Frequently Asked Questions
Hemangiomas are a unique biologic tumor: they typically present during the first several weeks of life and then grow for up to one year. Each hemangioma is truly unique and needs to be evaluated for treatment based upon the size, location, and age of patient. Current therapies include medical (i.e., steroids, propranolol), laser (pulsed-dye laser), and surgical excision.
The current recommendation is for all patients with a vascular birthmark to be referred to a specialist at the 4 week well-baby check up or when it first appears. At this time, hemangiomas are in the initial growth phase and most develop slowly or remain small and can be safely watched. I typically follow patients monthly for the first 4-6 months as this is the period when most of the growth occurs. During these monthly evaluations, if the hemangioma remains stable or unchanged, then it is reasonable to continue to follow these for any signs of progression. With close follow up, we are then in a position to recognize any changes in size and/or thickness and begin treatment when necessary.
As a specialist, I see my role as providing information and empowering the parents to make the best decision for their child. Having had a daughter with a hemangioma, I can understand the concerns that most parents have when making the decision to begin treatment. When deciding on treatment options with patients and families, I try to keep things simple and clear, so that the benefits of treatment and any associated risks can be easily discussed.
False! This is perhaps the biggest misconception and predates current practice. All hemangiomas grow for 9-10 months, and then over several years go through a process of involution whereby the hemangioma shrinks in size and fades in color. However, the hemangioma does not “disappear” but rather is replaced by fibrofatty tissue. If the hemangioma was small to begin with, then it may fade to something clinically insignificant; however for larger birthmarks, the hemangioma often results in a residual soft tissue deformity, especially when involving the head and neck.
Unfortunately, it is impossible to predict which hemangiomas will remain small (the majority) and which ones will progress to large, deforming tumors (minority). The best practice is to constantly reevaluate these on a monthly basis starting at initial presentation through the first year of life, so that we don’t miss the opportunity to intervene early when necessary. However while most hemangiomas do not require treatment, the majority of those occurring on the head and neck, or those on the body that become raised or bulky, do require some form of therapy.
Propranolol is a well known cardiac medication that in one study from France, was shown to reduce the progression and in some cases reverse the growth of hemangiomas. It was initially noted to work best on patients with segmental hemangiomas (i.e., involving large areas of the face or body), but has also been shown to be intermittently successful for large focal (tumor-like) hemangiomas as well. We have seen that it does not work for all hemangiomas, and so depending on the size of the hemangioma, one has to balance the risks, benefits and need for cardiac monitoring before starting this medication.
I have found that treatment success is highly correlated to proper indications; the caveat being that what works for some patients may not work for others, and thus each patient must be evaluated individually to determine what treatment (and when) is appropriate.
The feel of a laser is similar to a rubber band snapping against the skin; if there are only a few spots to treat, then no anesthesia is appropriate. However if the surface area to be treated is large, then I recommend an inhalational (general) anesthetic for the patient’s comfort.
You can see photos on this Web site in the the Before & After section.
In order to best evaluate your child, yourself, or your patient, photographs of any visible birthmarks are necessary. The photographs are best taken on a digital camera and then emailed to us.
1. The photographs should be taken in a room with good lighting and in front of a neutral clean background. Please don’t take the photographs in an area where there are a lot of objects in the background. All photographs should be taken with the camera held vertically.
2. Please use a macro mode setting (when possible) to help with clarity and color. The setting may appear on your camera as a flower icon. Clothes and jewelry should be removed so that the visible lesions are clearly seen.
3. When photographing the face, please take both a smiling and non-smiling photograph (a “passport-style” photo of just the face and neck is ideal). Take photographs from the front, back, and sides, if appropriate, to better show the area involved.
4. If the lesions are on the arms and/or legs, please include photographs of both the affected and unaffected limbs so that we can compare them. Take photographs from a distance to include both limbs, then focus in closer on the individual lesions themselves.
