Infantile Hemangiomas

Infantile hemangiomas are common benign vascular tumors of infancy that between 4-5% of infants, making it the most common infantile tumor. It arises due to an abnormal proliferation of endothelial cells and vascular networks, likely driven by factors such as hypoxia, aberrant stem cell activation, and dysregulated signaling pathways. The progression of infantile hemangiomas is classically biphasic. There is first a proliferative phase that is typically up to 3–5 months, followed by gradual involution over subsequent years. It should be noted that some lesions may plateau or have minimal growth rather than a full proliferative phase prior to involution. 

In lighter Fitzpatrick skin colors, I-III and seen in Figures VI and VII, infantile hemangiomas often manifest as a vivid bright red “strawberry” plaque or nodule. On Fitzpatrick skin colors IV-VI and seen in Figures V and VIII, the red hue may appear muted, darker red, purplish, or violaceous rather than bright red. Some lesions tend to be deeper, these may be mistaken for skin‐colored or bluish nodules, making detection more difficult. Since erythema is less obvious, infantile hemangiomas in darker skin may be underrecognized or misdiagnosed as a bruise, pigmented lesion, or other vascular malformation. 

A recent study of hospitalized infantile hemangiomas found disparities in presentation and that Black infants may experience diagnostic and therefore possible treatment  delays due to limited provider familiarity with hemangiomas in darker skin. 

The treatment for infantile hemangiomas is guided by risk stratification and timing. Many are observed to allow natural involution. However, early intervention is favored in high-risk lesions. High risk lesions are often defined by location and number. Lesions that are near the eye, ear, or nose have a likelihood of disfigurement, as do large hemangiomas,

characterized by greater than 2 or 5 cm depending on the location . First-line pharmacotherapy for infantile hemangiomas is oral propranolol started in infancy. However, for smaller superficial lesions, topical timolol is an option. Additional modalities include intralesional corticosteroids, pulsed dye laser, and surgical resection or excision for residual tissue or for lesions in high risk areas. Multidisciplinary evaluation is standard for large or syndromic‐risk hemangiomas.

1. Wildgruber, M., Sadick, M., Müller-Wille, R. et al. Vascular tumors in infants and adolescents. Insights Imaging 10, 30 (2019). https://doi.org/10.1186/s13244-019-0718-6

2. Kowalska, M., Dębek, W., & Matuszczak, E. (2021). Infantile Hemangiomas: An Update on Pathogenesis and Treatment. Journal of clinical medicine, 10(20), 4631. https://doi.org/10.3390/jcm10204631

3. Taye ME, Shah J, Seiverling EV, Lawley LP. Diagnosis of Vascular Anomalies in Patients with Skin of Color. J Clin Aesthet Dermatol. 2024 Oct;17(10):54-62. PMID: 39445318; PMCID: PMC11495159.

4. Kumar, K. D., Desai, A. D., Shah, V. P., & Lipner, S. R. (2023). Racial discrepancies in presentation of hospitalized infantile hemangioma cases using the Kids' Inpatient Database. Health science reports, 6(2), e1092. https://doi.org/10.1002/hsr2.1092

5. Hoover L. Infantile Hemangioma: AAP Releases Guideline for Management. Am Fam Physician. 2019 Aug 1;100(3):186-187. PMID: 31361095.