Infantile hemangioma in Child
Ulceration occurs in about 5% of hemangiomas and can occur at any location. Ulcerated hemangiomas are painful regardless of location, often become secondarily infected, and leave a scar. Bleeding and ulceration can incorrectly cause or increase concern for possible physical abuse; however, their characteristic development in early infancy and typical regression should help differentiate them from the former. Ulceration is of particular concern when it involves the periocular, nasal, perioral, or anogenital areas, given regional risk for severe complication. Ulceration of the nasal or laryngeal areas can cause respiratory compromise. Perioral ulceration can interfere with latching and feeding. Anogenital ulceration adversely affects diaper changes, urination, and defecation. Periocular ulceration and attendant scarring can distort the eyelids, scar the cornea, and/or affect development of binocular vision. Only about 1%-2% of hemangiomas involve the genitalia. Such hemangiomas of the urethra, the labia, hymen, vulva, or perihymenal area may raise concern for sexual abuse. When extensive ulceration is present, there may be concern that these represent perineal burns. Knowledge of the clinical appearance and natural course of untreated hemangiomas may help prevent misdiagnosis.
Segmental infantile hemangiomas raise concern for regional abnormalities. A segmental infantile hemangioma of the upper face, ears, and/or scalp requires evaluation for PHACE syndrome (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies). Involvement of the lower face and neck warrant assessment for laryngeal involvement. If the anogenital area is involved in a segmental fashion, evaluation for associated anomalies associated with the synonymous LUMBAR syndrome (lower body hemangioma, lipoma, or other cutaneous anomalies, urogenital anomalies, myelopathy, bony deformities, anorectal and arterial anomalies, and renal anomalies), SACRAL syndrome (spinal dysraphism, anogenital anomalies, cutaneous anomalies, renal and urologic anomalies, associated with angioma of lumbosacral localization), or PELVIS syndrome (perineal hemangioma, external genitalia malformations, lipomyelomeningocele, vesicorenal abnormalities, imperforate anus, and skin tags) should ensue.
D18.01 – Hemangioma of skin and subcutaneous tissue
83343001 – Infantile hemangioma
- Congenital hemangioma (CH) – Fully formed vascular tumors at birth; 2 main types are rapidly involuting congenital hemangiomas (RICH) and noninvoluting congenital hemangiomas (NICH), and variants have been reported. The proliferative phase in these tumors occurs in utero, and tumors do not typically proliferate postnatally in the pattern seen with infantile hemangiomas. RICHs present as exophytic pink to purple vascular plaques, nodules, or tumors, sometimes with ulceration. NICH presents as a bluish patch or plaque overlaid with coarse telangiectasia and a peripheral rim of pallor. Histologically, they are GLUT-1 negative, which helps to differentiate them from other hemangiomas. Partially involuting congenital hemangiomas (PICH) add to this spectrum with features of both RICH and NICH. PICH and NICH have been shown to demonstrate delayed enlargement years after diagnosis. These can also be painful without ulceration as compared to infantile hemangiomas.
- Capillary malformation or "port-wine stain" – Early superficial or segmental infantile hemangiomas, or their precursor lesions, may be confused with port-wine stains, which are capillary malformations present at birth. They are pink or red patches that persist throughout life and do not have the typical infantile growth phase of hemangiomas. They do, however, proliferate after puberty.
- Tufted angioma and kaposiform hemangioendothelioma represent a spectrum of vascular tumors that may mimic hemangiomas. They present as deep red, purple, or brown vascular plaques or nodules, sometimes with deep fibrotic consistency. They may be localized or segmental and carry risk for the Kasabach-Merritt platelet sequestration phenomenon.
- Infantile myofibromatosis – Fibrohistiocytic proliferations characterized by skin-colored to purple, firm to hard or rubbery nodules, single or multiple in presentation. Failure to thrive and spasticity may be present.
- Venous malformations have a similar blue tint as deep infantile hemangioma, but they do not proliferate rapidly unless there is vascular obstruction. Phleboliths are often seen in venous malformations on ultrasound, and compared to hemangiomas, they demonstrate slow flow.
- Neuroblastomas can mimic deep infantile hemangiomas, but they blanch when stroked / rubbed.
- Rhabdomyosarcoma – Soft tissue sarcoma of skeletal muscle origin typically seen in the first and second decades of life. In children, this presents as an asymptomatic, rapidly growing, red, firm cutaneous nodule or tumor, and may involve the head and neck.
- Lymphangiomas may mimic deep infantile hemangiomas.
- Arteriovenous malformations are pulsatile and relatively warmer than infantile hemangiomas.
- Nonvascular tumors with a nodular appearance and bluish or red / purple tint may also mimic infantile hemangiomas; not all present during the infantile period.
- Plexiform neurofibroma
- Cystic neurilemmoma
- Fibrous histiocytoma (see, eg, malignant fibrous histiocytoma)
- Vascular leiomyoma
- Kaposi sarcoma
- Epidermoid cyst
- (Nasal) glioma
- Nevus anemicus
- Leukemia / lymphoma cutis