Guidelines Summary

Guidelines on the management of infantile hemangioma were released in December 2018 by the American Academy of Pediatrics.^{[77, 78]}

Five indications for early treatment of problematic infantile hemangiomas include the following:

Life-threatening lesions, such as those that obstruct the airway, those that are associated with high-output congestive heart failure, or those that are ulcerative and profusely bleed
Infantile hemangiomas associated with functional impairment, such as a disturbance in vision or feeding interference
Infantile hemangioma ulceration
Infantile hemangioma–associated congenital anomalies such as PHACE (posterior fossa abnormalities, hemangioma, arterial lesions, cardiac abnormalities/aortic coarctation, and eye abnormalities) syndrome
Risk of permanent scarring

Consult with a hemangioma specialist by age 1 month for infants that are high risk.

Infantile hemangioma growth occurs most rapidly from age 1-3 months.

Imaging is not necessary unless the diagnosis is uncertain, there are five or more cutaneous infantile hemangiomas present, or there is suspicion of anatomic abnormalities.

Oral propranolol (2-3 mg/kg/dose) is the recommended first-line treatment for cases requiring systemic therapy.

Counsel about the adverse events of propranolol, such as sleep disturbances, bronchial irritation, and clinically symptomatic bradycardia and hypotension.

Use oral prednisolone or prednisone if there are contraindications or if the propranolol response is inadequate.

Intralesional injection of triamcinolone and/or betamethasone can be recommended to treat focal or bulky infantile hemangiomas in certain critical locations (eg, the lip) or during proliferation.

Topical timolol maleate may be prescribed for thin or superficial infantile hemangiomas.

Surgery and laser therapy may be recommended for certain situations such as ulcerated lesions or lesions that obstruct vital structures.

Caregivers should be educated about infantile hemangioma, the natural history of tumors, and the potential for complications or scarring.

Medication

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Media Gallery

Histopathology of a proliferating infantile hemangioma with plump endothelial cells in the dermis.
This proliferating superficial infantile hemangioma on the trunk required no therapy.
Exquisitely painful ulcerated mixed hemangioma (superficial and deep) of the left deltoid in a 6-month-old female infant. This lesion was treated successfully with pulsed dye laser.
This superficial and deep infantile hemangioma resulted in astigmatism of the left eye, requiring spectacles to correct the refractive error and to prevent amblyopia. Further growth of this hemangioma necessitated a course of oral prednisolone. The hemangioma shrunk rapidly, and the patient's astigmatism decreased such that the spectacles were unnecessary 1 month after beginning steroids.
Segmental infantile hemangioma in a female infant with PHACE syndrome involving the posterior neck and right forehead associated with an absent right vertebral artery and a laryngeal hemangioma.
Segmental infantile hemangioma with minimal or arrested growth of the bilateral buttocks and posterior thigh in this male infant with PELVIS syndrome (complicated by cutaneous ulceration, hypospadias, anal stenosis, intraspinal lipoma with tethered cord). The white material is a barrier diaper cream.
Superficial proliferating infantile hemangioma on the lower extremity

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