Infantile Haemangioma


Infantile Haemangioma 1
  • 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.
Infantile Haemangioma 2
  • 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.
Infantile Haemangioma 3
  • 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.
Infantile Haemangioma 4

Periorbital IH

Infantile Haemangioma 5

Ulcerated IH of the lip


Infantile Haemangioma 6
  • 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
  • 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.


  • 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.
Infantile Haemangioma 7
Large periorbital IH before and after treatment

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.


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.

Infantile Haemangioma 8
Rose’s parents want to know what the lesion is and whether it will continue to grow. Choose the correct answer(s):

  • Most infantile haemangioma involute well with most children having normal skin at the lesion site.
  • All infantile haemangioma should be investigated to exclude an underlying cause.
  • Most infantile haemangioma are solitary lesions.
  • Most infantile haemangioma show rapid growth over the first year of life, follow by a plateau phase, then regress over several years.
  • The lesion is an infantile haemangioma, a benign vascular tumour, usually noted in the first few weeks of life.

Answers: True, False, True, False, True

Rose’s parents then ask you what management and treatment options are available. Choose the correct answers:

  • Monitoring is sufficient for small lesions with low risk of complication.
  • All infantile haemangioma should be treated with oral propranolol.
  • Parents should represent if the lesion ulcerates.
  • The lesion needs urgent review by Plastic Surgery as it is growing rapidly.
  • High output cardiac failure should be counselled for.

Answers: True, False, True, False, False

Written by Dr Stanley Leong

Senior Paediatric Registrar and Dermatology Registrar

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