About HemangiomasA hemangioma is a benign proliferation of blood vessels, and in some cases supporting stroma, in the dermis. Hemangiomas are traditionally divided into two broad categories, cavernous and capillary, thought classification schemes abound. Capillary hemangiomas, in turn, have several subtypes: nevus flammeus, strawberry hemangioma, and cherry angioma. Cavernous hemangiomas are large, deep vessels, while the blood vessels of capillary hemangiomas are smaller and more superficially located. Hemangiomas are red, blue or purple in appearance, and soft or firm in consistency, depending on location and vessel size. They can be macular, papular or nodular. The lesions is often blanchable. They are asymptomatic unless large and obstructive, such as over an eye, where it can impede vision.
Nevus flammeusIn newborns, these common lesions occur on the eyelids and the back of the neck ("stork bite"). They are flat and pink. Nevus flammeus usually appear as only a faint pink macule at birth, which then enlarges rapidly over several weeks.
Strawberry hemangiomaThis lesion protrudes from the skin surface and has a rough texture and bright red color. They can occur anywhere. They are far less common than nevus flammeus. These are more likely to present as a cosmetic concern.
Cherry angiomaUnlike the first two categories of capillary hemangiomas, the cherry angioma occurs in middle age and older individuals. They are extremely common. They are small, dome-shaped papules, red to blue in coloration and smooth in surface texture.
Cavernous hemangiomaAs the name implies these uncommon lesions are composed of deep larger vessels; some also have a superficial capillary involvement. They appear as dome-shaped blue nodules.
With what can a hemangioma be confused?
The diagnosis is usually not in doubt. A cherry angioma, if dark in coloration, can sometimes be confused with a melanoma or a blue nevus. Kaposi's sarcoma, a vascular tumor associated with AIDS, can be confused with a hemangioma.
A vascular malformation can be confused with a hemangioma. However, vascular malformations are present at birth, do not proliferate, and do not involute.
How is a hemanioma diagnosed?Hemangiomas are diagnosed clinically based upon appearance and history. Biopsy is typically unnecessary, unless there is suspicion of malignancy.
How is a hemangioma treated?Childhood strawberry hemangiomas usually spontaneously involute over several years, though they may enlarge during the first two years of life. Often no treatment is necessary other than parental reassurance; however, laser treatment of enlarging hemangiomas is sometimes advocated. Camouflage make-up can be helpful. Cavernous hemangiomas also spontaneously regress, but less often than strawberry hemangiomas. They can sometimes impinge upon structures such as the eye or pharynx, necessitating treatment. Oral steroids are often effective in arresting enlargement. More recently, propanolol has been advocated.
What is the prognosis for hemangiomas?Faint nevus flammeus lesions of the eyelid usually resolve within the first year of life. Strawberry hemangiomas will also spontaneously involute over several years if left untreated. Strawberry hemangiomas, due to their raised profile, are subject to ulceration and secondary infection. Large cavernous hemangiomas can rarely give rise to the Kasabach-Merrit syndrome, in which platelets are destroyed in tortuous blood vessels. Cherry angiomas are persistent, but are amenable to laser treatment if of cosmetic concern.
Hemangioma of Infancy
Hemangioma of infancy,caused by a proliferation of endothelial cells (which line blood vessels), is the most common tumor of infancy. Hemangioma of infancy ranges in color from red to purple, and are soft and compressible. Lesions are usually solitary, favoring the head and neck. Girls are affected more often than boys. Hemangioma of infancy is not present at birth but appears postnatally.
Hemangioma of infancy goes through three stages: proliferation, involution, and involuted. The proliferation stage usually occurs during the first year of life, during which the hemangioma can enlarge rapidly. The hemangioma then gradually involutes over the two to six years, and is usually completely involuted by the fifth year. Ulceration may occur in the course of regression. Hemangioma of infancy usually resolves without scarring, but atrophy, depigmentation and scarring sometimes occur.
Variations of hemangioma of infancy include deep hemangioma, multiple hemangiomas of infancy and congenital hemangiomas. Deep hemangiomas are located deep in the dermis or subcutaneous fat and are typically bluish in color, possibly with overlying telangiectases or a superficial hemangioma of infancy. Multiple hemangiomas of infancy are small papular lesions that can affect either skin alone (termed benign cutaneous hemangiomatosis) or skin and internal organs (termed diffuse neonatal hemangiomatosis). Congenital hemangiomas are present at birth, unlike hemangioma of infancy. They are divided into rapidly involuting congenital hemangiomas (RICH) and non-involuting congential hemangiomas (NICH).
Hemangiomas of infancy may interfere with vital functions such as vision or breathing during the proliferation stage. Specific subtypes (tufted angiomas and Kaposiform hemangioendothelioma) may give rise to the Kasabach-Merritt syndrome, in which platelets get entrapped in the hemangioma leading to thrombocytopenia.
Infantile hemangiomas that do no interfere with vital functions are best observed for resolution. Treatment options, if necessary, include: pulse dye laser, cryosurgery, intralesional or systemic glucocorticoids, interferon alpha, and most recently propanolol. Deep hemangiomas rarely regress and may warrant surgery.