Infantile hemangiomas are common benign vascular tumors of infancy characterized by a proliferative phase in early infancy followed by gradual involution over years. Most are uncomplicated and require observation only, but lesions that threaten function, ulcerate, or risk disfigurement warrant active therapy. First-line systemic therapy for complicated IH is oral propranolol; topical timolol is useful for small superficial lesions. Early risk stratification and referral (ideally by 4–6 weeks of life) improve outcomes.
Epidemiology and Risk Factors
- Occur in ~4–5% of infants; higher in females, premature/low-birth-weight infants, multiple gestations, and white infants.
- Subtypes by depth: superficial (bright red “strawberry”), deep (blue, subcutaneous), mixed.
- Patterns: focal, multifocal, segmental (plaque-like across developmental units; higher complication risk).
- Associations: PHACE syndrome (large segmental facial IH with Posterior fossa brain malformations, Hemangiomas, Arterial anomalies, Cardiac defects/coarctation, Eye anomalies); LUMBAR/PELVIS/SACRAL syndromes with lumbosacral IH.
Natural History
- Minimal/absent at birth; rapid growth weeks 1–12 (most growth by 5 months).
- Involution begins around 6–12 months; most involute substantially by 3–5 years; residual changes (telangiectasia, fibro-fatty tissue) may persist.
Risk Stratification (red flags for treatment/referral)
- Life-/function-threatening: periocular (amblyopia, astigmatism), airway (beard distribution), hepatic IH with high-output heart failure/hypothyroidism, ulceration with pain/bleeding, nasal/philtrum/lip (feeding, disfigurement), perineal (ulcer risk), ear (cartilage deformation), large facial segmental IH (PHACE evaluation).
- Five or more cutaneous IHs suggest possible hepatic involvement—screen with ultrasound.
Diagnosis and Workup
- Clinical diagnosis in most.
- Imaging (usually ultrasound) for uncertain deep lesions, airway involvement, or suspected hepatic hemangiomas.
- MRI/MRA for segmental facial IH when PHACE suspected before starting propranolol.
- Labs: thyroid function if large hepatic IH suspected (risk consumptive hypothyroidism).
Management
- Observation and Local Care
- Many small, uncomplicated IHs: reassurance; photograph and monitor growth; protect from trauma; wound care if mild breakdown.
- Pharmacologic therapy
- Oral propranolol (first-line for complicated IH):
- Typical dose 2–3 mg/kg/day divided bid–tid after feeds; titrate over several days.
- Baseline assessment: cardiac history/exam ± ECG if risk factors (bradycardia, arrhythmia), consider PHACE workup for large segmental facial IH.
- Counsel on dosing with feeds, hold during poor oral intake/illness; monitor for hypoglycemia, bradycardia, hypotension, bronchospasm, sleep disturbance.
- Duration: often until 12 months of age (minimum 6 months) with taper.
- Topical timolol 0.5% gel-forming solution:
- For small, thin superficial IH; 1–2 drops bid–tid; avoid on ulcerated areas in very young or large surface areas to limit systemic absorption.
- Alternatives/adjuncts:
- Systemic corticosteroids when propranolol contraindicated or ineffective.
- Intralesional triamcinolone ± betamethasone for focal bulky lesions (e.g., lip).
- Oral nadolol or atenolol in select cases (specialist use).
- Sirolimus reserved for refractory complex vascular tumors under specialist care.
- Ulcerated IH
- Pain control, non-adherent dressings, barrier pastes; treat secondary infection.
- Consider pulsed dye laser for residual telangiectasia or to aid healing; propranolol often accelerates healing.
- Procedural/Surgical
- Laser (PDL, Nd:YAG) for residual telangiectasia after involution or early for ulcer control.
- Surgery for residual fibro-fatty tissue or refractory anatomic distortion, typically after involution phase (≥3–4 years), earlier if function compromised.
- Counseling and Follow-up
- Most IHs involute with good outcomes; early referral for high-risk sites is key.
- Discuss residual changes and potential need for cosmetic procedures later.
References (recent guidelines and key reviews)
- AAP and multidisciplinary consensus on IH diagnosis and management, 2021–2024.
- Safety and dosing studies of propranolol/timolol in IH, 2021–2024.
- PHACE and hepatic IH evaluation/treatment literature, 2021–2024.