5. If you know that the lesion fills up and becomes larger in certain dependent positions (for example, when the head is down or the arm/leg is down) please take photographs with the area both upright and down so that we can appreciate the difference.
6. If there are lesions inside the mouth, please take photographs with the mouth open in good lighting. You may need to have someone hold a flashlight aimed into the mouth in order to get a good photograph.
7. IMPORTANT: Once the photographs are taken and loaded into your computer, please look at the photographs on a full screen to be sure they aren’t blurry when enlarged. If they are, you should retake the photographs on a different camera setting.
8. When emailing multiple photographs, please zip only 2-3 photographs to each submission in order to be sure that they will reach our account. Use our form here.
Early surgical excision is indicated for any hemangioma that threatens the eye (vision), airway (breathing), or around the nose or mouth (breathing or feeding). These are considered true emergencies and should be evaluated by a vascular anomaly specialist as soon as possible. Other indications for surgery include hemangiomas with recurrent ulcerations, bleeding or scarring; for those hemangiomas causing significant soft tissue deformity; or for large, bulky lesions that do not show signs of involution or which would ultimately require surgical therapy due to residual fibrofatty tissue.
Surgery is typically deferred until after the proliferative phase is completed, as there is a small risk of regrowth if the hemangioma is removed too soon. For most patients, surgery can be safely performed electively under general anesthetic after 3-6 months of age.
The main risks of surgery are bleeding and infection, however when performed in the controlled environment of an operating room by a specialist for vascular anomalies, these risks are extremely small. Furthermore, the risk of general anesthesia is also very low given the use of new and safer anesthetics over the last two decades. With the development of specialty care, I now work with a team of trained specialists including pediatric anesthesiologists, cardiologists, intensivists, and dedicated nursing for every case that minimize these general risks of surgery.
When determining whether to treat with surgery, it is important to first realized that if left untreated, hemangiomas (particularly for those involving the head and neck) often result in atrophic changes to the skin due to loss of collagen, causing the involved skin to look prematurely aged or wrinkled. If an ulceration has occurred, this will often heal with a broad scar that is irregular in appearance. Further hemangiomas do not “go away” or “disappear” but are replaced by fibrofatty tissue often resulting in a soft tissue deformity in its place.
Surgery can relieve all of the above mentioned deformities and replaces the hemangioma with a surgical incision that should heal as a linear, white, thin line. When placed in a desirable location, may scars heal so well as to be minimally noticeable except with close inspection. In my experience, I often notice that many scars become “blemishes” over time, particularly for patients who are treated early in infancy and childhood, as younger patients seem to heal with less scarring than older or adult patients.
Early surgical excision or debulking is indicated for any hemangioma that threatens the eye, airway, or around the nose or mouth (i.e. affecting vision, feeding or breathing). Other indications include hemangiomas with recurrent ulcerations, bleeding or scarring; for those hemangiomas causing significant soft tissue deformity; or for large bulky lesions that do not show signs of involution or which would ultimately require surgical therapy due to residual fibrofatty tissue.
This is dependent on the size and location of the hemangioma. Essentially, I try to minimize the appearance of any surgical scars and determine the best timing to perform this so as to minimize the need for future interventions.
Surprisingly, most children bounce back quite quickly, and parents are often surprised that they are back to their usual level of activity within a day or so. Sutures may be dissolvable, or may need to be removed in 7-10 days after surgery.
Incisional pain is typically mild and treated easily with oral pain medications. This usually peaks in the first two days and then is not usually noticeable to most patients after a few days.
If left untreated hemangiomas will often result in atrophic changes to the skin due to loss of collagen, causing the involved skin to look prematurely aged or wrinkled. If an ulceration has occurred, this will often heal with a broad scar that is irregular in appearance. Further, as mentioned earlier, hemangiomas do not disappear but are replaced by fibrofatty tissue often leaving a soft tissue deformity in its place.
