infantile haemangioma

Last edited 07/2022 and last reviewed 07/2022

• are the commonest benign tumours of infancy, characterized by a rapid proliferative phase, a slow involution phase and an involuted phase (1,2)
• seen in up to 12% of Caucasian children by one year of age, but less common in Asian and African infants. The female: male ratio is about 5:1 (3)
• seen more frequently in twins and premature infants
  • prevalence of infantile haemangiomas at 1 year in preterm infants was shown to be inversely related to gestational age at birth, being recorded as 8% for babies born after the 35th week, 11% for those born between the 30th and 35th weeks, and 19% for those born between the 25th and 29th weeks
• evidence that infantile haemangiomas occur with greater frequency following chorionic villous sampling; one study reported a 21% incidence, and in a third of the cases, the haemangiomas were multiple
  • in this situation it would be anticipated that placental injury would lead to increased detachment of placental cells into the blood
    • infantile haemangiomas might therefore result from embolisation of fetal placental endothelial cells via the right-to-left shunts characteristic of the fetal circulation
    • hypothesis is supported by the finding that infantile haemangiomas share reactivity for GLUT1, an immunohistochemical marker also present in placental endothelium
    • infantile haemangiomas, however, do not express placental trophoblastic markers
    • rapid proliferation in the postnatal period may reflect loss of angiogenic inhibitors of placental and maternal origin
• there is an independent inverse relationship to birth weight in preterm infants
  • at 1 year, the prevalence in preterm babies with a birth weight below 1500 g is about 16%, and, in preterm babies with a birth weight below 1000 g, about 23%
• infantile haemangiomas become apparent during the first month of life in about 90% of cases, and virtually 100% by the 9th months
  
  
• approximately 60% of infantile haemangiomas are superficial, 15% deep and 25% mixed superficial and deep
  • term 'deep' is preferable to 'subcutaneous' as most of those infantile haemangiomas that are covered with normal epidermis are situated largely in the dermis rather than in the subcutis, although they may extend to this depth
    • in the case of superficial lesions, an initial 'precursor' lesion is very frequently visible on the first day of life
      • premonitory lesions may be quite subtle, and most characteristically take the form either of a macular area of hyperaemia resembling a bruise or a pale port-wine stain, or a macular area of pallor
        • pallid type of precursor lesion area may contain grouped punctate telangiectases from the outset, or these may develop within a few days
  • superficial infantile haemangioma is most commonly known as a 'strawberry' naevus, on account of its usual clinical appearance in the form of a sharply circumscribed oval or round, soft, domed swelling of intense scarlet-red colour
    • surface may be smooth or lobulated
      
      
• infantile haemangiomas may occur at any site, but about 60% occur on the head and neck
  • next in frequency are lesions on the trunk, about 25% of the total
  • in some 80% of cases, a single lesion only is present, but in the remaining 20%, lesions are multiple; occasionally, very large numbers may occur
    
    
• infantile haemangiomas increase in size over a period that varies from about 3-18 months
  • however, the great majority will have reached their maximum size within 12 months of their first appearance, and most within 6 months
  • final diameter may vary from less than 1 cm to 25 cm or more
  • there is frequently a deep element to superficial infantile haemangiomas of 'strawberry' type, particularly when these are large; such lesions should be termed 'mixed' infantile haemangiomas
  
  
• most of the infantile haemangiomas resolve spontaneously
• 10-20% of infants may require treatment due to life and function threatening haemangiomas e.g. vision impairment, airway obstruction, congestive heart failure, and hepatic involvement and/or significant disfigurement (1)

Glucose transporter-1 (GLUT-1) is strongly expressed by the cells of infantile haemangioma (3):

• positivity for GLUT1 can be very valuable in distinguishing infantile haemangiomas from other vascular tumours

A review noted (5):

• most infantile haemangiomas are small, harmless, and resolve without treatment
• treatment is indicated for lesions that have potential to cause functional impairment (to vision, breathing, feeding, or by compression of internal organs), ulceration, or cosmetic disfigurement
• refer children with high risk haemangiomas promptly, as most rapid growth occurs in the first two months of life
• oral propranolol is recommended to treat problematic infantile haemangiomas

Reference:

• 1. Pope E et al. Oral versus high-dose pulse corticosteroids for problematic infantile hemangiomas: a randomized, controlled trial. Pediatrics 2007;119:e1239-e1247
• 2. Mulliken JB et al. Case 13-2004. A newborn girl with a large cutaneous lesion, thrombocytopenia, and anemia. N Engl J Med. 2004;350(17):1764-75.
• 3. Macfie CC et al. Diagnosis of vascular skin lesions in children: an audit and review. Ped Dermatol. 2008;25(1):7-12
• 4. Burton BK et al. An increased incidence of haemangiomas in infants born following chorionic villous sampling. Prenat Diagn 1995;15:209-214.
• 5. Surlis T, De Sa Reilly H, Sadlier M, Nelson J. Infantile haemangiomas BMJ 2022; 378 :e068734 doi:10.1136/bmj-2021-068734