist is often beneficial, however, for parental education, further investigation, and treatment.

When a hemangioma is ulcerated, painful, or in a location that has significant psychological impact, such as on the face or perineum, an experienced physician may use vascular laser-such as pulsed-dye-therapy to hasten resolution. Surgical excision of atrophic or hypertrophic skin, or of redundant skin, is an option only in the involuting phase to improve cosmesis.

An infant with a periorbital hemangioma should be referred to an ophthalmologist, and one with a rapidly growing hemangioma that is affecting vital structures of the head and neck should be referred to an otolaryngologist.

Corticosteroids are effective at decreasing the size of complicated hemangiomas, with oral drugs preferred to intralesional. Because oral corticosteroids have only a negligible effect on involuting hemangiomas, they should be administered during the proliferative phase.

SUGGESTED READING

Amir J, Krikler R, et al: Strawberry hemangioma in preterm infants. Pediatr Dermatol 1996;3:331

Conlon JD, Drolet BA: Skin lesions in the neonate. Pediatr Clin North Am 2004;51:863

Werner JA, Dunner AA, Lippert BM, et al: Optimal treatment of vascular birthmarks. Am J Clin Dermatol 2003;4:745

Please see Dr. Cohen's Web site, http://www.dermatlas.org/, for additional images