Infantile Hemangioma: Strawberry Birthmark Guide

What Is Infantile Hemangioma?

Infantile hemangioma is a benign (non-cancerous) vascular tumor that develops from abnormal growth of blood vessel cells in the skin. It is the most common tumor of infancy, affecting approximately 4-5% of all babies, and typically appears within the first few weeks of life as a red, raised, or bluish mark on the skin.

Infantile hemangiomas consist of a collection of blood vessels that form under or within the skin. Unlike other birthmarks that are present at birth, most hemangiomas are not visible immediately after delivery but develop during the first days to weeks of life. The condition is also commonly known as a strawberry birthmark or strawberry hemangioma due to its characteristic bright red, textured appearance that resembles a strawberry.

These vascular growths follow a predictable natural history that distinguishes them from other vascular anomalies. They undergo a proliferative phase of rapid growth during the first several months of life, followed by a gradual involution phase where they slowly shrink and fade over several years. This unique growth pattern is driven by the abnormal proliferation of endothelial cells, which are the cells that line blood vessels.

The vast majority of infantile hemangiomas are completely harmless and require no treatment whatsoever. They are not cancerous and do not become cancerous. However, depending on their location, size, and whether complications develop, some hemangiomas may require medical intervention to prevent functional impairment or permanent disfigurement.

Types of Infantile Hemangioma

Infantile hemangiomas are classified based on their depth within the skin and their location on the body. Understanding the type of hemangioma helps determine the likelihood of complications and the need for treatment.

Superficial hemangiomas are the most recognizable type, appearing as bright red, raised lesions on the skin surface. They are often described as looking like a strawberry because of their lobulated, textured appearance. These hemangiomas involve only the superficial layers of the skin and typically have the characteristic vivid red color due to the blood vessels being close to the surface.

Deep hemangiomas develop in the deeper layers of the skin and subcutaneous tissue. They appear as bluish or skin-colored soft masses that may be less obvious than superficial hemangiomas. Because the blood vessels are deeper beneath the skin surface, the characteristic red color is not visible, and the overlying skin may appear normal or have a slight bluish hue.

Mixed hemangiomas have both superficial and deep components. They may present with a bright red surface component overlying a deeper bluish mass. These hemangiomas can be larger and more complex than purely superficial or deep types.

Who Gets Infantile Hemangioma?

While any baby can develop a hemangioma, certain factors increase the likelihood. Female infants are three times more likely to develop hemangiomas than males. Premature babies, particularly those born before 37 weeks of gestation, have a significantly higher incidence. Low birth weight babies and those born from multiple pregnancies (twins, triplets) also have increased risk. Hemangiomas are more common in Caucasian infants compared to other ethnicities.

Family history may play a role, though the inheritance pattern is not straightforward. Advanced maternal age and certain placental abnormalities have also been associated with increased hemangioma risk. Despite extensive research, the exact cause of infantile hemangiomas remains incompletely understood, and there is nothing a parent can do to prevent them or that caused them during pregnancy.

What Are the Symptoms of Infantile Hemangioma?

Infantile hemangiomas typically appear as raised, bright red lesions (superficial type) or bluish soft masses (deep type) on the skin. They may be present at birth but more commonly develop during the first few weeks of life. Most hemangiomas grow rapidly during the first 3-6 months before beginning to slowly shrink and fade.

The appearance of an infantile hemangioma varies depending on its type and stage of development. During the earliest phase, before the characteristic redness develops, you may notice a precursor lesion. This can appear as a pale or white area of skin, a faint pink or red patch, or a small cluster of tiny red blood vessels (telangiectasias). These early signs are easily overlooked but may be present at birth in some cases.

As the hemangioma enters its proliferative phase, it grows more rapidly and develops its characteristic features. Superficial hemangiomas become bright red and raised, with a distinctive "strawberry-like" texture. The color comes from the dense network of blood vessels near the skin surface. The lesion is typically soft and compressible, and it may blanch (turn white) briefly when gentle pressure is applied.

Deep hemangiomas present quite differently. They appear as soft, compressible masses beneath the skin surface. The overlying skin may appear normal, slightly bluish, or have a subtle bluish-purple hue. Because these lesions are beneath the skin surface, they may not be immediately recognized as hemangiomas and can sometimes be confused with other types of growths.

Growth Pattern and Timeline

The natural history of infantile hemangioma follows a predictable pattern that is important for parents to understand. The proliferative phase occurs during the first months of life, with the most rapid growth typically happening between 1 and 3 months of age. During this time, the hemangioma may grow significantly in both size and thickness. Growth usually slows by 5-6 months of age, though some hemangiomas continue to grow until around 9-12 months.

