Hemangioma

Hemangiomas generally appear as red to purplish-blue marks or bumps, on or under the skin. They usually tend to be redder on light skin and more purple on dark skin.

They can develop anywhere on the body. In children, they often grow on the scalp, neck or face. Less commonly, they may also grow on the membranes lining the child’s anus, genitals or mouth. Some children have just one hemangioma, and others have several. Adults who develop hemangiomas typically have many of them on the trunk of their body, their arms or legs.

Hemangiomas may vary in appearance. They can be

• flat or raised: Hemangiomas often develop in the top layer of skin. Some of them are embedded in the surface and look flat, while others are visibly raised. Sometimes they develop in lower layers of skin and can be seen through the upper layers. Some hemangiomas are a mix of these different types.
• smaller spots or larger areas: Hemangiomas usually grow around one central point. In adults, they are normally small spots and stay that way. Infantile hemangiomas are a few millimeters to several centimeters in size. In rare cases, they spread out over individual regions (segments) of the body. They are then called “segmental hemangiomas.”

Sometimes hemangiomas develop inside the body – for example, on organs like the liver, or in bones (usually the spine).

Hemangiomas don’t normally cause any pain or other symptoms. But larger hemangiomas in very visible places (like the face) can attract attention and sometimes unpleasant comments, too. That can be mentally distressing for children and make them feel ashamed, hide the affected part of their body under clothing, or no longer want to take part in activities like swimming. If hemangiomas develop in difficult places, they may also have other effects on your health.

Hemangiomas develop if certain cells (endothelial cells) in the blood vessels multiply quickly. It is not clear why this happens. Hemangiomas are benign (not cancer): They don’t destroy any tissue and don't spread to other parts of the body.

In very rare cases, infantile hemangiomas develop as part of a syndrome (PHACE syndrome or LUMBAR syndrome). People with these syndromes have large hemangiomas – usually on their head, neck, face, lower back or perineum – together with birth defects in places like the spinal cord, heart, urinary system and sex organs. It isn't clear how these syndromes develop. Neither of them are curable, but the symptoms can be partially relieved.

About 5% of all newborn babies have hemangiomas. They are roughly three times as common in girls as they are in boys. The likelihood is also higher in premature babies: Up to 30% of all premature babies who weigh less than 1,000 grams at birth develop hemangiomas. Babies with fair skin have a higher risk than babies with dark skin.

Hemangiomas in adults usually develop in older age: More than half of people aged over 60 have at least one hemangioma.

In babies, hemangiomas usually appear on the skin within the first few days or weeks of their life. You can sometimes already see abnormal areas of skin shortly after the birth – like reddish to bluish marks on the skin, or blood vessels that you can see through the skin.

Hemangiomas then go through three phases:

1. Proliferation (growth): Hemangiomas grow in the first 6 to 9 months after birth. They grow fast at first. After about the third month, they start growing less, and more slowly. In rare cases, hemangiomas are already fully developed at birth. Then they're called congenital hemangiomas.
2. Plateau: The hemangioma doesn’t grow anymore in the second phase. The length of this phase varies.
3. Involution: The hemangioma starts to go away again by itself. Hemangiomas disappear in about 80 to 90% of children by the age of four. But this can take up to ten years for large hemangiomas.

In adults, hemangiomas usually start to appear after the age of 30 and remain a few millimeters in size, but don’t go away again.

Most hemangiomas don’t cause any physical problems. But large hemangiomas (especially in the face) can affect your appearance, which can be distressing. After going away, large hemangiomas in particular can leave behind scars or other abnormal-looking areas of skin, too.

