Infantile Hemangioma — Living with the Red Mass That Appears in the First Month

Lead

In the first one to three weeks of life, a patch of redness appears on skin that had none before. Over the following months it grows into a raised, bright red lesion. This is an infantile hemangioma — sometimes called a strawberry hemangioma — and the trajectory is predictable once you know it. Most parents are startled by how quickly it grows and find themselves asking: "Is this getting dangerous? Does it need treatment?"

Since 2008, the answer to that second question has changed significantly. A drug called propranolol was discovered to produce dramatic shrinkage of hemangiomas, opening treatment options that simply did not exist before.

What Is an Infantile Hemangioma?

An infantile hemangioma is a benign proliferation of vascular endothelial cells, seen in 3–5% of infants [1,4]. It is more common in premature and low-birthweight infants and in girls [4].

The natural history has three phases:

Proliferating phase (approximately 1–5 months): Rapid growth. The surface is glossy red; the texture is soft to the touch.

Plateau phase (approximately 6–12 months): Growth stops.

Involuting phase (from around 12 months onward): Gradual fading and shrinkage. 50% have involuted by age five; 70% by age seven; 90% by age nine [3].

Most infantile hemangiomas, in other words, disappear on their own. The critical variables are where the hemangioma is located and how large it is.

When to Observe and When to Treat

Small lesions on the trunk or extremities with no functional involvement can reasonably be managed with observation and expectant waiting [3,5].

However, early specialist evaluation and consideration of treatment are recommended in the following situations:

• Near the eye (eyelid or periorbital): Risk of visual axis occlusion and deprivation amblyopia affecting visual development
• Nasal tip or lips: Risk of structural deformity if involution is incomplete
• Larynx or airway: Can cause voice hoarseness or respiratory compromise
• Ulcerated lesions: Pain and infection risk
• Large or multiple lesions: May be associated with internal organ involvement, including the liver [3,5]

The Discovery of Propranolol

In 2008, Léauté-Labrèze and colleagues in France made a serendipitous observation: propranolol, a beta-blocker, being given for a congenital cardiac condition, was causing striking regression of infantile hemangiomas in the same patient [1]. Until then, available treatments — intralesional corticosteroids, surgical excision, laser therapy — had meaningful limitations in both efficacy and adverse effect profile.

In the subsequent multicenter randomized controlled trial (Léauté-Labrèze et al. 2015), 60% of infants in the propranolol group achieved complete regression, compared with 4% in the placebo group — an overwhelming difference [2]. Propranolol is now the globally established first-line treatment for hemangiomas with functional impairment or significant cosmetic implications [3].

The optimal treatment window is during the proliferating phase — roughly from five to six weeks to five months of age [4]. Treatment initiated after the growth phase has ended is substantially less effective. For this reason, early evaluation by a specialist is important when any concerning features are present.

What to Know About Propranolol Treatment

The usual dose is 2–3 mg/kg/day, given in divided doses with feeding or meals. Because adverse effects — hypoglycemia, bradycardia, hypotension — are possible, initiation is typically accompanied by cardiac monitoring, either inpatient or in an ambulatory setting [3]. A history or family history of reactive airway disease should be disclosed before starting, as this is a relative contraindication.

Treatment duration is generally six months or longer. Rebound growth after stopping is possible; dosing is reduced gradually in consultation with the treating physician.

Translating Evidence into Everyday Decisions

• Near the eye, nose, lips, or larynx: Seek specialist evaluation (dermatology, pediatrics, or plastic surgery) as soon as possible — the treatment window is narrow
• Small lesions on the trunk or extremities: Confirm the observation plan with a pediatrician; waiting for natural involution is often the appropriate choice
• Fast-growing lesions: Photograph the lesion serially and bring the photos to appointments — the growth trajectory informs the treatment decision
• During propranolol treatment: Administer with feeds; watch for signs of hypoglycemia (lethargy, sweating, poor feeding)

Summary

Most infantile hemangiomas are benign vascular lesions that will eventually involute without intervention. The location and size determine whether observation is sufficient or specialist evaluation is urgent. The discovery of propranolol has transformed the treatment landscape for hemangiomas that require intervention — but the drug works best during the growth phase, which makes early evaluation matter.

References

1. Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. Propranolol for severe hemangiomas of infancy. N Engl J Med. 2008;358(24):2649–2651. doi:10.1056/NEJMc0708819. PMID: 18550886.
2. Léauté-Labrèze C, Hoeger P, Mazereeuw-Hautier J, et al. A randomized, controlled trial of oral propranolol in infantile hemangioma. N Engl J Med. 2015;372(8):735–746. doi:10.1056/NEJMoa1404710. PMID: 25693013.
3. Drolet BA, Frommelt PC, Chamlin SL, et al. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics. 2013;131(1):128–140. doi:10.1542/peds.2012-1691. PMID: 23266923.
4. Tollefson MM, Frieden IJ. Early growth of infantile hemangiomas: what parents' photographs tell us. Pediatrics. 2012;130(2):e314–e320. doi:10.1542/peds.2011-3683. PMID: 22826573.
5. Janmohamed SR, Madern GC, de Laat PC, et al. Educational paper: approaches to the child with a haemangioma. Eur J Pediatr. 2015;174(5):557–566. doi:10.1007/s00431-014-2441-0. PMID: 25316529.