Practice Guidelines

Infantile Hemangioma: AAP Releases Guideline for Management

 

Am Fam Physician. 2019 Aug 1;100(3):186-187.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Although most infantile hemangiomas are self-limited, some are higher risk requiring immediate referral.

• Infants with hemangiomas need imaging only if there are signs of underlying structural abnormalities or diagnostic uncertainty.

• Oral propranolol is the first-line therapy for infantile hemangiomas.

From the AFP Editors

Infantile hemangiomas are the most common benign tumors of childhood, occurring in up to approximately 5% of infants. These benign vascular tumors are small, self-resolving, and do not require treatment. A minority of hemangiomas have been recently recognized to be at high risk of functional impairment or disfigurement and require prompt evaluation and treatment. The American Academy of Pediatrics (AAP) published this guideline to enhance the ability of primary care physicians to assess and manage infantile hemangiomas using evidence-based recommendations.

Clinical Presentation

Infantile hemangiomas grow rapidly between one and three months of age, and usually complete growing by five months. They are more common in girls, twins, infants born preterm or with low birth weight, and in white infants. Patients at the greatest risk of permanent skin changes are those with larger lesions, lesions elevated greater than 2 mm above the skin, and lesions that abruptly transition to normal skin.

High-risk infantile hemangiomas are characterized by location, size, and number. Hemangiomas near the eye may affect vision, and lesions near the eye, ear, and nose have high risk of disfigurement. There is an increased risk of ulceration for lesions on the lips, face, or neck area and they are at very high risk of scarring. Hemangiomas in the beard area are associated with airway hemangiomas and asphyxiation. Larger hemangiomas are associated with permanent skin changes (e.g., thickening, atrophy, scarring). Larger infantile hemangiomas on the face or in the lumbosacral area may also be associated with underlying structural anomalies. If the infant has five or more cutaneous hemangiomas at any site, it may indicate hepatic hemangioma, which is associated with high output congestive heart failure and severe hyperthyroidism. Table 1 lists characteristics of high-risk infant hemangiomas. Small lesions on the torso are lower risk and do not typically require treatment.

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TABLE 1.

High-Risk Features of Infantile Hemangiomas

FeatureRisk

Location

Axillae

Ulceration

Beard area

Obstructive airway hemangiomas, scarring, structural abnormalities

Breast (female)

Developmental anomaly in breast or nipple

Diaper area (perineal or perianal)

Ulceration

Ear helix

Disfigurement

Eyes

Vision changes, disfigurement

Lips

Ulceration, disfigurement, feeding impairment

Neck

Ulceration

Nose

Disfigurement

Larger hemangioma by location

Any location > 5 cm

Scarring and disfigurement

Face or scalp (> 2 cm)

Scarring and disfigurement, structural abnormalities if > 5 cm

Lumbosacral or perineal (> 5 cm)

Structural abnormalities

Neck, trunk, or extremity (> 2 cm or > 2 mm thick)

Scarring and disfigurement

5 or more hemangiomas

Hepatic hemangiomas, severe congestive heart failure, severe hyperthyroidism

TABLE 1.

High-Risk Features of Infantile Hemangiomas

FeatureRisk

Location

Axillae

Ulceration

Beard area

Obstructive airway hemangiomas, scarring, structural abnormalities

Breast (female)

Developmental anomaly in breast or nipple

Diaper area (perineal or perianal)

Ulceration

Ear helix

Disfigurement

Eyes

Vision changes, disfigurement

Lips

Ulceration, disfigurement, feeding impairment

Neck

Ulceration

Nose

Disfigurement

Larger hemangioma by location

Any location > 5 cm

Scarring and disfigurement

Face or scalp (> 2 cm)

Scarring and disfigurement,

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

 

 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

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