Infantile haemangioma

strawberry naevus · strawberry mark · infantile hemangioma · IH

The commonest benign tumour of infancy, in up to 5% of infants - mostly harmless, but a minority need referral within weeks and the window to act is short.

URGENT DERMBand B

Red flags

Periorbital or periocular lesion - the risk is permanent visual impairment from deprivation or astigmatism, and it does not need to cover the eye to do it
Beard-distribution lesion (chin, jawline, anterior neck), or any stridor or noisy breathing - consider airway haemangioma. This is the one that kills
A large segmental facial lesion - look for associated intracranial and aortic arch vascular anomalies; a large lumbosacral lesion raises spinal and urogenital anomalies
Any facial haemangioma, not only a large segmental one. The AAP guideline names facial IH in its own right as carrying a risk of permanent scarring and disfigurement, and the nasal tip, the lip and the eyelid are where that risk is highest. This is the gap a size-based list leaves: a moderate lesion on the cheek, nose or lip in a growing infant is a referral, not a watch-and-see
Ulceration - painful, scarring, and a reason for urgent rather than routine referral
Five or more cutaneous lesions - consider hepatic haemangiomas and arrange imaging via the specialist team
A lesion in a baby who is anaemic, has heart failure, or is failing to thrive

Recognise

On light skin

A bright red, raised, compressible plaque or nodule with a strawberry-like surface when superficial. A deep lesion may show only a bluish swelling with normal overlying skin. Often preceded by a pale patch, a faint telangiectatic mark or a bruise-like area in the first weeks.

On brown and black skin

The bright strawberry red that gives this lesion its common name is a description of pale skin, and on brown and black skin a superficial haemangioma more often reads as deep red-purple, violaceous or almost black-brown, which is routinely under-recognised and sometimes mistaken for bruising. A deep haemangioma may show no colour change at all. Diagnose by what is tone-independent: a soft compressible swelling, growing visibly week by week in a baby under five months, is a haemangioma until proved otherwise, and the growth history is the finding that matters most. The precursor mark that precedes it - a pale patch or faint telangiectasia - is particularly easy to miss in darker skin, so a parent reporting a mark that is now enlarging deserves to be believed and measured rather than reassured on appearance. Ulceration, which is the commonest complication, is tone-independent. No skin-of-colour series was identified for infantile haemangioma; this draws on general sources.

In any skin tone

The growth curve is the diagnosis. Most rapid and significant growth is between 1 and 3 months of age, and growth is complete by 5 months in most cases
Soft, compressible, and enlarging - unlike a vascular malformation, which grows with the child
Often absent or barely visible at birth, then appearing and growing in the first weeks
Ulceration is the commonest complication needing active treatment, and causes pain and permanent scarring. The commonest lasting consequence, though, is permanent skin change - the AAP guideline puts the risk of scarring and disfigurement above the functional and life-threatening ones, because it affects far more infants
Up to 5% of infants are affected, so most are ordinary; the job is to pick out the minority that are not

Distribution

Anywhere, but the site is what decides urgency. Head and neck carry the highest risk of permanent disfigurement. Periorbital lesions threaten vision. A beard-distribution lesion - chin, jawline, anterior neck - raises the possibility of airway involvement. A large segmental facial lesion raises the possibility of associated intracranial and aortic arch anomalies. Lesions in the nappy area and at skin folds are the ones that ulcerate.

Photographs

Infantile haemangioma on the nose of a one-year-old - a well-circumscribed, red-violet, exophytic vascular tumour, in the source's own words. **Note the site.** A lesion here sits beside the eye and beside the airway, and facial haemangiomas are the ones that scar. The eyes are masked in the original published figure, not by this page. This is light skin, which is a limitation of this page and not of the disease; on brown and black skin the same lesion reads deep purple or almost black-brown rather than strawberry red.
Fitzpatrick II (Fitzpatrick type estimated from the photograph, not stated by the source) · M. Sand, D. Sand, C. Thrandorf, V. Paech, P. Altmeyer, F. G. Bechara · Sand M, Sand D, Thrandorf C, Paech V, Altmeyer P, Bechara FG. Cutaneous lesions of the nose. Head Face Med 2010;6:7 (PMID 20525327), via Wikimedia Commons · CC BY 2.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Benign mechanical petechiae — A new purple mark in a baby raises bruising and safeguarding; a haemangioma is compressible, enlarges over weeks and does not change colour like a bruise
Molluscum contagiosum — Also discrete papules in an infant, but pearly, umbilicated and multiple, and they do not follow a proliferation curve
Skin abscess, boils and folliculitis — An ulcerated haemangioma is frequently treated as an abscess or infected lesion; the history of a preceding vascular lesion is what separates them

What to do in the ED

Establish the age and the growth history, and measure or photograph the lesion. A static lesion and a rapidly growing one need completely different responses, and only the history tells you which this is
Decide whether any high-risk feature is present - and treat this as a prompt list, not a complete one. Periorbital; beard distribution or any airway concern; any facial lesion, including the nasal tip and lip; large segmental facial or lumbosacral; ulcerated; or five or more lesions. The AAP guideline's own high-risk table is broader than any summary, and includes site and size thresholds this page deliberately does not reproduce because the guideline is paywalled and could not be read in full. If the lesion is facial, large, growing fast, or you are hesitating - refer rather than reassure
Refer high-risk lesions urgently, and understand why the urgency is real. Growth is fastest between one and three months and is largely over by five months, so the guideline asks for early intervention or referral ideally by 1 month of age. A referral that arrives at six months has missed the window, and many haemangiomas leave permanent skin change behind
For a stridulous or distressed infant with a beard-distribution lesion, treat as a potential airway emergency and involve ENT and paediatrics immediately - do not refer and discharge
Treat an ulcerated lesion as painful: analgesia, a non-adherent dressing, and urgent specialist contact
Do not start propranolol in the ED. It is the systemic drug of choice at 2 to 3 mg/kg/day, usually continued at least six months and often to twelve months of age, but initiation requires cardiovascular assessment and specialist oversight. Topical timolol is an option for selected small, thin, superficial lesions - again, a specialist decision
For a low-risk lesion, reassure with the natural history and arrange GP or community paediatric follow-up so that growth is actually watched rather than assumed

Disposition

URGENT DERM

Urgent referral - dermatology, paediatrics or the local vascular anomalies service - for any high-risk feature, and the referral should be measured in days, not the next available clinic. A low-risk lesion in a thriving infant can be managed with GP follow-up and a clear explanation of the growth curve. Airway involvement is an emergency and goes to ENT and paediatrics the same day.

Safety-netting

Return immediately for noisy or difficult breathing, feeding difficulty, or any bleeding or ulceration of the lesion. Return sooner than the appointment if the lesion is growing quickly, if it begins to affect the eye or eyelid, or if it breaks down. Expect it to grow for the first few months before it starts to shrink, and expect that growth itself to be normal. Come back anyway if the growth is fast, if the lesion is on the face, eyelid, nose, lip or chin, or if you are simply worried - the first few months are exactly when treatment works best, so bringing a growing lesion back early is the right thing to do even though growth is expected.

Local variation

Which service holds infantile haemangiomas varies - paediatric dermatology in some regions, a dedicated vascular anomalies multidisciplinary team in others, plastics or ENT elsewhere. Find out the local route before you need to use it urgently, because the referral window here is weeks wide, not months.

Sources

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