Hemangioma – Strawberry Birthmark – Should you fear it?

What is Hemangioma – Strawberry birthmark?

Hemangiomas, or strawberry birthmarks, are commonly seen in children, occurring in approximately 5-10% of 1-year-old infants. These marks are reddish, which is the result of blood vessel collection under the skin.

Despite being called strawberry birthmarks, hemangiomas do not necessarily appear at birth, as some children may not experience them until weeks after birth.

Typically, hemangiomas are small in size, but in some cases, they may grow very large, which naturally is quite worrisome for the parents.

However, you should know that these birthmarks are benign in nature, meaning you have no reason to worry, but it is still recommended by the American Academy of Pediatrics (AAP) to contact your baby’s pediatrician as soon as you notice strawberry-like structures on your child’s skin.

In this article, we will provide you with a comprehensive guide on how to identify infantile hemangiomas (I Hs), their causes, diagnosis, and available treatment options.

How to identify hemangioma

To identify strawberry birthmarks, you need to be familiar with where it might appear, as well as the types of hemangiomas there is.

As mentioned earlier, these benign tumors can appear anywhere in the body, with a special predilection towards certain areas, including:

• Face
• Neck
• Scalp
• Torso
• Back

When you notice a reddish area on your child’s skin, try to focus on the lesion; if you see superficial blood vessels accumulated together, it is probably a hemangioma.

Note that I said “probably” because of the resemblance of this lesion with several other dermatological conditions, such as port-wine stain.

Depending on the connection of hemangiomas with other tissues, we have three types:

• Superficial hemangiomas
  A superficial hemangioma is mostly composed of blood vessels near the outer layer of the skin (i.e. epidermis), which gives it a bright, red color and a relative elevation over the skin. In other words, if you touch the lesion, you will feel as if it’s a bump.

• Deep hemangiomas
  Deep hemangiomas are spread into the deeper layers of the skin, including the adipose and muscular tissue. Typically, these tumors appear blue or purple, and they are also known as cavernous hemangiomas.
• Combined hemangiomas
  If the strawberry birthmark does not qualify the two definitions above, it might the combined type.

What causes hemangioma on a baby?

The exact causes of infantile hemangiomas are not yet identified; however, experts pinpointed common risk factors that may lead to this condition.

These include:

• Caucasian children
  While this risk factor is commonly cited, evidence shows that it’s related to an increased in preterm labor incidence in white females, which is a documented risk factor for hemangiomas.
  Regardless of the underlying mechanism, infantile hemangiomas are more prevalent in white females compared to other races, especially Africans who have the lowest incidence of this condition.
• Female gender
  Several studies confirmed that the female gender of the newborn increases the risk of developing infantile hemangiomas; however, scientists are not completely sure about the mechanism that leads to this finding.
• Advanced maternal age
  Advanced maternal age predisposes newborns to a variety of conditions, including chromosomal abnormalities (e.g., down syndrome), maternal diseases (e.g., preeclampsia), and birth complications (e.g., postpartum hemorrhage).
  In a 2007 prospective study, researchers analyzed the risk factors of infantile hemangiomas and found that advanced maternal age (over 40 years old) may augment the prevalence of this condition.
• Preeclampsia
  Preeclampsia is a common medical condition that occurs during pregnancy and is characterized by elevated blood pressure in the pregnant mom.
  In a 2017 study, researchers confirmed the link between preeclampsia and hemangiomas, concluding that “Early-onset pre-eclampsia is associated with increased risk of hemangioma at birth, but detection bias due to longer hospital stays and closer follow-up may be part of the reason.”
• Prematurity
  Premature newborns are at higher risk of developing cardiovascular and respiratory problems, which is explained by the immature organ systems that are not ready for the outside environment.
  While many reputable sources linked infantine hemangiomas to premature birth, JAMA dermatology went one step further and analyzed the characteristics of hemangiomas in term and preterm babies.
  The prospective study found that the number of hemangiomas in preterm newborns surpass those observed in term babies. Additionally, the female to male ratio decreases, which means that males are as likely to develop hemangiomas as females.
• Twin births
  Multiple pregnancy is a prenatal maternal risk factor for preeclampsia, placenta previa, and gestational diabetes. All of which increase the risk of hemangiomas in infants.
  The biological mechanism is quite complex and involves the over-secretion of vascular endothelial growth factors (VEGFs) that induce blood vessel formation and expansion in the skin, resulting in full-blown hemangiomas.
• Taking fertility medications
  Fertility medications’ mechanism of action involves the modification of estrogen and progesterone concentration in the blood, which is thought to activate certain metabolic pathways that induce blood vessel expansion, and eventually hemangiomas.
• Genetics
  Despite the absence of any evidence that suggests the involvement of genetics in hemangiomas, experts believe that the difference in prevalence between races can only be explained by genetic predisposition.

