Angeioma

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Photo credit: https://durablehealth.net/birthmarks/strawberry-hemangioma/

        On a baby's tender skin, infant hemangiomas can sometimes appear. They look like bright red lumps, resembling a' strawberry 'growing on the skin. These' strawberries' grow rapidly and often cause concern among parents. However, apart from a few special cases, most infant hemangiomas are harmless to the body, will eventually disappear on their own, and there is no risk of them turning into malignant tumors, so treatment is not necessary.

        Although infant hemangiomas are common, their rapid growth often leads to two common misconceptions in daily medical practice: one is over-treatment, where babies who do not need treatment are given excessive medication and surgery; the other is misdiagnosing rare conditions as infant hemangiomas, leading to delayed treatment. Given the concerns raised by many parents, we have reviewed the recommendations and guidelines on infant hemangiomas from the American Academy of Pediatrics and related literature, and will share some knowledge about these 'little strawberries' with you.

 

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        1. Infantile hemangioma is the most common benign tumor in children and has no risk of becoming malignant (cancer).

        2. Changes in infant hemangiomas often follow a clear pattern: they begin to appear a few days to a few weeks after birth, grow rapidly within a few months, and gradually shrink and fade after the age of one, with most hemangiomas completely fading by the age of five.

        3. Infants with hemangiomas should be diagnosed and evaluated by an experienced physician (pediatric or dermatological). The vast majority of infant hemangiomas will resolve spontaneously without treatment; however, a small number of "high-risk" hemangiomas require active treatment.

        4. The growth pattern of infant hemangioma is very typical, and parents and medical staff should closely observe the changes in their children's hemangioma. If there are any deviations from the pattern, further examination and diagnosis should be conducted to prevent misdiagnosis. There have been reports in the literature of other cancers being misdiagnosed as infant hemangioma. ​

 

What is infantile hemangioma?

 

        Infant hemangiomas, or simply hemangiomas, are the most common tumors in infants and young children. They form due to the rapid growth of cells that make up the blood vessel walls, also known as vascular endothelial cells. Hemangiomas typically appear on the skin's surface or just beneath it; however, they can also develop inside organs, particularly the liver, though this is less common. Hemangiomas begin to grow about one month after birth and usually complete their development by the age of one (we will discuss more details later).

 

        The incidence of infantile hemangiomas is approximately 5% among Caucasians, meaning one in every 20 babies will develop a hemangioma. The incidence is relatively lower among Asians, with reports from Japan and Taiwan indicating that about 1 in 50 to 100 babies will be affected. Currently, there is no detailed data on the incidence of hemangiomas in Chinese mainland regions, but medical professionals generally cite a rate of 4-5%. Hemangiomas are more common in females, twins, premature infants, and Caucasians. Girls are approximately 2 to 3 times more likely to develop hemangiomas than boys. Premature infants (born before 37 weeks) have a higher incidence of hemangiomas, with the rate potentially reaching up to 20% for those born with lower birth weights.

 

What does an infantile hemangioma look like?

 

        The clinical characteristics of hemangioma are varied, mainly depending on the location, size and number of hemangioma.

        ● In terms of location, about three-fifths (60%) of hemangiomas are located in the head and neck, about a quarter (25%) in the trunk and about one-fifth (15%) in the limbs.

​ Photo from Healthychildren.org, a website affiliated with the American Academy of Pediatrics

        ● The appearance of hemangiomas largely depends on whether they are located in the superficial or deep layers of the skin. The most common type, which is superficial, appears as a bright red patch or lump on the skin's surface, often protruding from the skin, resembling a small strawberry, hence the name' strawberry hemangioma.'

        ● If a hemangioma is not on the skin's surface but grows beneath it, it is classified as a deep-seated type. Deep-seated hemangiomas appear as lumps under the skin (sometimes protruding from the skin), with a bluish-green color, which is characteristic of subcutaneous blood vessels. Some people refer to this as a' cavernous hemangioma. 'If a hemangioma has both deep-seated (subcutaneous bluish-green) and superficial (bright red on the surface) components, it is called a' mixed type' (as shown in the figure).