Following the proliferative phase, hemangiomas enter the involution phase, where they gradually shrink and fade. This process is slow, often taking several years to complete. As involution occurs, the bright red color fades to a duller red or grayish hue, and the lesion becomes softer and less prominent. Most hemangiomas show significant improvement by age 3-4 years, and approximately 90% of hemangiomas have substantially involuted by age 9.

After complete involution, some hemangiomas leave no trace on the skin. However, larger hemangiomas or those that developed complications may leave residual changes. These can include redundant skin, telangiectasias (small visible blood vessels), scarring, or areas of discoloration. Hemangiomas that ulcerated during their growth phase are more likely to leave permanent scarring.

When Hemangiomas Can Bleed

As hemangiomas grow, particularly during the rapid proliferation phase, they may develop complications. The most common complication is ulceration, which occurs in approximately 10-15% of hemangiomas. Ulceration happens when the skin over the hemangioma breaks down, creating an open wound. This is most common in hemangiomas located in areas of friction or moisture, such as the diaper area, lips, or skin folds.

When ulceration occurs, the hemangioma may bleed and can be painful for the baby. Ulcerated hemangiomas are also at risk for bacterial infection. Parents should contact their healthcare provider if they notice any open sores, crusting, bleeding, or signs of infection such as increased redness, warmth, swelling, or pus around the hemangioma.

When Should You See a Doctor for Hemangioma?

Consult a healthcare provider if your baby's hemangioma is located near the eyes, nose, lips, or in the diaper area; if it becomes ulcerated or bleeds; if there are multiple hemangiomas (5 or more); if it is growing very rapidly; or if you notice signs of infection such as increased redness, warmth, or swelling around the lesion.

Most babies with infantile hemangiomas do not experience significant problems, and the growths resolve naturally without intervention. However, certain situations warrant prompt medical evaluation. Understanding when to seek care helps ensure your baby receives appropriate treatment when needed while avoiding unnecessary worry for benign hemangiomas that will resolve on their own.

Location is critical. Hemangiomas in certain anatomical areas require early evaluation because of their potential to cause functional problems. Periocular hemangiomas (near the eyes) can interfere with vision development and lead to permanent visual impairment if not treated promptly. Hemangiomas on the nose, lips, or ears can cause disfigurement and may affect breathing, feeding, or hearing. Large facial hemangiomas, particularly those in a "beard" distribution, may be associated with airway hemangiomas that can obstruct breathing.

Contact your baby's healthcare provider or a pediatric clinic if:

• Your baby develops a hemangioma after 6 weeks of age (later appearance is less typical)
• Your baby has 5 or more hemangiomas (this may indicate a need to check for internal involvement)
• The hemangioma is near the eye, nose, mouth, ear, or genital area
• The hemangioma becomes ulcerated (develops an open sore)
• The hemangioma is bleeding or painful
• The skin around the hemangioma becomes red, warm, or swollen (possible infection)
• You have any concerns or questions about your baby's hemangioma

How Is Infantile Hemangioma Diagnosed?

Infantile hemangioma is usually diagnosed through physical examination alone. A trained healthcare provider can typically recognize the characteristic appearance and natural history of these lesions without additional testing. Imaging studies such as ultrasound or MRI may be needed for deep or complex hemangiomas or when internal involvement is suspected.

The diagnosis of infantile hemangioma is primarily clinical, meaning it is based on the appearance of the lesion, its location, and its growth pattern rather than laboratory tests or biopsies. An experienced pediatrician, dermatologist, or specialist in vascular anomalies can usually diagnose an infantile hemangioma by examining the skin and taking a thorough history.

During the evaluation, the healthcare provider will ask about when the lesion first appeared, how it has changed over time, and whether it has caused any symptoms or complications. They will examine the hemangioma's size, color, texture, and depth, and will check for any signs of ulceration or infection. They may also examine your baby for additional hemangiomas, as having multiple lesions may indicate a need for further evaluation.

When Additional Testing Is Needed

In most cases, no additional testing is required to diagnose an infantile hemangioma. However, certain situations may warrant imaging or other studies:

Ultrasound may be used to evaluate deeper hemangiomas, assess blood flow within the lesion, or distinguish a hemangioma from other types of masses. Ultrasound is non-invasive, does not involve radiation, and does not require sedation, making it an ideal first-line imaging study for infants.

MRI (magnetic resonance imaging) provides detailed images of soft tissues and is useful for evaluating complex or deep hemangiomas, assessing the extent of large lesions, or checking for associated anomalies. MRI is particularly important for large facial hemangiomas that may be associated with PHACES syndrome (a constellation of findings including posterior fossa brain abnormalities, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities, and sternal defects).

