Haemangiomas

A haemangioma is a collection of small blood vessels that form a lump under the skin. They’re sometimes called ‘strawberry marks’ because the surface of a haemangioma can look like the surface of a strawberry.

We’ll explain all about haemangiomas and what to expect when your child comes to Great Ormond Street Hospital (GOSH).

Eighty percent of haemangiomas don’t develop any problems at all and, in those that do, the problems aren’t always severe.

Haemangiomas can be superficial or deep. Some haemangiomas are a combination of the superficial and deep kinds, with a raised, red area on the surface of the skin, and a bluish swelling that comes from deeper in the skin.

We don’t fully know the cause, but there’s evidence that some cases may arise from placental tissue very early in pregnancy.

About one in ten babies have a haemangioma.

They are more common in:

• girls

• premature babies

• low birth weight babies

• multiple births (twins, triplets and quadruplets).

Haemangiomas aren’t inherited, but families often say a relative had a haemangioma in childhood, because they’re very common.

Superficial haemangiomas

• are usually a raised, bright red area of skin

• feel quite warm because the abnormal blood vessels are close to the surface

• might at first appear as a small area of pale skin on which a red spot develops

Deep haemangiomas

• might look bluish in colour because the abnormal blood vessels are deeper in the skin

• aren’t always noticeable for the first few weeks, only appearing as a lump

Haemangiomas don’t usually develop until a few days or weeks after a baby is born, but often grow rapidly in the first three months. It’s unusual for haemangiomas to grow after six to 10 months of age, when most of them tend to have a ‘rest period’ and start to shrink.

Most haemangiomas appear on the head or neck – mainly on the cheek, lips, or upper eyelids – but they can develop anywhere on the body. Some children have multiple haemangiomas, but this mostly happens in twins or other multiple birth babies.

Haemangiomas can also appear on the organs inside the body, commonly on the liver, but occasionally the airway, heart and brain can be involved. Internal haemangiomas are most common when a child has multiple haemangiomas, so we might give babies who have more than one an ultrasound scan, to help us confirm or rule this out.

We can clearly notice superficial (raised, red) haemangiomas and they’re quite different to other types of birthmark, so we don’t usually need to do special diagnostic tests for these.

We might need to do ultrasound and/or MRI scans on a child who has a haemangioma that is deep, near their eye, or affecting internal organs.

Most of the time, haemangiomas just need looking after carefully.

Haemangiomas can bleed if they’re scratched, so it’s important to keep your child’s nails short and buffed smooth to protect the surface of the lump.

If the haemangioma starts bleeding, apply pressure with a clean piece of cloth or tissue for at least five minutes. If blood soaks through the material, put another one on top and keep up the pressure. Don’t take it off to have a look, as this could start the bleeding again.

If the bleeding continues, even after pressing down on the haemangioma for five minutes, we recommend people go to your nearest NHS Walk-In Centre or Accident and Emergency department. You can usually contact us at GOSH if you need advice.

The surface of the haemangioma is delicate and can get dry, so avoid using bubble bath, rinse any soap or shampoo off carefully and pat the area gently afterwards. A thin layer of Vaseline® put gently over the top of the haemangioma twice a day can stop it drying out.

The nappy area is naturally warm and moist, so put a layer of Vaseline® or other water-resistant cream over the haemangioma at each nappy change. Baby wipes can be irritating, so a better alternative is to use damp cotton wool.

Like the rest of a child’s skin, haemangiomas need protection from the sun, so use a high factor sun cream on all areas of exposed skin, use a hat to protect the child’s face and/or an umbrella over the buggy or pushchair.

Most haemangiomas don’t require any further treatment, but please contact us at the Birthmark Unit if you have any concerns.

Ulcerated haemangiomas (open sores or ulcers)

Most haemangiomas do not require any further treatment, but there are circumstances when treatment might be needed. If you are concerned about any of these, please contact The Birthmark Unit.

Haemangiomas can form a painful open sore or ulcer. It’s important to visit your GP if this happens, because ulcers can become infected and might need treatment with antibiotics.