Photo courtesy of the American Academy of Pediatrics website Healthychildren.org

 

        ● While most hemangiomas are solitary (i.e., a single lesion), about 20% of infants have multiple (more than one) hemangiomas. Most hemangiomas are visible on the skin or under the skin, but in rare cases, they can also develop in internal organs, particularly the liver. Liver hemangiomas typically do not cause symptoms. If there are more than five hemangiomas on the skin, it is recommended to screen for any concurrent liver hemangiomas. Screening for liver hemangiomas can be done through ultrasound examinations.

Photo by hemangiomaeducation.org

 

What is the growth cycle of hemangioma?

 

        Infant hemangiomas grow in a very regular pattern, transitioning through a rapid growth phase (where the tumor grows quickly) and a regression phase (where the tumor gradually diminishes). Most hemangiomas begin to grow within 4 weeks after birth, with the fastest growth and most noticeable changes occurring between 1 and 3 months. By 5 months, most hemangiomas have completed their growth, although they can continue to grow slowly between 6 and 12 months. By the age of 1 year, most hemangiomas stop growing.

 

        The next phase is the regression period of infantile hemangiomas, during which the tumors gradually shrink and eventually disappear. Traditionally, it has been believed that over 10% of hemangiomas regress each year as children grow older, with about 50% disappearing by age 5, and over 90% by around age 9. However, recent studies suggest that this view is not entirely accurate, as 90% of hemangiomas have already completely regressed by ages 4 to 5. After regression, hemangiomas may leave behind skin scars, pigmentation, or wrinkles.

 

        There is another type of vascular tumor known as congenital vascular tumor, which, as the name suggests, is a vascular tumor present at birth. Unlike infantile vascular tumors, treatments for congenital vascular tumors are often ineffective. Some congenital vascular tumors may resolve on their own, but those that do not usually require surgical removal.

 

Are infant hemangiomas dangerous? How to assess them?

 

        Here, we want to emphasize that various types of hemangiomas, including infantile hemangiomas, are typically benign and have little chance of becoming malignant. However, infantile hemangiomas, especially those that grow rapidly during the 'proliferative phase,' can easily cause parental anxiety. If you suspect your child has a hemangioma, it is best to consult an experienced pediatrician or dermatologist. According to the American Academy of Pediatrics, the optimal time for evaluating and treating infantile hemangiomas is around one month of age, although any time is suitable for a visit to the doctor.

 

        While in most cases, we can wait for the baby's hemangioma to resolve naturally, some hemangiomas, due to their location or size, are classified as' high-risk' and require more proactive treatment. High-risk hemangiomas typically include those in special areas of the body (such as the face, nose, ears, lips, near the eyes, neck, or the middle to lower back), those with multiple lesions (more than 5), or those that ulcerate or bleed. These conditions particularly require the care of experienced doctors.

 

        We will talk more about the treatment of infant hemangioma in a future article.

 

Which tumors may be confused with hemangiomas?

 

        Since infant hemangiomas are quite common, other tumors are less frequent in infants and young children. As a result, other tumors can sometimes be mistaken for infant hemangiomas. Some tumors may look very similar to hemangiomas, making the initial diagnosis challenging. Medical literature has reported cases of rare pediatric tumors, such as infantile fibrosarcoma or lipoblastoma, being misdiagnosed as hemangiomas.

 

        So how do you tell a baby hemangioma from other tumors?

        ● The development of infantile hemangiomas is highly characteristic, so it is crucial to conduct long-term observation and follow-up on the tumor's growth. This requires the cooperation and attention of both parents and medical professionals. Infantile hemangiomas rarely appear at birth; instead, they typically begin to appear and grow a few weeks after birth. After the baby turns one, the hemangioma will start to gradually darken and shrink. If the tumor does not exhibit these characteristics, it may be a cause for concern.

        ●There is a type of tumor called angiosarcoma, which shares a similar name with infantile hemangioma but is quite different. Angiosarcoma, also composed of blood vessel cells, is a rapidly developing malignant tumor. It is more common in dogs than in humans, typically affecting the elderly and extremely rare in children. ●Hemangiomas are not related to blood cancers, such as leukemia or lymphoma.

