Hemangiomas are the most common soft tissue tumors of infancy, occurring in approximately 5% to 10% of 1-year-old infants. In newborns, hemangiomas may originate as a pale white macule with threadlike telangiectasia. When the tumor proliferates, it assumes its most recognizable form as a bright red, lobulated plaque or nodule (superficial component, Fig. 194-1). Hemangiomas that lie deeper in the skin are soft, warm masses with a slightly bluish discoloration (deeper component). Frequently, hemangiomas have both a superficial and a deep component. They range from a few millimeters to several centimeters in diameter and are usually solitary; 20% involve multiple lesions. Hemangiomas occur predominantly in females (3:1) and have an increased incidence in premature infants. Approximately 55% are present at birth; the rest develop in the first weeks of life. Superficial hemangiomas reach their maximal size by 6 to 8 months, but deep hemangiomas may grow for 12 to 14 months. They then undergo slow, spontaneous resolution, which takes 3 to 10 years.
Figure 194-1 Hemangioma (chest).
Despite the benign nature of most cutaneous hemangiomas, there may be the risk of functional compromise or permanent disfigurement depending on the location and extent. Ulceration, the most frequent complication, can be painful and increases the risk of infection, hemorrhage, and scarring. Areas frequently associated with complications include the periocular region, lip, nasal tip, beard, face (large lesions), groin, and buttocks.
Periorbital hemangiomas pose considerable risk tovision and should be monitored carefully. Amblyopia canresult from the hemangioma causing obstruction of the visual axis or pressure on the globe, resulting in astigmatism. If there is any concern, the patient should have urgentevaluation by an ophthalmologist. Treatment may be indicated to prevent blindness. Subglottic hemangiomas manifest as hoarseness and stridor; progression to respiratoryfailure may be rapid. Symptomatic airway hemangiomasdevelop in more than 50% of infants with extensive facialhemangiomas on the chin and jaw (beard distribution);any infant with a beard hemangioma should be referredfor laryngoscopy. Multiple cutaneous (diffuse hemangiomatosis) and large facial hemangiomas may be associated with visceral hemangiomas. Extensive cervicofacialhemangiomas may be associated with multiple anomalies,including posterior fossa malformations, hemangiomas,arterial anomalies of the cerebrovasculature, coarctation of aorta and cardiac defects, and eye abnormalities (PHACE syndrome). Lumbosacral hemangiomas suggest an occultspinal dysraphism with or without anorectal and urogenital anomalies. Magnetic resonance imaging of the spine is indicated in all patients with midline cutaneous hemangiomas in the lumbosacral area.
Most hemangiomas do not necessitate medical intervention and involute spontaneously; however, if complicationsarise and treatment is warranted, oral propranolol is themainstay of therapy.
A pyogenic granuloma is an acquired, benign vascular tumor commonly seen in children. Initially, the lesions appear as pink-red papules that often arise after minor trauma, growing rapidly over a period of weeks into a bright red, vascular, often pedunculated papule measuring 2 to 10 mm. The lesions often have the appearance of granulation tissue and are very friable. They may occur anywhere on the body, but the head, neck, and upper extremities are most commonly affected. When traumatized, these lesions may bleed profusely, often requiring emergent medical attention. Surgical excision is the most definitive treatment option, though pulsed dye laser can be useful for very small lesions.