How to diagnose hemangioma

In most cases, the diagnosis of hemangiomas is straightforward.

When you suspect this condition and visit the pediatrician, he/she will take a look at the lesion during the physical examination to analyze its color, size, and depth.

If the doctor suspects that the strawberry birthmark extends into deeper layers of the skin, further testing might be warranted.

The most commonly ordered tests include CT scan, MRI, or a biopsy to study the cellular architecture of the tumor.

Finally, if the tumor is large enough and/or extending into deeper tissues, the doctor might recommend surgical excision, which requires brief hospitalization in a specialized surgical center.

How to treat hemangioma in babies?

The treatment options for hemangiomas are numerous due to how diverse these tumors are.

For instance, the doctor must take into account, the size, location, and invasiveness of the tumor, as well as the rate of growth before choosing the appropriate treatment approach.

Regardless of these considerations, here are the most commonly used treatments for hemangiomas:

• Therapeutic abstinence (doing nothing)
  
  While this might seem counterintuitive, small hemangiomas often resolve without leaving scars, especially in areas covered by clothes. For this reason, the physician might choose to closely observe the tumor without any therapeutic intervention to make sure no complications are developing.

  If the tumor starts to grow in size or invade surrounding tissues, it might be time to consider other treatment options.

• Beta-Blockers

  Beta-blockers are a class of medication used to treat blood hypertension, hyperthyroidism, and migraines. Since 2008, these drugs have become the number one prescribed treatment for hemangiomas. In infants who are 5 weeks of age or older, the FDA approved oral propranolol to treat IH.

  Generally speaking, the treatment lasts for 6 months taking the drug twice a day. Additionally, your pediatrician might prescribe timolol (topical form) to apply on the site of hemangioma, which is a preferred choice for small tumors.

  Both drugs proved their efficacy in slowing down the progression of hemangiomas and reducing the risk of complications.

• Corticosteroids

  Before approving beta-blockers as a treatment of IH by the FDA, corticosteroids were the gold standard therapy.

  Physicians prescribe these drugs as monthly injections or topical use on the site of the hemangioma. However, due to the heavy side effect profile, most clinicians today favor propranolol, leaving cortisones to rare situations such as beta-blocker intolerance.

• Phototherapy

  Phototherapy, or laser therapy, uses high-intensity beams of light to heal ulcerated hemangiomas. The mechanism of action involves the destruction and vasoconstriction (shrinking) of superficial vessels to stop the bleeding and ulcerations.

  Physicians may order laser therapy to treat all different types of IH, especially those located in the airways, risking to compromise the child’s normal breathing.

• Surgical ablation

  The vast majority of IH do not require surgical interventions, but in some cases, the damage is too extensive to control with noninvasive treatments.

  For instance, if the hemangioma damages the surrounding tissues, threat vital functions (e.g. breathing), or cause recurrent hemorrhages (bleeding), removing the tumor becomes inevitable.

  This procedure requires general anesthesia and may lead to important scarring, which is one of the most important factors that physicians take into consideration when doing the benefit/risk analysis of the surgery.

  Conclusion

Hemangioma in babies, or strawberry birthmark, are benign tumors that often cause great concern to parents, especially those who have never heard of this condition.

The pathophysiology and causes of this condition are poorly understood, but researchers are constantly conducting studies and clinical trials to better comprehend the underlying mechanism, as well as potential treatment approaches for hemangiomas.

Hopefully, you found this article helpful and informative, but if you still have any questions, feel free to ask in the comment section below.