 

        To summarize, infant hemangiomas, the most common tumors in infants and young children, are typically benign and do not have the risk of becoming malignant. However, these tumors have a unique growth cycle. In the first few months after birth, they often grow rapidly, causing concern among parents. In reality, these 'little strawberries' will naturally regress after their growth phase, with most cases resolving on their own. Of course, infant hemangiomas can present in various ways. While most cases do not require intervention, a small number of 'high-risk' cases still need to be approached with caution. We will discuss in detail which infant hemangiomas require active treatment and how to treat them in our next article.

 

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        This article aims to provide basic knowledge about infantile hemangiomas. The recommendations on diagnosis, evaluation, and treatment are based on the 2019 clinical practice guidelines published by the American Academy of Pediatrics and should not be used as a substitute for the advice of your healthcare provider. For specific patient diagnoses and treatments, please consult your primary care physician. May every child have a bright future!

 

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Clinical Management

In infants and young children, the most common type of tumor is infantile hemangioma. This is a benign tumor that does not become malignant. In a previous article (insert link here), we discussed the characteristics and unique growth patterns of this tumor. Here, we will delve into how to treat this tumor and what precautions should be taken.

 

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        1. Most infantile hemangiomas do not require active treatment, the primary treatment is close observation and waiting for natural regression.

        2. Targeted treatment is only necessary in the case of vascular tumor ulceration, bleeding or special location affecting other organ function (which are rare).

        3. If treatment is needed, drugs are preferred to surgery and laser therapy.

        4. The mainstream drugs for infant hemangioma are safe and effective, but when it comes to medication for infants, parents must cooperate with doctors and pay close attention to possible side effects.

        5. Facial infantile hemangiomas may affect appearance. If the hemangioma leaves excess skin or scarring after it fades, further plastic surgery can be considered for repair, but it is recommended to wait until the child is older and the natural regression period of the hemangioma has ended to reduce the risk.

 

 

 

Order of treatment option selection

        The preferred treatment for hemangiomas is close monitoring, often referred to as 'non-intervention.' This approach is chosen because, although hemangiomas grow rapidly in the early stages and can cause significant worry for parents, they will mostly resolve on their own without the risk of becoming cancerous, thus eliminating the need for intervention. However, if the hemangioma becomes damaged, causing ulceration and bleeding, or if it is found that its progression could affect other organs, a timely treatment plan should be developed, shifting from close monitoring to active intervention. Additionally, a small number of hemangiomas, such as those described in the previous article (please replace this with the title of the previous article and insert a link), are classified as 'high-risk' and are likely to pose a threat to the child's health from an early stage, necessitating prompt treatment.

 

        Since each child's condition is unique, the specific treatment options should be based on the advice of experienced doctors. Here, we briefly list some common treatments for hemangiomas to provide educational information. However, given that there are cases of over-treatment in clinical settings, it is important to note that most children with hemangiomas do not require these interventional treatments and can simply be monitored.

 

        Interventional treatment methods for infantile hemangioma include oral medication, local treatment (external application or intra-tumor injection of drugs), and surgery and laser therapy. Among these treatments, drug is the first choice, but according to different conditions, doctors may also recommend different treatment methods at different ages, or a combination of drug and surgery.

 

 

 

Oral medication

 

        Let's start with the most common treatment method: oral medication. The preferred choice is a drug called Propranolol, also known as' Xinshian. 'Propranolol is commonly used to treat hypertension and arrhythmia in both children and adults. Research has shown that it is highly effective in inhibiting the growth of hemangiomas, making it the first choice for treating this condition. In 2014, the U.S. Food and Drug Administration (FDA) approved it for the treatment of infantile hemangiomas. Propranolol is a well-established drug with proven safety through years of clinical use. However, when used in infants with hemangiomas, close monitoring of blood pressure, heart rate, and blood sugar levels is still necessary. Specific usage methods and dosages should be discussed with a doctor experienced in the treatment of hemangiomas. Additionally, oral hormone medications can also be effective in treating hemangiomas, but they have largely been replaced by Propranolol. In certain cases, they may be used under a doctor's guidance.

