The Word on Hemangiomas in Infancy- A Type of Red Bump

The Word on Hemangiomas in Infancy- 

A Type of Red Bump

Since about one in twenty of all people born develop a particular type of red bump, called an infantile hemangioma, we thought you might be interested in the latest information about them.

These are so common that most people have a child with one or know someone who does.  They are often called strawberry hemangiomas, or strawberries, which is how I will refer to them in this note.

What is a Strawberry Hemangioma?

Strawberries have the wonderful property of tending to go away all on their own.   But what are they?

To understand them, it helps to know just a bit about blood vessels.  Blood vessels are not inert pipes, but rather are formed by cells that are especially adept at forming living tubes.  Strawberries are clumps of these special cells that form a tangle of tiny, tiny blood vessels.

Strawberries are very different than the usual assembly of these special cells.  Strawberries do not contain arteries, veins, or even well-developed capillaries.  Rather, they contain clumps of the cells that make these structures and so really are a tangle of nearly developed blood vessels.

The Timing of a Strawberry Appearing and Disappearing

The timing of appearance and disappearance of these red bumps is quite striking.  Here is how it usually goes:

1. The strawberries tend not to be present at birth.
2. They tend to appear in the first few weeks of life.
3. Then they grow for a few months, typically to age 4-8 months old.
4. If any part of a strawberry darkens a bit blue or gray, that usually is the signal that it will no longer grow.
5. After it ceases to grow, it slowly shrinks in a process that can take several years.  Often by age 4-6 years old, the strawberry is gone.
6. Most strawberries that are small and not too deep disappear completely.  
7. Deeper or larger strawberries also tend to have their color fully clear, but may leave behind a small rubbery lump.

What is the Cause of the Strawberry Hemangioma?

So what causes these to occur, and who is more likely to get them?

The who is more likely question is well known.  We see strawberries more often the more prematurely someone is born.  We also see them more often in girls than boys, European more than African or Asian, multiples more than singletons, and in children of older mothers more than younger mothers. 

As to what causes them, recent leads have been quite intriguing.  

The first is the idea that some early embryonic cells from the placenta sometimes find their way into the fetal circulation and lodge in the skin.

The second idea is that as the fetus is forming, certain areas may be relatively short on oxygen.  We know that shortages of oxygen supply stimulate blood vessel formation and so this  concept suggests that as the body develops a local area of relatively low oxygen the cells that make blood vessels might form a lump.

And, there are some observations that some of the molecules that signal to the body- make some blood vessels- might accumulate for some reason in certain spots after birth.

Types of Strawberries

Whatever the mechanism of cause, strawberries come in three varieties:  small and single, many, one very large.  By far and away, the small and single type is the most common.

Treatment for Strawberry Hemangiomas

The small and single types tend to go away entirely on their own, but can take 4-6 years to do so.

Since the end result of these small, single strawberries can be full clearing, any intervention has to be measured against that result:  painless, complete, disappearance with no side effects, and no scars at all.

For the larger strawberries, or those located in very sensitive areas, like the airway, there are treatments that can work.

Treatments tend to fall into one of three categories:

1.  Topical agents applied to the strawberry.  

2.  Lasers.

3.  Oral medications.

4.  Doing nothing.

Topical agents

These are limited to a couple of medications.  

Topical steroids might help in specific circumstances, but overall have little impact.  

Injected steroids are local if not topical, and do work, but this can be very uncomfortable.

Timolol, a new drug for use in strawberries, is like the propranolol discussed below and may turn out to be effective, but carries some of the same risks as oral propranolol.  

Lasers

Laser therapy is set to burn areas that are just the right color of red, effectively burning the clump of cells that make the strawberry.  But the cells can only eliminated a zap at a time, clearing just a very small area of redness away.  So for most strawberries, full clearing of the red area may take a large number of treatments.

Each treatment is said to feel like a rubber band snapping onto your skin.  So if a large area needs treatment, that is many zaps and can be quite painful.  Laser therapy has its own side effects- including some breakdown in the strawberry, and even scarring.

Oral medications

A number of drugs have been tried to make the strawberry hemangioma go away, but one seems to be offering real possibilities.  That is propranolol, which has had some dramatic success in making strawberries go away, but there are potentially very serious side effects to worry about in young infants, including sharp drops in blood sugar levels, drops in blood pressure, and trouble breathing.  So the use of this drug is currently limited to very large strawberries, and its use requires observation in a hospital.

Doing Nothing

For the vast majority of strawberries, this is by far the best choice.  

After all, if even at its peak size the strawberry is small and not too deep, doing nothing typically gives the best possible result- nothing left over and no scar.

The only problem with doing nothing is that you have to do nothing for several years.

But your child is safeguarded from exposure to potentially harmful medications, painful procedures, and/or long-term scarring.

Bottom Line

• Infantile hemangiomas, or strawberries, are very common.
• They are made up of the cells that usually form blood vessels and may come from stray cells from the placenta, or be responding to conditions present during embryonic and fetal development.
• For most children the strawberries are small.  
• They grow in size for a few months, then a bit of blue or gray appears in the center.  At that point they stop growing and slowly disappear over several years time.
• For the usual small strawberry, doing nothing is an excellent choice of therapy.  It works, it is painless, there is no risk, and you are left with no mark or scar.
• Unusually, the strawberry hemangiomas can be too large or placed in too risky an area to leave alone.
• For these very unusual circumstance, a new drug, propranolol, although risky, may turn out to be very effective in making them shrink or even clear.

Dr. Arthur Lavin

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