Liver ultrasound may be recommended for babies with multiple cutaneous hemangiomas (typically 5 or more), as these infants have an increased risk of hepatic (liver) hemangiomas. Liver hemangiomas can sometimes cause complications such as high-output heart failure or thyroid dysfunction.

How Is Infantile Hemangioma Treated?

Many infantile hemangiomas require no treatment and are managed with observation ("watchful waiting"). When treatment is needed, oral propranolol is the first-line therapy and is highly effective. Other options include topical timolol for small superficial lesions, laser therapy for residual redness, and surgical excision in select cases.

The approach to treating infantile hemangioma has evolved significantly over the past two decades. The serendipitous discovery that propranolol, a medication traditionally used for heart conditions, causes rapid shrinkage of hemangiomas revolutionized treatment in 2008. Today, most hemangiomas requiring treatment can be effectively managed with oral propranolol.

Observation (Watchful Waiting)

Because the majority of infantile hemangiomas resolve spontaneously without causing problems, observation is appropriate for many cases. This approach, sometimes called "active non-intervention" or "watchful waiting," involves regular monitoring without immediate treatment. Parents are educated about the natural history of hemangiomas and what warning signs to watch for.

Observation is typically recommended for hemangiomas that are small, located in non-critical areas, and not causing functional impairment or significant cosmetic concern. Regular follow-up appointments allow the healthcare provider to monitor growth and intervene if the hemangioma begins causing problems. Many parents find it reassuring to know that most hemangiomas will fade significantly by age 3-5 years and nearly completely by age 9.

Medical Treatment: Propranolol

Oral propranolol is the first-line treatment for infantile hemangiomas requiring intervention. This beta-blocker medication was FDA-approved for treating infantile hemangioma in 2014 under the brand name Hemangeol. Propranolol works through multiple mechanisms, including vasoconstriction (narrowing of blood vessels), inhibition of new blood vessel growth, and promotion of programmed cell death in hemangioma cells.

The response to propranolol is often dramatic and rapid. Parents typically notice softening and fading of the hemangioma within days to weeks of starting treatment. Most hemangiomas show significant improvement within 1-2 months. Treatment is usually continued until the hemangioma has involuted, typically for 6-12 months or until the child is about 1 year old.

Before starting propranolol, babies undergo a cardiac evaluation (listening to the heart, possibly an ECG) to ensure there are no contraindications. Treatment is typically initiated in a medical setting where heart rate and blood pressure can be monitored. Once treatment is established, it can be continued at home with regular follow-up visits.

Common side effects of propranolol include sleep disturbances, cool hands and feet, and diarrhea. More serious but rare side effects include low blood sugar (hypoglycemia), low blood pressure, and bronchospasm (breathing difficulties, particularly concerning in babies with respiratory conditions). Parents are advised to give the medication with or after feeding to reduce the risk of hypoglycemia.

Topical Beta-Blockers: Timolol

Topical timolol is a beta-blocker available as an eye drop or gel that can be applied directly to the hemangioma. It is used for small, thin, superficial hemangiomas where systemic treatment is not necessary. Topical timolol is applied directly to the hemangioma surface, usually twice daily, and can be effective for appropriately selected lesions.

While topical treatment avoids systemic side effects, it is less effective than oral propranolol for larger or deeper hemangiomas. Some absorption through the skin can occur, so it should be used cautiously in very young infants or when applied to large surface areas.

Other Treatment Options

Laser therapy, particularly pulsed dye laser (PDL), can be useful for treating residual telangiectasias (tiny visible blood vessels) that remain after a hemangioma has involuted. Laser treatment is generally not used during the active growth phase of hemangiomas. It is most commonly employed to improve cosmetic outcomes after the hemangioma has naturally regressed.

Surgical excision may be considered in certain circumstances. Surgery is rarely needed during the proliferative phase but may be appropriate for hemangiomas that have ulcerated and are not responding to medical management, hemangiomas in locations where they are causing significant functional impairment, or to correct residual skin changes after involution. When surgery is performed for cosmetic reasons, it is often delayed until the child is older (typically 8-10 years or later) when the full extent of natural involution can be assessed.

Corticosteroids were the primary treatment for hemangiomas before propranolol. While largely replaced by propranolol, corticosteroids (oral, injected, or topical) may still be used in certain situations, such as when propranolol is contraindicated or for very specific indications. However, corticosteroids have more significant side effects than propranolol and are now rarely used as first-line therapy.

What Can You Do at Home for Hemangioma?

Most hemangiomas require no special care at home. Keep the area clean and protect it from trauma. If bleeding occurs, apply gentle pressure with a clean cloth until bleeding stops. If the hemangioma develops an open sore (ulceration), contact your healthcare provider for guidance on wound care.

