basic overview for primary care physicians

1. Hooman Rowshan, M.D M.Sc.
Southampton-Stony Brook Hospital
June 2016

2. 
 An infantile hemangioma is also called “strawberry
mark”. This is a very common type of birthmark
made of blood vessels. These are benign vascular
neoplasms that come about by uncontrolled growth
of endothelial cells
 These lesions are usually not detectable at birth but
appear during the first 4 to 6 weeks of life.
 These lesions may appear on the skin or in the
internal organs
 Most Hemangiomas are not painful
Basic Features

3. 
 All skin hemangiomas will be visible by six months
of age
 May occur anywhere on the skin surface
 They are most common on the scalp, face and neck
 They may first show up as a small bruise, scratch or
tiny red bump
 The lesions grow most often on the skin and less
frequently in the internal organs
Basic Features Skin

4. 
 Superficial hemangiomas, occur on the outer layers
of the skin, typically bright red to purple in color
 Deep hemangiomas, grow under the skin in the fat,
may be blue, purple or even skin color if deep
enough under the skin
 Mixed hemangiomas, the most common type of
hemangioma; have both superficial and deep
components
Types of Skin Lesions

5. 
 Most hemangiomas are round or oval in shape
 larger lesions may follow the shape of the affected
body part
 The size of hemangiomas varies; Some are very small
(1 mm), while others are very large (20 cm or larger)
 Every hemangioma differs in how fast it grows and
how long it grows before it stops
Hemangiomas’ shape,
size and growth rate

6. 
 The growth phase: Newborn to 14 months (average 8
months); Hemangioma is growing rapidly (puffing
out), and the color is bright red
 The resting phase: 8 to 14 months old, no change in
size, and the skin becomes less shiny
 The Shrinking Phase:1 to 5 years, lesion shrinks, the
color changes to purple and gray, it may even fade
completely
Life Cycle

7. 
 The cause of infantile hemangioma is unknown although
Vascular endothelial growth factor (VEGF) regulation
anomalies may be at play
 More common in girls than boys
 Associated with Caucasians
 More frequently in babies born very small or born several
weeks before their due date, the relationship to these
events is unknown
 There is no specific geographical distribution
 Increased risk in twin births but risk association is
unknown
Epidemiology

8. 
 Most lesions follow a predictable life cycle and
shrink without any additional treatment
 About 25% of these lesions could develop
complication, requiring specialty care
 Specialty care is offered through multidisciplinary
teams by vascular anomalies specialists
 Factors affecting complications are the size, location
and speed of growth
Complications

9. 
 Interference with organ function: As a hemangioma
grows, it can interfere with organ function; often,
this interference relates to vision if a hemangioma
around the eye grows rapidly, may even lead to loss
vision; Monitor hemangioma on the eyelid
 Ulceration: Skin over the hemangioma can break
down until the skin appears raw or shiny, it might
even develop a scab or crust, increases the risk of
infection and scarring, watch lesions in the diaper
and around the mouth, these heal slowly
Common Complications

10. 
 Bleeding: Skin over the hemangioma protects it from
bleeding easily, if a hemangioma is cut or injured, it
can bleed or develop a crust or scab, these blood
vessels are not normal and they tend to bleed rapidly
 Scaring: final appearance of a hemangioma varies
from person to person and will depend on size,
location, and whether or not there was ulceration or
infection; Nose, lips, forehead, and ears are prone to
scaring
Common Complications

11. 
Superficial
Hemangioma

12. 
Deep Hemangioma

13. 
Mixed Hemangioma

14. 
Histopatholgy

15. 
 Thymus
 Liver
 Parotid gland
 Nasopharyngeal hemangioma
 Spleen
 Heart
 Central nervous system, it will appear in older
pediatric patients (20 year olds)
 Orbit
Non Cutaneous
Variants

16. 
Orbital Hemangioma

17. 
Subglottic hemangiomas

18. 
Hemangioma on ventral
surface of tongue

19. 
large neck mass

20. 
Capillary Hemangioma

21. 
Cavernous
Hemangioma

22. 
Parotid Hemangioma

23. 
 Role of primary care physician is mostly supportive
 Complicated cases are referred to vascular anomalies
specialists
 Beta blocker (Propranolol) is highly effective
 Steroids
 Surgery
 Vast majority of lesions do not need treatment
Treatment

24. 
 Ballah D, Cahill AM, Fontalvo L, et al. Vascular anomalies: what
they are, how to diagnose them, and how to treat them. Curr Probl
Diagn Radiol. 2011;40:233-247.
 Bauland CG, Lüning TH, Smit JM, Zeebregts CJ, Spauwen PHM.
Untreated hemangiomas: growth pattern and residual lesions. Plast
Reconstr Surg. 2011;127:1643-1648.
 Boye E, Yu Y, Paranya G, et al. Clonality and altered behavior of
endothelial cells from hemangiomas. J Clin. Invest. 2001;107:745-
752.
 Chen TS, Eichenfield LF, Friedlander SF. Infantile hemangiomas:
an update on pathogenesis and therapy. Pediatrics. 2013;131:99-108.
 Chiller KG, Passaro D, Frieden IJ. Hemangiomas of infancy.
Clinical characteristics, morphologic subtypes, and their
relationship to race, ethnicity, and sex. Arch Dermatol.
2002;138:1567-1576.
References