Infantile hemangioma (strawberry birthmark)

What is an infantile hemangioma?

An infantile hemangioma is a type of birthmark. It's a tangle of extra blood vessels and is the most common type of tumor (growth) in infancy, occurring in about 4 to 5 percent of babies.

The growth usually isn't present at birth (though it may appear as just a little red spot) but develops in the first two weeks of life and then quickly grows. A hemangioma typically begins as a mark or colored patch on the skin and grows to a bright red, bumpy patch – which is why it's sometimes called a strawberry birthmark. It might be any size – from a few millimeters to many centimeters in diameter.

Infantile hemangiomas typically go through three stages:

• The proliferative phase. This is when the hemangioma grows. Typically, the most rapid growth is from 5 ½ to 7 1/2 months of age. By about 9 months, most hemangiomas will be their maximum size.
• The plateau phase. This is when the tumor doesn't grow or shrink but remains relatively stable.
• Involution. Finally, the growth begins to fade, become less firm, and flatten. This stage can begin at 12 to 18 months, but the process can take years.

There are different types of infantile hemangiomas:

• A superficial hemangioma is the most common type, and it appears on the surface of the skin. It may appear as a small area of white, pink, or red at first and change to a brighter red, raised lesion. The superficial hemangioma may be in one spot or spread out over a larger area.
• A deep hemangioma forms under the skin, with a smooth outer surface (though the skin may look swollen). It may have a bluish tint and look like a bruise. Deep hemangiomas may grow longer than superficial hemangiomas.
• A mixed hemangioma is a combination of both deep and superficial growths – both the surface and deeper layers of the skin are affected.
• Extracutaneous hemangiomas are uncommon, but they grow on organs, bones, tissue, or in muscle.

Some hemangiomas do appear at birth. These are called congenital hemangiomas, and they're caused by gene mutations. They're full size at birth, and they either completely go away by a baby's first birthday or don't go away at all. Congenital hemangiomas are much less common than infantile hemangiomas.

What causes hemangiomas in babies?

Experts don't know what causes hemangiomas in babies, but for some reason the baby's blood vessels receive signals to grow rapidly, causing an overgrowth. Scientists are studying these possible causes:

• Genetics. Scientists haven't identified a gene, but some family links have been reported. In one study of 185 patients, one-third had a family history of infantile hemangiomas.
• Hypoxia. Low oxygen levels before birth would help link hemangiomas with some of the risk factors, such as low birthweight and placental problems. Experts think that perhaps the overgrowth of cells is the body's attempt to make up for the earlier lack of oxygen to the tissues.
• Proteins that develop in the placenta during pregnancy may cause the overgrowth of the cells.

Where do infantile hemangiomas usually appear?

Infantile hemangiomas are usually single growths, and they can grow anywhere on the skin, though 80 percent of them appear in the face and neck region. A hemangioma can even appear on a baby's lip. Hemangiomas also commonly show up on the chest and back.

It's not common, but an infantile hemangioma can also grow on organs, tissues, and in muscles. One can show up anywhere in the body, including the liver and other parts of the gastrointestinal system, the respiratory system organs, the spleen, adrenal glands, and brain. If your baby's healthcare provider suspects your baby may have a hemangioma internally, they may do imaging (an ultrasound or MRI, for example) to take a look.

Signs and symptoms of strawberry birthmarks 

If your baby has a strawberry birthmark, you may first notice a small red patch on the skin. It may look like a scratch or bump, or it may be flat. Eventually, it will start to grow outward from the skin.

A hemangioma on your baby's skin is unlikely to cause problems, unless it grows very large, becomes sore, or is in an area that interferes with bodily functions, such as the eyes, mouth, or diaper area.

If your baby has a hemangioma inside the body, it may cause symptoms that relate to any organ that's affected. If the hemangioma is on the liver or gastrointestinal tract, for example, your baby may have nausea or vomiting or a loss of appetite.

What are the risk factors for infantile hemangiomas?

