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Hemangioma

Hemangioma is an abnormal buildup of vascular structures on the cutaneous surface or the internal organs. These lesions are elevated, reddish, and hyperplastic and appear within the first month of life in almost a third of all cases. The majority of these lesions spontaneously resolves or involutes with time, although some may require surgical repair especially those that block the airways or obstruct normal vision.


Presentation

Hemangiomas can present spontaneously during birth but usually appear within the first several months of the infant’s life. Hemangioma initiates as a small solitary lesion or multiple red marks notably seen in the face, chest, back, and scalp. Consequently, the small red mark progressively increases in size within the first year of life until it protrudes as a spongy mass on the skin. The lesion eventually enters a lag phase or “rest phase” until it starts to slowly resolve by involution. Majority of the hemangioma resolves by 10 years old but the skin discoloration left behind may be permanent.

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Angiokeratoma
  • Histopathology is crucial for the correct diagnosis: while in angiokeratoma the vascular alterations are limited to the papillary dermis, verrucous hemangioma extends deep into the dermis, reaching the subcutaneous tissue.[ncbi.nlm.nih.gov]

Workup

The diagnosis of hemangioma is done clinically by a thorough history taking and a meticulous physical examination of the affected skin areas. Diagnostic tests are no longer required to verify the diagnosis. Although imaging modalities like magnetic resonance imaging (MRI) can be used to rule out other soft tissue masses that mimic hemangioma lesions.

Treatment

The greater majority of hemangiomas do not require any treatment; thus, physicians often recommend observation or benign neglect of the disease’s symptomatology [8]. Although, parents of child patients often feel that the hemangioma may deem immediate treatment to be necessary for the fear of a permanent disfiguring mark that can cause psychological stigmata to the growing child. Treatment interventions may be necessary for hemangiomas that causes obstruction of vision and breathing.

Patients can be given corticosteroids which can directly be injected to the nodule, given orally, or topically applied on the affected skin [9]. However, the use of corticosteroids has inherent side effects like high blood sugar, poor growth, high blood pressure, and infantile cataracts. Laser surgery is utilized to remove hemangioma and treat non-healing sores on the fleshy lesions [10]. Pain, infection, bleeding, and scarring are relatively common side effects of this type of treatment.

Prognosis

In general, there is a good outlook for patients presenting with superficial hemangioma because they usually resolve without therapeutic interventions. Almost 50% of these skin lesions disappear by 5 years old of age, and almost all lesions resolve by the age of 9 years old. Larger hemangiomas may complicate to skin ulcerations which are harder to treat and are almost always considered aesthetically challenging.

Etiology

The exact etiology of hemangioma is still unknown up to this time, although, theories have postulated that there might be some hereditary links in the causation of the disease process. Researches from Stanford Children’s Surgical laboratory have suggested that localized tissue hypoxia coupled with increased levels of estrogen just before childbirth contributes significantly in the etiology of hemangioma [1].

Another recent etiologic theory has been proposed from Harvard University and Arkansas University that hemangiomagenesis is a direct effect of placental embolization to fetal dermis during the time of gestation [2]. Currently, there are more and more researches conducted to determine the pathogenesis of hemangioma and find a therapeutic breakthrough to stop its menace.

Epidemiology

In the United States, approximately 1 to 2% of hemagiomas appear at birth while 10% of infantile hemangioma occur within 1 year from birth in white infants [3]. The relative incidence of hemangioma among infants with lower birth weights climbs to 22% especially among infants having less than 1.5 kg of birth weight [4]. The risk of developing infantile hemangioma is relatively increased with older maternal age, uncontrolled preeclampsia, and maternal placenta previa [5].

Sex distribution
Age distribution

Pathophysiology

It has been hypothesized that during the third trimester of fetal life, the immature endothelial cells along with the immature pericytes exist, which continue their proliferative capacity for only a limited period of time during the postnatal period [6]. At the same time, the angiogenic peptides like the vascular endothelial growth factor, beta-fibroblast growth factor, and proliferating cell nuclear antigen also propagate these immature cells resulting to a hemangioma. Tissue inhibitors of metalloproteinases (TIMP) with the interferon from the mast cells causesthe cessation of the endothelial cell proliferation. This process also triggers the involution of the enodothelial cells through programmed cell death or senescence [7].

