Vascular (blood vessel) birthmarks are common. They come in two forms. A malformation is an excessive number of normal vessels in a single spot. Too many veins, for example, would be called a venous malformation. The behavior of malformations is characteristic. They are always present at birth and their growth is always proportional to the child. Malformations do not get smaller over time.
Much more common are hemangiomas. These are true vascular tumors. They result from an embryologic defect in which a particular zone of skin or subcutaneous tissue “decides” to produce only blood vessels instead of the normal combination of dermis, fat, and muscle. Only 30% of hemangiomas are present at birth but they usually appear within the first month of life. The growth pattern of hemangiomas is explosive at first. This is frequently alarming to parents. The growth phase usually lasts between 3 and 8 months. For the next six to eighteen months hemangiomas are stable in size and color. After that they gradually fade and shrink. This process is called involution. Despite this apparent improvement, hemangiomas usually leave behind characteristic reminders of their existence. The affected skin can have an unusual, wrinkled texture. Pigmentation abnormalities persist.
Hemangiomas can be very disfiguring, especially when located on exposed parts of the body such as the face, arms, or legs. Families feel anxious and embarrassed when their child is noticed as unusual or defective. Children are quite sensitive about their appearance. The stares and comments that are so distressing for parents affect the child as well. Sometimes a hemangioma will outgrow its own blood supply and ulcerate. Such wounds can be quite painful. Rapidly growing hemangiomas of the eyelids or in the vicinity of the eye can affect opening of the eyelid, deform the globe causing astigmatism or even block the child’s visual axis causing loss of effective vision in the eye. In other vital locations, hemangiomas can impair respiration, create abnormal blood clotting or cause heart failure.
Parents attempting to learn about hemangiomas are presented with a wealth of confusing information. Many different treatments have been advocated. These include corticosteroids, interferon therapy, laser, and surgery. Not all hemangiomas require treatment, depending upon location. The same birthmark that would be unacceptable on the face can be, after involution, quite unremarkable on the back. Steroids are frequently advised as a means to slow rapid growth. Unfortunately this therapy does nothing to change the color of the lesion. Laser treatment has received a great deal of attention in the media but is generally over-used in hemangiomas. The light beam penetrates very poorly, does not reduce redness, and does little to change the size or thickness of the hemangioma. Surgical removal in infancy can often be done depending upon the type and location of the hemangioma. Overnight hospitalization is rarely necessary.
Our philosophy at St. Louis University and SSM Cardinal Glennon Children’s Hospital is early removal of hemangiomas in infancy whenever possible, depending upon type and location. There are few, if any, advantages to postponing treatment into later childhood. Scars formed early in life tend to be better. Children have little or no recollection of their condition when surgery is performed before age three. Early treatment avoids the emotional impact of an unsightly birthmark and relieves the family’s anxiety regarding the condition.
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