Risk factors for infantile hemangiomas are:

• Female gender. Infantile hemangiomas are two to three times more common in girls than boys.
• Twins and other multiples. Multiple hemangiomas occur more often in babies who are multiples.
• Prematurity with low birth weight
• Caucasian race
• Older maternal age
• Placental problems, such as placenta previa and preeclampsia
• Progesterone therapy

Are there any ways to prevent hemangiomas in babies?

Because we don’t know what causes hemangiomas, it's hard to say how you might prevent them. Getting good prenatal care – which may help prevent preterm birth and placental problems – is always a good idea, though.

And you can help minimize the skin damage caused by the hemangioma by getting your baby treatment early on, if necessary. If you think your baby is developing an infantile hemangioma, show it to their healthcare provider so they can monitor it and treat it at the best time, if treatment is needed. The American Academy of Pediatrics recommends that problematic hemangiomas be evaluated and treated, if necessary, by about 1 month of age.

Will my baby's hemangioma go away on its own?

Most hemangiomas go away on their own, without any treatment. After the initial growing phase in your baby's first year, you'll probably see slow improvement as the hemangioma fades from bright red to grey or white, flattens, and shrinks from the center outward.

While complete involution (resolving) can take as many as ten years, studies have shown that ninety percent of involution is complete by four years of age. (Your child's hemangioma may continue to improve after then, but probably not significantly.)

Depending on the size and severity of the hemangioma, the skin may have some scarring, including a different texture and discoloration, after involution is complete. Sometimes laser treatment is used to reduce the remaining scarring, if it's severe.

Treatment options for infantile hemangiomas

Most infantile hemangiomas are small and get better by themselves, without treatment. But about 10 percent of them require treatment. This may be because they're large and disfiguring, because they're causing pain and/or bleeding, or because they're obstructing something – like a baby's eye or airway. The goal of treatment is to slow growth during the phase of maximum growth and/or speed the shrinkage.

Options for treatment are:

Medication

Beta-blockers can slow the blood flow to the hemangioma. The drug propranolol may be given orally for at least 6 months and sometimes a year or more. It may help slow the growth and fade the hemangioma. The topical drug timolol (a gel) may be used for small, thin, superficial hemangiomas.

Corticosteroids can also help slow the growth and stop inflammation. Steroids are most effective in early stages – they aren't much help once the hemangioma has grown to its peak size. Most often the steroid is injected into the hemangioma, but it can also be applied to the skin. These may be recommended for a child who isn't able to take beta blockers.

If neither beta-blockers nor corticosteroids are effective, your baby's healthcare provider may recommend interferons. These medications – proteins that are usually used to interfere with the multiplying of viruses – take longer to work and aren't the first-line choice.

Surgery and/or laser treatment

Surgery is rarely done on babies, though it may be done later to repair scarring after involution. Surgery is also sometimes necessary to remove some very large hemangiomas or those that are causing problems – because they're in a bad location (on an organ or covering an eye or nostril, for example).

Laser therapy can be used to shrink and lighten a superficial hemangioma or to treat sores that have developed on a hemangioma.

Ask your baby's doctor about the side effects of each treatment and how likely the growth is to go away on its own before making a decision about treating your child's hemangioma. And keep in mind that an infantile hemangioma that shrinks naturally usually looks better in the long run that one that's been treated.

Should I be concerned about my baby's strawberry birthmark?

A strawberry birthmark can be upsetting to see, but it's rarely cause for concern. They are always benign growths (non-cancerous), and the majority go away on their own.

Occasionally, a hemangioma is problematic. For example, a hemangioma may:

• Become sore and painful. It may even become infected or bleed uncontrollably.
• Be located in a place that interferes with breathing, hearing, vision, or elimination.
• Strain the child's heart because of the amount of blood flowing to it.
• Affect your child's appearance.

Hemangiomas are also sometimes associated with other problems, such as underlying neurological or other concerns. Large hemangiomas on the face can be associated with PHACE syndrome, for example, which involves the brain, heart, and eyes.

Your baby's doctor can tell you whether your baby's infantile hemangioma is something that needs to be treated.

If your baby has a birthmark and you're not quite sure what kind it is, check out our photos of birthmarks.

You might also like to chat with other parents in our community about your baby's birthmarks.