Complications occur in about 10 to 15% of affected children – usually if the hemangioma is in one of the following areas of the body:

• Eye: That can make it harder for the child to see properly, perhaps because it's difficult to open the eye. Over time, this may lead to long-term vision problems such as amblyopia (lazy eye).
• Mouth: The growth can affect your ability to eat, deform your lips, or push teeth out of place.
• Airways: Hemangiomas in the nose or on the voice box, for example, can make it harder to breathe. In very rare cases, that can be life-threatening.
• Inside the body: Depending on its size and location, a hemangioma can cause pain or internal bleeding, and in extremely rare cases also bone deformations or fractures.
• Anal or genital region: Because different areas of skin rub against each other here and come into contact with stool (poop) and urine (pee), hemangiomas are more likely to lead to sores in these parts of the body. That can cause pain, bleeding, inflammation or infections and usually results in scarring. This is also more likely in other areas where skin rubs against skin, like the armpits.

Hemangiomas can lead to sores (ulcers) in other parts of the body, too – especially hemangiomas that cover a large area. These hemangiomas can also put strain on the cardiovascular system (heart and blood vessels). Like in heart failure, that can cause symptoms like shortness of breath or exhaustion.

Hemangiomas can affect the development of certain body parts, too. The nose might then grow crooked, for instance.

In rare cases, hemangiomas can lead to an underactive thyroid. That is more common with larger hemangiomas or if there are more than four hemangiomas, and with those that are inside the body – regardless of whether they're near the thyroid gland. These hemangiomas sometimes increase the production of certain enzymes, which then inhibit thyroid hormones.

Unusual changes in the skin should always be examined by a doctor just in case. Children’s skin is also examined during pediatric check-ups.

Doctors can usually diagnose hemangiomas on the skin just by looking at them. They will examine the unusual area closely and ask questions – like how long it has been there and if it has changed since it first appeared.

An ultrasound scan is sometimes done to see how deep the hemangioma is beneath the skin. A special technique (Doppler ultrasound) can also help doctors to see whether an infantile hemangioma is likely to carry on growing.

Other examinations, such as magnetic resonance imaging (MRI), are only done if the diagnosis is not clear. In very rare cases, doctors may take a sample of the tissue (biopsy) under local anesthetic to have it tested in a lab.

In certain situations it can be a good idea to investigate further:

• Hemangiomas on larger areas of the head, neck, face, lower back or in the genital area can be a sign of a syndrome (PHACE or LUMBAR syndrome). MRI or ultrasound scans can be done to find out if one of these syndromes is present.
• If children have large hemangiomas on their chin or neck, the upper airways are examined to see if they are affected. That can be done with a laryngoscopy.
• If a child has large or many (more than four) infantile hemangiomas, a blood test is done to check whether they have an underactive thyroid.
• If someone has more than five hemangiomas, an ultrasound scan is done to see if there's also a hemangioma on the liver.
• People who have a hemangioma close to their eye are advised to see an eye doctor.

Hemangiomas on internal organs or in bones are usually only discovered by chance – for instance, during an ultrasound scan of the abdomen for other reasons.

Because hemangiomas are usually harmless, treatment is often not needed. But it can be a good idea if they cause problems in children. A medication containing propranolol (a beta blocker) is then normally given. This can stop the hemangioma from growing more and make it go away sooner. It is best if the treatment is started when the baby is 1 to 5 months old. The medication is taken twice a day as a syrup for at least 6 months. Most children tolerate the treatment well.

If treatment with beta blockers isn't possible or isn’t successful, the hemangioma can also be treated with a laser, for example.

Adults normally don’t need treatment for hemangiomas. If they find them unattractive or annoying, the treatment options include laser therapy, cryotherapy or surgery.

Hemangiomas on organs (e.g. the liver) or on the spine also only have to be treated if they cause complications. The affected blood vessels are then closed off (embolization) under local anesthetic – for instance, by injecting a tissue adhesive into the vessel through a catheter. This makes the blood vessel tissue stick together. Hemangiomas are only rarely removed by surgery.

If you or your child are ill or need medical advice, it's usually best to see your family doctor or pediatrician first. You can read about how to find the right doctor in our topic "Health care in Germany" – and our list of questions can help you to prepare for your appointment.