Introduction

• Infantile haemangioma (IH) are commonly known as “strawberry naevi”.
• IH are the most common benign vascular skin tumours in children. They are caused by proliferation of the vascular endothelium.
• They are usually not present at birth, but the precursor lesions (flat pale or pink macules) may be present soon after birth.

• IH rapidly proliferate in the first few weeks of life. They can grow rapidly over the first 6 months, followed by a period of stability or growth arrest by 4-9 months of age, and then gradually and spontaneously involute from the age of 12 months, over a period of several years.

• They can occur anywhere on the skin or in the subcutaneous tissues, or both (often on the head and neck areas).
• They don’t usually cause functional or long-term cosmetic problem and will involute over a period of 4-5 years, even if they are not treated

Indications for treatment:

• • Life or function-threatening IH
    • Airway IH – subglottic or tracheal – these present with stridor and are at increased risk in association with IH in the “beard” distribution
    • Periorbital IH – risk of amblyopia from occlusion or pressure-induced astigmatism
    • Large IH associated with high flow and cardiac compromise eg Hepatic lesions
    • Large IH interfering with physical development eg on the hand
    • Large segmental IH of the head and neck – may be associated with PHACES syndrome and abnormalities of the cerebral vasculature, great arteries and neurological abnormalities.
    • Large segmental IH of the lumbosacral region – may be associated with LUMBAR or PELVIS syndromes and abnormalities of the spine or renal tract.
    • Multifocal IH – may be associated with intrahepatic IH (and cardiac failure) and hypothyroidism.
  • Ulcerated IH (or sites at high risk of ulceration)
    • Lip, perineum, flexures
  • IH at risk of long term psychosocial impact or deformity
    • Located on the lips, cheeks, nose and ears
    • Exophytic IH with a “step-edge” in a cosmetically sensitive site.
• IH on the scalp are at low risk of complication and do not result in areas of baldness unless associated with ulceration and scarring
• Children will usually be assessed by Paediatric Dermatology, ENT, Ophthalmology or Paediatric Surgery depending on the location of the haemangioma.

Periorbital IH

Ulcerated IH of the lip

Approach

History

• Age at which lesion was first noted
• Number and location of lesion(s)
• Subsequent growth
• Presence/ history of ulceration, pain, bleeding or infection
• Interference with feeding or breathing

Examination

• Examine the location, size, number and appearance of lesions
• Check for evidence of bleeding, ulceration, or infection
• Check for hepatomegaly, high output cardiac failure, signs of congenital heart disease, bruising.

Management

• Oral propranolol 1-3mg/kg/day in divided dose (twice daily)
  • On initiation of oral propranolol (especially in young infants), this should be done in inpatient/ day stay setting. Check infant’s BP, heart rate every hour for 4 hours post administration. Also check blood sugar 3 hours after administration.
  • Adverse effects include hypotension, bradycardia, hypoglycaemia and sleep disturbance.
  • Advise parents to temporarily withhold oral propranolol if infants are not feeding well (eg vomiting illness).
• Topical timolol can sometimes be used as alternative to minimise systemic adverse effect
• Laser therapy can also be useful.
• Oral prednisolone is no longer the first line treatment for IH due to possible systemic side effects.

Management goals

• Prevent life or function threatening complications
• Prevent or treat ulceration to minimise pain, bleeding and infection.
• Prevent or minimise residual scarring and disfigurement.
• Minimise long term psychosocial distress for the patient and family.

Scenario

Rose is a 6-week-old baby girl whose mother has brought her to Emergency Department (ED) as she has noticed a rapidly growing lesion on her abdomen. She is an otherwise well infant, born following a normal pregnancy and unremarkable antenatal scans.

Written by Dr Stanley Leong

Senior Paediatric Registrar and Dermatology Registrar