Haemangioma
(Strawberry Naevus)
Definition
A haemangioma (also known as a strawberry birthmark) is
a type of birthmark caused by an abnormal collection of
abnormal blood vessels just below the skin.
Incidence/Age/Sex
Haemangiomas are very common; about 10% of babies are affected.
15 - 20% of babies have more than one haemangioma. They
typically appear in the first few weeks of life. Females
are more commonly affected than males (3:1). Haemangiomas
are less common in dark skinned races and may occur anywhere
on the body surface; however, 60% are in the head and neck
area.
Signs & Symptoms
The typical haemangioma is not be present at birth; most
appear in the first few weeks of life as a small, flat,
red blemish (“herald patch”). The blemish will
change day by day initially to form some flat spots which
then become raised and join together to form a red swelling.
Subsequently all haemangiomas follow a typical pattern of
behaviour; initially there is rapid growth in area and depth
(“proliferative phase”). After the proliferative
phase, which lasts about six months, they remain stable
(“plateau phase”) for a period of months or
occasionally years before beginning to fade away (involution).
The appearance of a haemangioma depends upon how deep it
is in the skin and the growth phase in which it is observed.
Early growing lesions are typically elevated with a bright
red, irregular surface (“strawberry birthmark”).
If the haemangioma is in the deeper layers of the skin they
may produce a blue swelling. Involution typically begins
with the fading of the colour to purple and the development
of colourless or grey areas with softening of the birthmark
and then shrinkage of the lesion. The end result may be
complete resolution or the production of a scar consisting
of redundant, wrinkly skin. About 50% of haemangiomas will
have resolved by the age of 5 years.
Parents are usually advised that no treatment is required
as most will resolve without leaving any scar or deformity.
Some haemangiomas develop complications (see below) that
produce additional signs and symptoms.
Causes/preventions
The cause of these birthmarks is unknown. Contrary to many
old wives’ tales the appearance of a haemangioma has
nothing to do with what the mother ate or saw during her
pregnancy. They are not hereditary, although because they
are so common more than one family member may be affected.
When a haemangioma appears it is impossible to predict how
large it will grow, how long it will persist and whether
it will leave any residual mark after it resolves.
No treatment has been scientifically proven to prevent the
development of haemangiomas. Preliminary work has suggested
that it may be possible to prevent the growth phase of haemangioma
if they are treated with a laser called the flash lamp pulsed
dye laser as soon as possible after they appear. A major
research project at Birmingham Children’s hospital
and Birmingham Heartlands hospital is currently underway
to see if laser treatment can prevent the growth of haemangioma
by treating them as soon as they occur.
Complications of disorder
Most haemangiomas resolve without problems and without scarring;
however, some lesions will develop complications, most typically
during the early proliferative growth phase. Complications
include: bleeding, ulceration, infection, and obstruction
of visual fields, airway obstruction, heart failure and
bleeding disorders. The rapid growth of proliferating haemangiomas
may also distort or destroy growing structures; this may
have major implications when structures such as the nose,
lips, ears or eyes are involved.
Tests
For most children with haemangiomas no special tests are
needed; if complications develop then some tests might be
need.
Treatment: Medical
The majority of haemangiomas require no specific treatment.
Once a haemangioma enters the growth phase observation by
appropriately trained personnel may be required. During
the growth phase complications occasionally occur; in these
cases expert advice should be sought as more active treatment
may be advised. The management of most complications is
non-surgical.
Applying firm pressure with a clean cloth or sterile gauze
for about ten minutes can usually control bleeding. Infection
can often be controlled with an antibiotic cream and/or
antibiotics by mouth or injection. Ulceration may be very
painful and there is some suggestion that laser treatment
to the ulcerated haemangioma may help speed up healing of
the ulceration; interestingly ulceration of a haemangioma
often speeds up its resolution; however scarring is typical.
Haemangiomas enlarging in critical areas or associated with
major complications may be treated with high dose steroids.
The steroids can be given by injection into the haemangioma
or taken by mouth. Steroids may induce some shrinkage in
50 - 90% of patients; sometimes the treatment may need to
be repeated. Short-term high dose steroids have not been
associated with acute or long-term problems such as growth
disturbance.
Repeated treatment of early proliferating haemangiomas with
a flash lamp pulsed dye laser may keep the haemangioma “under
control” without achieving complete destruction of
the lesion. The laser may also be helpful in treating any
residual redness left in resolved haemangiomas.
Treatment:
Surgical
Surgical excision during the proliferative phase is rarely
necessary; indeed many lesions are surgically unresectable.
The main use of surgery in the treatment of haemangiomas
is for the treatment of abnormally textured or redundant
skin and scar left behind after the haemangioma has resolved.
Thus surgery is not usually performed until several years
after the haemangioma first appeared.
Outcome
Half of all haemangiomas will have resolved completely be
the age of five years. In time 75 - 90% will resolve.
