History and exam

Key diagnostic factors

common

presence of risk factors

White ethnicity, female sex, prematurity, low birth weight, multiple gestation, and advanced maternal age are strong risk factors for development of haemangioma.

variable onset

Haemangioma promontory marks/signs may be present at birth, but they more typically present during the first few weeks of life.[2][16] These initial clinical signs may be subtle pink patches or telangiectasias. They are also sometimes thought to be bruises or secondary to birth trauma. Deep haemangiomas appear later, in the first few months of life.

pink, red, or blue colour

The red or blue colour is a sign that a vascular lesion is present.[2][16]

rapid growth

Infantile haemangiomas grow or proliferate rapidly during the first months of life.[2][16]

variable compressibility

An infantile haemangioma is soft and not fixed. Superficial haemangiomas develop a tight and tense surface with time, whereas deep haemangiomas feel tense and may swell with crying or dependency. With involution, the haemangioma is palpably softer.

flat or nodular character

Present as flat macules or patches; alternatively, the haemangioma may present as a papule or nodule.

Other diagnostic factors

common

islands of normal skin

With involution, colour changes to blue and pink with islands of normal-coloured skin.[2][6][23]

ulceration and bleeding

Ulceration and bleeding, particularly in areas subject to increased friction and trauma.

warmth

Haemangiomas may develop into raised, warm, firm-textured lesions.

uncommon

history of low birth weight

Studies suggest that low birth weight is a significant risk factor.[14]

variable pain

Haemangiomas are not typically painful, with the exception of ulcerated infantile haemangioma. Ulceration results in significant pain and discomfort.[2][16]

associated defects

PHACES syndrome (posterior fossa malformations, haemangioma, cardiac defects and coarctation of the aorta, eye anomalies, sternal defects, and supra-umbilical raphe) has been associated with large, plaque-type cervicofacial haemangioma.[1][Figure caption and citation for the preceding image starts]: Tender, ulcerated haemangioma on the left lower lipFrom the collection of Carla T. Lane, MD, PhD; used with permission [Citation ends].com.bmj.content.model.Caption@4e229b0e

beard distribution and stridor

Haemangiomas located on the lower face and neck have been associated with laryngeal haemangioma.

lumbosacral location

Haemangioma located in the lumbosacral area may signal underlying spinal dysraphism. Other associated malformations include tethered cord, and renal and skeletal anomalies (LUMBAR syndrome).

multiple lesions

Infants who present with multiple haemangiomas should be screened for visceral lesions as part of a constellation called multifocal infantile haemangiomas with extracutaneous involvement.

poor infantile feeding, failure to gain weight

Multifocal infantile haemangiomas with extracutaneous involvement may present with gastrointestinal involvement. Oral and lip lesions may cause difficulty feeding.

high-output cardiac failure

Unrecognised, large, proliferative visceral haemangioma may lead to high-output cardiac failure.

Risk factors

strong

low birth weight

In a large multivariate analysis, low birth weight was shown to be the most significantly associated risk factor for infantile haemangioma.[14][17]

birth prematurity

Low birth weight seems to be more significant than prematurity.[14][17]

white ethnicity

Ethnicity is cited in several large studies as a risk factor for haemangioma.[14][17][19]

female sex

Female to male ratios of 2:1 to 5:1 may support arguments that parents of female infants are more likely to seek care and cosmetic intervention for haemangioma.[2][14][16][17][19]

maternal multiple gestation

May be explained by confounding factors of increased risk of prematurity and low birth weight.[14][17][19]

advanced maternal age

May be explained by confounding factors of increased risk of prematurity and low birth weight.[14][17][19]

weak

chorionic villus sampling

Though traditional thinking has held that chorionic villus sampling is contributory, more recent research has undermined the significance of chorionic villus sampling during pregnancy as an associated risk factor for haemangioma.[17]

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