Prevention

Hemangioma occurs spontaneously at birth or within a few months from birth. This lesion is not preventable in any way. Lesions that develop sores, bleed, or ulcerate must be brought in for immediate surgical intervention to prevent untoward complications.

Summary

Hemangiomas are vascular anomalies that appear bright red and rubbery on the skin surface of afflicted individuals. Hemangioma appearing since infancy usually evolves to a less conspicuous lesion when the child reaches the age of 10 years. Hemangioma can technically occur in almost all parts of the body but they are most commonly seen on the face, scalp, back, and chest regions.

Patient Information

Definition

Hemangiomas are vascular anomalies that appears bright red and rubbery on the skin surface of afflicted infants which usually recede with time. 

Cause

The exact etiology remains unknown. Hereditary transmission is currently considered as one of the possible causes. The development of hemangioma is theorized to have been caused by local tissue hypoxia with high levels of estrogen concentration in serum. Placental embolization is one of the leading theories considered for hemangiomagenesis. 

Symptoms

Hemangiomas appear as a solitary or multiple red mark on the skin surface. These lesion may gradually raise and spread fast in time. Majority of these lesions resolve in time. 

Diagnosis

A thorough clinical diagnosis is all that is needed to diagnose hemangioma. No further tests are required to confirm the diagnosis.

Treatment and follow-up

Most hemangioma lesions does not require treatment. Hemangioma that obstructs vision or interferes with breathing may be treated with corticosteroid therapy or surgical laser therapy for its removal.

References

Article

  1. Kleinman ME, Greives MR, Churgin SS, et al. Hypoxia-induced mediators of stem/progenitor cell trafficking are increased in children with hemangioma. Arterioscler. Thromb. Vasc. Biol. 2007 27 (12): 2664–70.
  2. Barnés CM, Huang S, Kaipainen A, et al. Evidence by molecular profiling for a placental origin of infantile hemangioma. Proc. Natl. Acad. Sci. U.S.A. 2005 102 (52): 19097–102.
  3. Jacobs AH. Strawberry hemangiomas; the natural history of the untreated lesion. Calif Med. Jan 1957; 86(1):8-10.
  4. Amir J, Metzker A, Krikler R, Reisner SH. Strawberry hemangioma in preterm infants. Pediatr Dermatol. Sep 1986; 3(4):331-2.
  5. Haggstrom AN, Drolet BA, Baselga E, et al. Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics. J Pediatr. Mar 2007; 150(3):291-4.
  6. Takahashi K, Mulliken JB, Kozakewich HP, Rogers RA, Folkman J, Ezekowitz RA. Cellular markers that distinguish the phases of hemangioma during infancy and childhood. J Clin Invest. Jun 1994; 93(6):2357-64.
  7. Ritter MR, Reinisch J, Friedlander SF, Friedlander M. Myeloid cells in infantile hemangioma. Am J Pathol. Feb 2006; 168(2):621-8.
  8. Margileth AM, Museles M. Cutaneous hemangiomas in children. Diagnosis and conservative management.JAMA. Nov 1 1965; 194(5):523-6.
  9. Frieden IJ, Eichenfield LF, Esterly NB, Geronemus R, Mallory SB. Guidelines of care for hemangiomas of infancy. American Academy of Dermatology Guidelines/Outcomes Committee. J Am Acad Dermatol. Oct 1997; 37(4):631-7.
  10. Garden JM, Bakus AD, Paller AS. Treatment of cutaneous hemangiomas by the flashlamp-pumped pulsed dye laser: prospective analysis. J Pediatr. Apr 1992; 120(4 Pt 1):555-60.

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Last updated: 2017-08-09 17:50