Hemangiomas: What Are They and How Are They Treated?
May 07, 2019
What is a Hemangioma?
A hemangioma is a benign tumor of blood vessels. It usually appears around 2-4 weeks of age as a small red-pink patch. It then grows rapidly for 5-6 months and continues to grow slowly until 1 year of age. After that, the hemangioma shrinks very slowly over several years. The process of the hemangioma shrinking over several years is known as “involution”.
Superficial hemangiomas have a bright red color, while deep hemangiomas have a bluish hue. As hemangiomas involute, their color changes to dark red, then purple/gray, then skin tone.
Hemangiomas should not be confused with vascular malformations, which are not tumors, but abnormally formed blood vessels.
When Should Hemangiomas Be Treated?
Because most hemangiomas can be expected to shrink and eventually disappear after 1 year of age, the vast majority of them do not require testing or treatment, and can simply be observed. There are, however, situations where a hemangioma may require additional testing or treatment:
A hemangioma on the upper or lower eyelid may cause compression of the eye and visual obstruction as it grows. For this reason, most eyelid hemangiomas require treatment. In addition to hemangioma and vascular malformation specialists, patients with an eyelid hemangioma will usually undergo an eye examination by a pediatric ophthalmologist.
Large Hemangioma on the Face
A large hemangioma on the face may cause distortion of normal structures, and may leave a large area of thin skin, even after it involutes. For this reason, many large facial hemangiomas require treatment. In certain situations, a large facial hemangioma may indicate the presence of PHACE syndrome, which is characterized by abnormalities of the eyes, brain blood vessels, and heart. If hemangioma and vascular malformation specialists suspect this condition, they may order additional testing.
The presence of a large hemangioma on the front of the neck and lower face (“beard distribution”) may indicate the presence of hemangioma inside the airway. If hemangioma and vascular malformations specialist suspects that, they will refer your child to a pediatric ear, nose and throat physician to undergo a scope of the airway. The presence of a hemangioma in the airway requires treatment to avoid enlargement of the hemangioma, which can lead to airway obstruction
Large or Multiple Liver Hemangiomas
The presence of four or more hemangioma on the skin may indicate the presence of a liver hemangioma. Specialists may order testing to check for liver hemangiomas. If large or multiple hemangiomas are present on the liver, treatment may be required to avoid enlargement of those hemangiomas.
Hemangioma in the Midline of the Back
Rarely, a hemangioma over the midline of the back may indicate a spinal cord abnormality. Specialists may order imaging to check for spinal cord abnormalities.
Sometimes, a hemangioma that is enlarging very rapidly can break through the overlying skin and cause an open wound. This is not usually dangerous, but it is painful to the child. Treatment may be required to accelerate the healing of the skin.
Involuted Hemangioma That Has Left Behind a Puffy Area With Thin Skin
Most hemangiomas disappear without a trace. However, large hemangiomas may leave behind extra tissue and thin skin after they involute. This may require surgery or laser to treat.
Sometimes, a fast-growing hemangioma can grow faster than the overlying skin. This leads to a wound in the skin that can be painful to the child. Specialists may recommend treatment in order to accelerate the healing of the ulceration.
How Are Hemangiomas Treated?
Observation: observation alone is sufficient for most hemangiomas.
Timolol: timolol is a gel that is applied to the skin of the hemangioma. It is effective for small superficial hemangiomas.
Propranolol: propranolol is an oral medicine that is very effective at treating most hemangiomas. It can stop hemangiomas from growing and may even shrink them. Propranolol is very well tolerated by the majority of children. If the hemangioma and vascular malformations specialist decides to start propranolol, they will usually watch for potential side effects, including sleep disturbance, low heart rate, low blood pressure, low blood sugar, and wheezing.
Intralesional steroids: the injection of steroids into a hemangioma is effective at stopping its growth or shrinking it. This procedure usually requires sedation of the child, and multiple injections may be needed.
Systemic steroids: for patients who do not respond to propranolol, or who develop side effects from propranolol, oral or even intravenous steroids may be required. Steroids are only used if absolutely necessary, because they can cause reversible growth delay.
Surgery: surgery is sometimes required when excess tissue and skin are left after a hemangioma involutes.
Laser: laser surgery can be used when excess skin redness persists after a hemangioma has involuted.
For more information about Nationwide Children's Hospital's Hemangioma and Vascular Malformations Clinic, click here.
Andrea Orban, CPNP-PC is a pediatric nurse practitioner in the department of Plastic and Reconstructive Surgery. Ms. Orban sees patients in the Cleft Lip and Plate Center and Center for craniofacial disorders, the Hemangioma and Vascular Malformations Clinic, General Plastic Surgery, as well as the Hand, Microsurgery, and Brachial Plexus Program.
Ibrahim Khansa, MD
Plastic and Reconstructive Surgery
Ibrahim Khansa, MD, is a surgeon within the Section of Plastic and Reconstructive Surgery at Nationwide Children's Hospital. Dr. Khansa received his medical degree from Harvard Medical School. He then completed a plastic and reconstructive surgery residency at The Ohio State University Wexner Medical Center, including serving as chief resident. This was followed by a pediatric craniofacial fellowship at Children’s Hospital Los Angeles.
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