Haemangiomas around the mouth, in the nappy area or in natural folds of skin, such as the armpit, ear and neck, are most likely to become ulcerated, because the skin rubbing together causes friction.

The nappy can rub haemangiomas in the nappy area – contact with faeces (poo) or urine (wee) makes the ulcer more painful.

In the long term, an ulcerated area is more likely to leave a scar than a non-ulcerated area of haemangioma.

If the child’s haemangioma develops an ulcer, it will need special attention until it heals.

• Wash the area twice a day, preferably in a bath or by pouring water over the area, and leave it to dry naturally

• Once the area is dry, cover the whole haemangioma with a non-sticky dressing (available on prescription from GPs)

• If you need any help applying dressings, contact us at the Birthmark Unit.

Haemangiomas near the eye

Haemangiomas near the eye can have long-term effects on a child’s vision, so a specialist eye doctor (ophthalmologist) needs to check them. The haemangioma can press on the eyeball, causing it to go slightly out of shape, which alters the messages sent to the brain from the eye.

If the haemangioma gets in the way of a child’s field of vision, a condition called ‘lazy eye’ (amblyopia) can develop because the brain will filter out the image from the lazy eye and will instead rely on the image produced on the retina from the ‘good’ eye.

Over time, the lazy eye loses the ability to see accurately. Our eye doctors treat this by forcing the brain to use the lazy eye instead of relying on the ‘good eye’, by covering up the good eye or blurring its vision with eye drops. This usually improves children’s vision.

Haemangiomas blocking vision may need treatment with beta blockers – these work mainly by slowing down the heart, blocking the action of hormones like adrenaline.

Haemangiomas on the lips

Haemangiomas on the lips often become ulcerated and might stop the child from feeding, because ulcers are so painful. Giving a child pain relief before feeding can help. It can also help to put some Vaseline® on the teat of the bottle (or around the nipple if breastfeeding) as this will reduce friction and make feeding less painful.

It’s impossible to put a dressing on an ulcerated lip and a child’s drooling means lip ulcers often take a long time to heal. As with haemangiomas near the eye, treatment with beta blockers may speed up healing.

Haemangiomas obstructing the airway

Haemangiomas on the child’s jaw, chin or neck can sometimes be associated with breathing difficulties. The first sign of this is a rasping sound with each breath (stridor).

Haemangiomas are painful when they’re ulcerated, so a child may need regular pain relief. Pain medicines (such as paracetamol) are enough if the child doesn’t seem to be in too much discomfort.

If the ulcerated area is large and/or around the lip or nappy area, you might need to give your child stronger pain medicines such as morphine before feeding or nappy changing. A GP will advise you on which medication to use. If the child’s haemangioma is ulcerated and covered in a dressing, you’ll need to give them pain relief each time the dressing is changed.

We recommend antibiotics if we suspect the ulcerated haemangioma is infected. These are usually given as a cream or ointment to put directly on the ulcerated area, but widespread infection may need antibiotics in the form of a liquid as well. Occasionally, a child might need intravenous (into a vein) antibiotics and a stay in hospital.

Your child might need to take a beta blocker called propranolol when the haemangioma is near the eye, lips, or nappy area. Treatment may need to continue for 18 months or longer, but results are promising.

Most haemangiomas will have disappeared completely by the age of five to seven years.

Large haemangiomas may continue to get smaller until the child is about eight to 10 years old. Occasionally, the affected area of skin might be a bit lighter in colour than the rest of the child’s skin, and thread veins (tiny red veins) may remain on the skin’s surface. These can be treated with a laser later on in childhood.

Large haemangiomas may distort the surrounding skin and, even when they disappear, leave behind an area of stretched skin that looks puckered or wrinkled or some leftover fatty tissue. This can be improved with plastic surgery. Haemangiomas affecting the ear or nose can leave some distortion, which can usually be improved using plastic surgery.

Vascular birthmark research is an area of medicine that is continually advancing. Studies have already given us improved options for treating haemangiomas and continue to tell us more about how and why they develop.