 

Local drug therapy

 

        Considering that infant hemangioma involves medication for infants and young children, when deciding on the treatment method, it is necessary to focus on how to prevent and reduce side effects. For this reason, in some cases, topical drugs (external application) can be used instead of oral drugs.

 

        Topical medications differ from oral medications in that they are applied directly to the affected area and do not spread throughout the body, thus reducing side effects. In terms of efficacy, topical medications are particularly effective for smaller, 'superficial' hemangiomas (for more on the classification of hemangiomas, see the previous article, please insert the link). The most commonly used topical medication is timolol, which works similarly to propranolol but is applied differently, making it a relative of propranolol. Timolol is available in eye drops or gel form (gel form is not yet available in China), and has been used clinically for treating pediatric glaucoma for over 30 years, with proven safety. Recent studies have shown that timolol is highly effective for treating 'superficial' infantile hemangiomas (see the figure below). In 2016, a Chinese expert consensus detailed the use and potential side effects of timolol eye drops for treating infantile hemangiomas. It is important to note that while timolol gel or solution, being a topical application, has fewer side effects compared to oral propranolol, it still has potential side effects that may affect heart rate and blood pressure, so it should be used under a doctor's guidance. Additionally, because the drug does not penetrate deeply into the skin, it is not suitable for treating deeper hemangiomas.

 

Effect of timolol gel on superficial hemangioma in Sydney Children's Hospital, Australia.

The left figure is before treatment, the middle figure is 12 weeks after medication, and the right figure is 24 weeks after medication.

 

        Another method of local treatment involves injecting hormone medications directly into the hemangioma, primarily for smaller, localized hemangiomas. This treatment has been used in clinical practice for many years and is considered safe and effective. However, it is only suitable for relatively small hemangiomas or those located in critical areas, such as the lips or nose. ​

 

 

Surgery and laser treatment

 

        Finally, let's discuss surgery and laser therapy. Since most hemangiomas will naturally resolve, and drug treatments are highly effective, only a small number of children require surgical or laser treatment for hemangiomas. Surgical removal is typically recommended for hemangiomas located in special areas, such as near the trachea or in the eye socket, to prevent breathing difficulties or vision impairment. Another type of hemangioma surgery is performed for cosmetic reasons. For example, some hemangiomas may leave scars or excess skin after they resolve, particularly on the face, which can affect appearance. Some surgeries can improve these issues. These cosmetic surgeries are usually recommended around the age of 3-5, when most hemangiomas have resolved, making the surgery safer. Laser therapy can reduce bleeding from hemangiomas or help heal ulcerated areas. After hemangiomas resolve, laser therapy can also help improve pigmentation. It's important to note that surgery and laser therapy should be considered after drug treatments. Only a small number of children need these treatments, and it's crucial to consult experienced experts when choosing these options.

 

Patients and family members share their experiences

 

        Infant hemangiomas are quite common and can often be over-treated. Waiting to observe is the primary treatment option. It is normal for infant hemangiomas to grow before the age of one, and they typically begin to naturally regress from this stage. Parents should consult multiple hospitals and doctors and not rush to decide on a treatment. Interventional treatment is generally recommended only if the hemangioma's location affects other organ functions, and drug therapy is preferred over laser or surgical options.

 

A parent MOCO shared a picture of the child's hemangioma after it had receded: The slightly darker, round part in the middle is the change in the skin after the hemangioma has receded

The image is copyrighted by MOCO.

   

        When it comes to facial issues, many parents panic and opt for surgery, but surgery often results in scarring. In fact, if the condition can heal naturally, the scars are usually minimal, leaving only slight pigmentation or fibrous tissue. If the hemangioma is large or located in areas with less skin elasticity, such as the forehead, the likelihood of scarring increases, and cosmetic surgery might be necessary as the child grows.

 

 

Another parent, Amy, shared the whole process of her child's hemangioma changes:

Figure 1: The right eyelid hemangioma began to be more obvious at 3 weeks; Figure 2: At 6 months, the hemangioma grew to the maximum and the color began to change slightly darker;

Figure 3: At the age of 5, most of the hemangioma has faded, leaving only a few remnants of red.

 

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