For the majority of infantile hemangiomas, no specific home care is needed beyond what you would normally do for your baby's skin. Keep the area clean during regular bathing and avoid picking at or rubbing the hemangioma. Dress your baby in soft, comfortable clothing that does not constantly rub against the hemangioma.

Managing Minor Bleeding

Hemangiomas have a rich blood supply and may bleed if scratched or injured. If minor bleeding occurs, apply gentle, firm pressure with a clean cloth or gauze for 10-15 minutes. Keep your baby calm during this time. Most minor bleeding will stop with sustained pressure. After bleeding stops, keep the area clean and dry.

If bleeding is heavy, does not stop with 15 minutes of pressure, or recurs frequently, contact your healthcare provider. Persistent bleeding may indicate ulceration that requires medical attention.

Caring for Ulcerated Hemangiomas

If a hemangioma becomes ulcerated (develops an open sore), your healthcare provider will give you specific instructions for wound care. This typically involves keeping the wound clean, applying prescribed barrier creams or ointments, and covering with appropriate dressings. Pain management may be needed, as ulcerated hemangiomas can be painful. If you notice signs of infection (increased redness, warmth, swelling, pus, or fever), contact your healthcare provider promptly.

For hemangiomas in the diaper area, frequent diaper changes and the use of barrier creams can help prevent and manage ulceration. Allowing air to reach the area when possible may also promote healing.

What Causes Infantile Hemangioma?

The exact cause of infantile hemangiomas is not fully understood. They result from abnormal proliferation of blood vessel cells (endothelial cells) in the skin, but what triggers this overgrowth remains unclear. Risk factors include female sex, premature birth, low birth weight, and Caucasian ethnicity. Hemangiomas are not caused by anything the mother did during pregnancy.

Infantile hemangiomas develop when endothelial cells, the cells that line blood vessels, begin to proliferate abnormally. This results in the formation of a mass of small, densely packed blood vessels. While the trigger for this abnormal cell growth is not fully understood, researchers have identified several factors that appear to play a role.

One leading theory suggests that hemangiomas may arise from placental tissue. Studies have found that hemangioma cells share many characteristics with placental blood vessel cells, and some researchers believe that placental cells may "seed" the developing fetus during pregnancy. This could explain why certain pregnancy-related factors, such as multiple gestations and placental abnormalities, are associated with increased hemangioma risk.

Another area of research focuses on tissue hypoxia (low oxygen levels). Conditions associated with reduced oxygen delivery to the fetus, such as prematurity and placental insufficiency, are associated with increased hemangioma risk. Hypoxia may trigger the release of growth factors that stimulate blood vessel formation and endothelial cell proliferation.

Genetic factors also appear to play a role, though infantile hemangiomas do not follow a simple inheritance pattern. Having a first-degree relative with a hemangioma may slightly increase risk. Several genes involved in blood vessel growth and development have been implicated in hemangioma formation.

What Is the Long-Term Outlook for Hemangioma?

The long-term prognosis for infantile hemangioma is excellent. Most hemangiomas resolve completely on their own without any permanent effects. Even hemangiomas requiring treatment generally respond well to propranolol therapy. Some larger hemangiomas may leave residual skin changes such as scarring, excess skin, or visible blood vessels, which can often be addressed cosmetically if desired.

Parents can be reassured that infantile hemangiomas, though sometimes worrisome during the rapid growth phase, have an excellent prognosis. The natural history of these lesions is to grow, stabilize, and then gradually shrink and fade away. By age 5, approximately 50% of hemangiomas have substantially involuted, and by age 9, approximately 90% have completed involution.

For hemangiomas that resolve completely, no trace remains on the skin, and no long-term health effects are expected. However, larger hemangiomas, those that were deeply located, or those that developed complications such as ulceration may leave some residual changes after involution.

Potential Residual Changes

Redundant or loose skin may remain where a large hemangioma once was, particularly if the hemangioma caused significant skin stretching during its growth phase. This excess skin typically becomes less noticeable as the child grows but may persist in some cases.

Telangiectasias are small, visible blood vessels that may remain on the skin surface after a hemangioma involutes. These can often be treated with pulsed dye laser therapy if they cause cosmetic concern.

Scarring is most likely to occur in hemangiomas that ulcerated during their growth phase. The extent of scarring depends on the severity and duration of ulceration and how it was managed. Scars may fade over time but some may be permanent.

Textural changes in the skin, such as a slight dimpling or "fibrofatty residuum" (a soft, yellowish lump), may remain at the site of a previously large hemangioma.

When residual changes cause significant cosmetic or functional concerns, various treatments can be considered. Surgical excision can remove excess skin or scar tissue. Laser therapy can address residual redness or telangiectasias. These treatments are typically performed when the child is older, often after age 3-5 years, once natural involution has had time to occur.