History and exam

Key diagnostic factors

common

variable onset

Hemangioma 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 hemangiomas appear later, in the first few months of life.

pink, red, or blue color

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

rapid growth

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

variable compressibility

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

flat or nodular character

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

Other diagnostic factors

common

islands of normal skin

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

ulceration and bleeding

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

warmth

Hemangiomas 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

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

associated defects

PHACES syndrome (posterior fossa malformations, hemangioma, cardiac defects and coarctation of the aorta, eye anomalies, sternal defects, and supraumbilical raphe) has been associated with large, plaque-type cervicofacial hemangioma.[1][Figure caption and citation for the preceding image starts]: Tender, ulcerated hemangioma on the left lower lipFrom the collection of Carla T. Lane, MD, PhD; used with permission [Citation ends].com.bmj.content.model.Caption@61e85d4b

beard distribution and stridor

Hemangiomas located on the lower face and neck have been associated with laryngeal hemangioma.

lumbosacral location

Hemangioma 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 hemangiomas should be screened for visceral lesions as part of a constellation called multifocal infantile hemangiomas with extracutaneous involvement.

poor infantile feeding, failure to gain weight

Multifocal infantile hemangiomas with extracutaneous involvement may present with gastrointestinal (e.g., liver) involvement. Oral and lip lesions may cause difficulty feeding.

high-output cardiac failure

Unrecognized, large, proliferative visceral hemangioma 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 hemangioma.[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 hemangioma.[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 hemangioma.[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

Although 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 hemangioma.[17]

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