Infantile Haemangioma Management

Infantile haemangioma

Infantile haemangioma is the most common benign vascular tumor of infancy, arising from abnormal proliferation of endothelial cells. It typically appears during the first few weeks of life, undergoes a period of rapid growth during infancy, and then gradually regresses over several years. Although many lesions resolve spontaneously without treatment, some may cause functional impairment, ulceration, or permanent cosmetic deformity and therefore require early intervention.

Most infantile haemangiomas occur on the head and neck, but they may develop anywhere on the body. Large segmental facial haemangiomas may be associated with PHACE syndrome, a rare neurocutaneous syndrome characterized by posterior fossa malformations, haemangiomas, arterial anomalies, cardiac defects, and eye abnormalities.

Pathophysiology (Brief)

The exact cause of infantile haemangioma is unknown. The condition is characterized by abnormal proliferation of vascular endothelial cells followed by spontaneous involution.

The natural course consists of three phases:

• Proliferative phase: Rapid growth during the first 6–9 months of life.

• Plateau phase: Growth stabilizes.

• Involution phase: Gradual regression beginning around 9–12 months of age and continuing over several years.

Most lesions involute substantially by 5–10 years of age.

Signs & Symptoms

Typical lesions include:

• Bright red macule or patch at birth or shortly thereafter

• Soft, compressible vascular nodule or plaque

• Progressive enlargement during early infancy

• Gradual spontaneous regression with age

Common sites:

• Face

• Scalp

• Neck

• Trunk

• Extremities

Complicated lesions may present with:

• Ulceration

• Bleeding

• Pain

• Secondary infection

• Cosmetic disfigurement

Functional impairment may occur when lesions interfere with:

• Vision

• Breathing

• Feeding

• Hearing (rare)

Associated syndrome:

Large segmental facial haemangiomas may occur as part of PHACE syndrome, which includes:

• Posterior fossa malformations

• Haemangiomas (primarily facial)

• Arterial anomalies

• Cardiac defects

• Eye abnormalities

• Sternal defects

Indications for Treatment

Treatment is indicated when the haemangioma:

• Interferes with feeding

• Interferes with breathing

• Interferes with vision

• Is rapidly enlarging with risk of permanent disfigurement

• Is ulcerated or painful

• Is associated with significant functional impairment

• Is suspected to be associated with PHACE syndrome

Diagnostic Criteria

Diagnosis is primarily clinical and based on:

• Typical history of appearance in infancy

• Progressive growth during the first months of life

• Characteristic vascular appearance

• Gradual involution after infancy

Investigations

Diagnosis is usually clinical.

Recommended investigations

Before initiating propranolol therapy:

• Fasting blood glucose (FBG)

• Electrocardiogram (ECG)

Monitoring

Before treatment:

• Record heart rate

• Record blood pressure

During initiation of propranolol:

• Monitor heart rate every 2 hours for the first 3 days

• Monitor blood pressure every 2 hours for the first 3 days

• Monitor blood glucose, particularly in young infants or those at risk of hypoglycaemia

• Adjust propranolol dose according to changes in body weight during follow-up

Treatment

Treatment aims to reduce haemangioma growth, prevent complications, preserve function, and improve cosmetic outcomes.

Non-pharmacological Treatment

• Observe uncomplicated small haemangiomas, as many regress spontaneously.

• Educate parents about the natural course of the condition.

• Protect ulcerated lesions with appropriate wound care.

• Monitor lesion size during follow-up.

• Refer complicated lesions early to a dermatologist, pediatrician, ophthalmologist, or surgeon as appropriate.

• Multidisciplinary management is recommended for infants suspected to have PHACE syndrome.

Pharmacological Treatment

Before treatment:

• Record heart rate and blood pressure.

Propranolol (PO) 1 mg/kg/day, divided into three doses given every 8 hours.

Monitor heart rate and blood pressure every 2 hours for the first 3 days.

If well tolerated:

• Increase propranolol to 2 mg/kg/day, divided into three doses daily, and continue until the lesion regresses.

• Adjust the dose according to changes in body weight during treatment.

• STG 2026 starts propranolol at 1 mg/kg/day in 2 doses for 6 months; check glucose before and during treatment and do an ECG/echo first.

• Alternatives: S: bleomycin (intralesional) 0.3–0.5 mg/kg monthly for 4–6 months, or pulsed-dye laser.

Note

• Request the pharmacist to prepare an appropriate propranolol syrup formulation for infants when a commercial preparation is unavailable.

Complications

• Ulceration

• Bleeding

• Secondary infection

• Permanent cosmetic deformity

• Visual impairment

• Airway obstruction

• Feeding difficulties

• Cardiac complications (rare, in very large haemangiomas)

• Residual skin laxity or fibrofatty tissue after involution

Prevention

There is no known method of preventing infantile haemangioma. However, complications can be minimized by:

• Early recognition of high-risk lesions

• Prompt referral for lesions affecting vital structures

• Early initiation of propranolol when indicated

• Regular monitoring during treatment

• Appropriate wound care for ulcerated lesions

Patient counselling (Important)

• Infantile haemangioma is a benign (non-cancerous) vascular tumor.

• Most haemangiomas grow during the first year of life and then gradually shrink over several years.

• Not every haemangioma requires treatment.

• Propranolol is highly effective for haemangiomas that threaten function or cause complications.

• Parents should administer propranolol exactly as prescribed and attend scheduled follow-up visits for monitoring.

• Seek immediate medical attention if the child develops difficulty breathing, poor feeding, excessive sleepiness, fainting, wheezing, or signs of hypoglycaemia such as lethargy or seizures.