Surgery relieves all of the above mentioned deformities and replaces it with a surgical incision that should heal as a linear, white, pencil-thin line. When placed in a desirable location, many scars heal so well as to be minimally noticeable except with close inspection. I often notice that many scars become “blemishes” over time, particularly for patients who are treated early in infancy and childhood.
The ideal time to treat a hemangioma is when it is still flat; as it becomes raised, it becomes less sensitive to laser treatment. Thus there is often a window of opportunity during the first several months of life when laser therapy is most effective; laser therapy is also effective during the involutional stage (i.e., after the growth phase is completed) for treatment of residual stain or dilated vessels.
For hemangiomas that remain relatively flat, the pulsed-dye laser is an excellent treatment option that can often control growth during the initial growth phase, and when used sequentially, can ultimately result in complete fading of the involved stain. For hemangiomas that are quite raised, laser is not usually effective as surgery is often necessary to first remove the deeper component; laser can be used postoperatively for any residual stained skin. Treatment therapy is best started early while the hemangiomas is flat, and if it involves a large area, it is recommended to consider general anesthesia for patient comfort. Laser therapy is also helpful to treat hemangiomas that have ulcerated and has beens shown to speed up the healing process. In addition, there are several strategies for wound care to help minimize the risk of bleeding and infection. Learn more about how to care for ulcerated hemangiomas here.
This is quite variable; for some 1 to 3 treatments, for others 4 to 6 treatments. Rather than state at the outset how many treatments are necessary, I prefer to constantly reevaluate the effects of treatment to determine if further treatment is necessary.
Laser treatment only lasts several seconds to couple of minutes depending upon the area to be treated.
If performed under anesthesia, then the patient does not experience the pain at the time of laser treatment. While the laser causes the skin to darken and appear “bruised,” this is not the case. The darkened color is due to clotting of the fine vessels; while it can appear slightly swollen, it is not painful and patients typically do not require pain medications afterwards.
If the child appears uncomfortable, then a dose of Tylenol should be sufficient to relieve any discomfort. Parents should contact their physician for any signs of severe pain or distress.
There is a small chance of ulceration from pulsed dye laser treatment, however this is extremely rare and typically seen in younger infants. Parents need to realize however that many hemangiomas develop ulcerations during the growth phase, and it is my belief that post-laser ulcerations after an initial laser treatment in young infants may simply have unmasked a hemangioma that was prone to ulceration. Furthermore, one of the treatment indications for ulcerated hemangiomas is pulsed dye laser, which has shown to significantly increase the healing rate.
Propranolol is a well known cardiac medication that in one study from France, was shown to reduce the progression and in some cases reverse the growth of hemangiomas. It was initially noted to work best on patients with segmental hemangiomas (ie involving large surface areas), but has also been shown to be intermittently successful for large focal (ie tumorlike) hemangiomas as well. There are several clinical trials currently ongoing to determine which hemangiomas are more likely to respond, what the major side effects are, and how best to manage these patients. Thus one needs to balance the risks, benefits, and need for cardiac monitoring before starting this medication.
Consulting with Dr. Levitin
The current recommendation is for all patients with a vascular birthmark to be referred to a specialist at the 4-week well-baby check up or when it first appears. At this time, hemangiomas are in the initial growth phase and mostly developed slowly and remain small and can be safely watched. I typically follow patients monthly for the first 46 months as this is the period when most of the growth occurs. During these monthly evaluations, if the hemangioma remains stable (i.e., flat) or unchanged, then it is reasonable to continue to follow these for any signs of progression. With close follow up, we are then in a position to recognize any changes in size and/or thickness and begin treatment when necessary.
Dr. Levitin’s diverse training and extensive experience has made him one of the most sought-after physicians in his field. An initial consultation with Dr. Levitin includes a full history of the patient’s disease course, a thorough evaluation of the patient, and a review of available radiologic studies and reports. Dr. Levitin then combines this information to provide an accurate diagnosis and review of treatment options. He listens closely to the experiences and concerns of the patient and his or her family, and makes himself available to answer any questions before, during, and after their visit.