Haemangioma

A haemangioma (American spelling ‘hemangioma’) describes a benign (non-cancerous) overgrowth of blood vessels in the skin, and is also simply called ‘angioma’. It is due to proliferating endothelial cells - these are the cells that line blood vessels. Haemangiomas are distinct from vascular malformations, which are less common birthmarks). Haemangiomas can develop in adults too.

Ten percent of babies develop one or more haemangiomas. Over 80% occur on the head and neck area. They can grow for up to 18 months before they start regressing. This regression is known as involution and can take as long as 3-10 years. Nearly all childhood haemangiomas eventually involute and disappear without treatment. However, some haemangiomas can be disfiguring and psychologically distressing so early medical intervention is sometimes necessary.

Types of haemangiomas

There are basically two main types of haemangiomas, capillary and cavernous. Capillary haemangiomas (superficial angiomatous naevi) affect the blood vessels in uppermost layers of the skin whilst cavernous haemangiomas (subcutaneous angiomatous naevi) are more deeply set in the dermis and subcutis. In some cases, both types of haemangiomas may occur together in an individual (mixed angiomatous naevi).

Capillary haemangioma

The capillary haemangioma or superficial angiomatous naevus is most commonly known as a strawberry haemangioma (strawberry birthmark, capillary naevus, haemangioma simplex). It is more common in premature babies and may appear when the baby is a few days or weeks old and rapidly grows over a few months. In most cases a single lesion is present but occasionally multiple lesions may occur (see below: eruptive neonatal haemangiomas). The eventual size varies from a tiny dot to several centimetres in diameter. Occasionally haemangiomas bleed or ulcerate, but this is rarely serious.

As most strawberry birthmarks disappear without any treatment by themselves over 5-7 years, treatment is rarely indicated. If there is a persistent birthmark or scar, it may be possible to improve the appearance when the child is older.

If the birthmark grows over the eye, nose or mouth it could interfere with the development of vision or cause breathing or feeding problems. Specialist advice should then be sought. Possible treatment includes oral steroids or laser therapy. Interferon may be useful but is rarely recommended, as it has been associated with the development of cerebral palsy in a few infants. Imiquimod has been reported to speed resolution in some cases.

Capillary haemangiomas

2 months of age	I year of age	2 years of age

Cavernous haemangioma

This type of birthmark is caused by overgrown blood vessels deep within the skin, resulting in a bluish swollen-up appearance. They may also grow and then get smaller, sometimes in conjunction with a strawberry mark.

The Kasabach-Merritt syndrome is also known as haemangioma-thrombocytopaenia syndrome. It is a rare complication of a rapidly growing vascular lesion, but is no longer thought to arise from cavernous haemangiomas.

Cavernous haemangiomas (mixed type)

Other haemangiomas

The haemangiomas described below are all very rare conditons.

Type	Features
Verrucous haemangioma	Haemangiomas that also show an overgrowth and thickening of skin cells May be a single lesion or group occurring most often on the legs Do not resolve spontaneously and may need to be surgically excised
Eruptive neonatal haemangiomatosis	Multiple capillary haemangiomas present at birth or develop with first few weeks of life If only the skin is involved the disorder is called benign eruptive neonatal haemangiomatosis: these usually resolve spontaneously over time If lesions are also present on internal organs of the body (e.g. GI tract, lungs, brain, eyes) this is called disseminated eruptive neonatal haemangiomatosis: death generally occurs within the first few months of life A newborn with multiple haemangiomas present must be investigated thoroughly for haemangiomas on internal organs
Ulcero-mutilating haemangiomatosis	Rare disorder of multiple haemangiomas that form ulcers that lead to severe tissue damage
Acquired multiple haemangiomatosis	Large numbers of haemangiomas appear in childhood or adulthood on the skin and internal organs, particularly the skeleton, brain and liver Lesions persist indefinitely but are usually free of symptoms or complications

Haemangiomas arising in adults

In older people haemangiomas may develop on any part of the body. Small capillary spots are called Campbell de Morgan lesions (also known as cherry angiomas), and appear most often around the midtrunk. They increase in number from about the age of 40. Their cause is unknown. They can be simply removed by diathermy or laser, but are usually left alone.

Angiomas are common on the face, particularly around the mouth. On the lip they are known as venous lakes, and are bluish in colour. No treatment is generally required.

Spider angiomas (also called spider naevi) characteristically have a central red papule with feeding capillary legs.

Haemangioma in adults

More images of cherry angiomas ...

Investigations

Haemangiomas are usually diagnosed clinically and no investigations are necessary for the majority of lesions. However, when there is uncertainty about the diagnosis or whether underlying tissues are affected, an ultrasound scan is often performed. Characteristically, a haemangioma has a firm lobular structure with vessels separating the lobules.

In more complicated cases it may be necessary to perform Magnetic Resonance Imaging (MRI) or angiography to help plan treatment.