In my practice, I am frequently asked about strawberry marks or hemangiomas in infants and children – will they stay? – will they grow? – will they go away? 

Jane Bellet, MD, FAAD, FAAP, an expert in pediatric dermatology, offers some information and advice designed to answer questions asked by parents of children with hemangiomas.

-- Dennis Clements MD, PhD, MPH

The most common birthmark is a hemangioma--one in every ten babies has one, yet the cause is still unknown. A hemangioma usually develops during the first two weeks after birth, often as a small red flat area or bump. This type of hemangioma is called “superficial” and involves the surface of the skin. The bump can continue to grow for the next nine to 12 months, when it begins to slowly “involute” or shrink and fade in color. Some hemangiomas are “subcutaneous,” which means they are below the surface of the skin and often appear blue. Many hemangiomas have both superficial and subcutaneous components, so they appear red on top and blue underneath. The majority of hemangiomas will never cause a problem and do not require treatment because their appearance will gradually diminish with time.  Since hemangiomas grow most rapidly between five weeks and six months of age, it is important that  infants are evaluated early, as treatments are often most effective during the growth phase.

Hemangioma Treatment

Patients with hemangiomas requiring treatment should be referred to a pediatric dermatologist. Location is one of the most important indications as most eyelid, nasal, lip, and “beard distribution” hemangiomas need treatment to prevent complications such as vision loss, feeding problems, and respiratory distress.  Any “beard distribution” hemangiomas along the jawline or in front of the ear may be associated with airway involvement. Large or ulcerated hemangiomas also require treatment. Infants with more than five hemangiomas may also have hemangiomas in other locations such as the liver or gastrointestinal tract, and these can grow just as the skin ones do.  Appropriate imaging needs to be performed to determine whether treatment is necessary. A large plaque-like hemangioma on the face may be indicative of PHACE syndrome:
 
Posterior fossa malformations,
Hemangioma-segmental,
Arterial abnormalities of the neck or brain,
Cardiac-often coarctation of the aorta, and
Eye abnormalities.

Treatment of hemangiomas is determined on an individual basis for each child as a number of factors are involved in the decision about which treatment to use. For many years, the mainstay of treatment has been oral corticosteroids such as prednisolone. Recently, propranolol has been found to be effective when systemic treatment is indicated. Topical timolol is also effective in appropriate situations. Ulcerated hemangiomas require a multi-faceted approach including pain management and treatment of infection. Once hemangiomas have stopped growing and have entered the involutional phase, any residual redness can often be treated with laser therapy. Excisional surgery may be required for any redundant skin.

Prognosis

For most patients, hemangiomas are not problematic and can be easily diagnosed and observed by your child’s pediatrician. Early referral and management by a pediatric dermatologist who specializes in hemangiomas is necessary for those who may require treatment.

-- Jane Bellet, MD, FAAD, FAAP, is a member of the Duke Vascular Malformation Team and is actively involved in the evaluation, diagnosis and treatment of patients with hemangiomas.  She also specializes in excisional surgery, laser surgery, port wine stains, nevi (moles), and hyperhidrosis.

-- Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital & Health Center.