Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Birthmarks and infantile haemangioma
Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Airway, cardiac or visual compromise
Stridor, increasing work of breathing, poor feeding, hepatomegaly, cardiovascular compromise or a rapidly enlarging periocular lesion can reflect a function-threatening haemangioma during its proliferative window.
Action: Use paediatric ABCDE for respiratory or cardiac instability and obtain urgent ENT, paediatric, dermatology or vascular-anomalies support. Assess vision immediately for periocular disease, image the airway or liver when indicated and begin specialist treatment without waiting for natural involution.
Overview
Differentiate vascular tumours from capillary, venous, melanocytic and dermal birthmarks, recognise haemangiomas that threaten vision, airway, feeding, skin or heart and use timely specialist propranolol with safe feeding and monitoring precautions.
Birthmark is a descriptive term, not a diagnosis. Establish timing: congenital melanocytic naevus, capillary malformation and dermal melanocytosis are present at birth, while infantile haemangioma often begins as pallor, telangiectasia or a faint mark and then grows. Ask about rate, ulceration, bleeding, pain, breathing, feeding, vision, hearing and development. Examine surface and deeper component, count lesions and look for segmental rather than focal distribution.
Infantile haemangioma is a benign vascular tumour with proliferative, plateau and involution phases. Growth is fastest in the first months, so a routine referral that waits several months can miss the useful treatment window. A superficial lesion is bright red and raised; a deep lesion is blue or skin-coloured and compressible; mixed lesions have both. Involution does not guarantee normal skin—telangiectasia, fibrofatty tissue, distortion and scar can remain.
Practice
Two practice questions
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Question 1 of 2
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Paediatrics and child healthOriginal SBA
Periocular haemangioma priority
A 7-week-old has a rapidly enlarging upper-eyelid infantile haemangioma that is beginning to narrow the visual axis. What is the most appropriate next step?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Urgency follows function and pattern, not simply diameter. A periocular lesion can induce astigmatism, visual-axis occlusion or amblyopia. A beard-distribution lesion raises airway haemangioma risk, especially with stridor or feeding difficulty. Nasal tip, lip and ear lesions distort cartilage and leave visible residue. Ulcerated lesions cause major pain. Large segmental face or scalp lesions can be part of PHACE; broad lumbosacral or perineal lesions can associate with spinal and pelvic anomalies.
Count all cutaneous haemangiomas. Five or more prompts liver ultrasound under specialist guidance because diffuse or multifocal hepatic lesions may create arteriovenous shunting, cardiac failure and consumptive hypothyroidism. Look for tachypnoea, sweating with feeds, hepatomegaly and poor growth. A single large hepatic lesion or other clinical features can also justify imaging; the threshold is a trigger, not a rule that four lesions are always risk free.
Propranolol has transformed treatment. For the licensed infantile-haemangioma oral solution, begin in the eligible age window and titrate weekly from 1 to 2 to 3 mg/kg/day, divided into two doses at least 9 hours apart; adjust dose for weight during growth. Give during or just after feeds. The initiating service checks heart rate and blood pressure around dose escalation and screens for bradycardia, hypotension, heart block, heart failure and bronchospasm risk.
Hypoglycaemia is the most important family safety issue. Beta blockade impairs glycogenolysis and can mask tremor and tachycardia. Do not give propranolol to an infant who is fasting, taking substantially less feed or vomiting repeatedly; contact the team for restart advice. Wheeze or lower-respiratory illness can worsen with a non-selective beta blocker and also needs dose advice. Overdose, lethargy, coldness, seizure or collapse requires emergency assessment.
Ulcer management includes non-adherent dressings, barrier protection from urine and stool, age-appropriate analgesia, infection assessment and rapid treatment of tumour proliferation. Propranolol often accelerates healing. Topical timolol may be considered off label by specialists for selected small thin superficial lesions, but systemic absorption still occurs and it is unsuitable as a casual alternative for deep, ulcerated, periocular or airway-risk disease.
Capillary malformations are flat pink-red or purple lesions present from birth. A central facial port-wine stain involving forehead or upper eyelid can associate with Sturge-Weber syndrome and glaucoma, warranting early specialist eye and neurological assessment. Salmon patches on glabella, eyelids or nape commonly fade and need reassurance. Venous and lymphatic malformations are soft, compressible or vesicular and enlarge with growth, infection or dependency; painful thrombosis or airway involvement needs a vascular-anomalies service.
Congenital melanocytic naevi are brown or black and vary in size and hair. Larger lesions and multiple satellites carry greater melanoma and neurocutaneous melanosis risk, so refer for dermatology or plastic-surgery surveillance and discuss sun protection and change recognition. Dermal melanocytosis produces blue-grey patches, commonly over sacrum, and usually fades. Record site, shape and colour at newborn examination because later clinicians may otherwise mistake it for bruising.
Explain the diagnosis and likely natural history rather than saying every mark will disappear. Parents may face intrusive comments, guilt or anxiety and should be offered reliable support. Serial photographs need consistent scale, lighting and consent. Follow treated haemangioma for growth rebound, function and residual skin; refer residual distortion when involution is complete enough for a reconstructive decision.
Key points
Describe whether a mark was fully present at birth or appeared during the first weeks, and record colour, depth, border, distribution, blanching, warmth, pulsation, size, texture, ulceration and growth with consented serial photographs.
Infantile haemangioma is usually absent or subtle at birth, proliferates rapidly during early infancy and then involutes over years; a capillary malformation is present at birth and grows proportionally without proliferative-involutive phases.
Refer infantile haemangioma urgently when periocular, airway or beard-distribution, nasal-tip, lip, ear, large facial segmental, lumbosacral segmental, ulcerated, rapidly growing or function-threatening.
Five or more cutaneous infantile haemangiomas warrants assessment for hepatic haemangiomas because high internal burden can cause high-output heart failure or thyroid-hormone consumption.
Large segmental facial haemangioma raises PHACE association and needs coordinated neurovascular, cardiac and eye evaluation before treatment; lower-body segmental lesions can signal spinal, urogenital or anorectal anomalies.
Ulceration is painful and can bleed, infect and scar; provide wound care and analgesia and expedite haemangioma treatment rather than treating it as routine nappy rash.
Oral propranolol is first-choice systemic treatment for problematic proliferating infantile haemangioma. The licensed solution is titrated over three weeks to 3 mg/kg/day in two doses at least 9 hours apart with feeds.
Aetiology
01
Infantile vascular tumour
Clonal endothelial proliferation after birth creates a GLUT1-positive haemangioma that later undergoes programmed involution and fatty replacement.
02
Developmental vascular malformation
Capillary, venous, lymphatic and arteriovenous anomalies arise from vessel-development errors and persist while growing proportionally with the child.
03
Melanocyte developmental pattern
Congenital naevi reflect melanocytic proliferation, while dermal melanocytosis results from melanocytes remaining within deeper dermis during migration.
04
Syndromic segmental development
Broad regional vascular patterns can share embryological disruption with brain, arterial, cardiac, eye, spinal, urinary or anorectal anomalies.
Pathophysiology
1
Early proliferative angiogenesis
Rapid endothelial growth and increased blood flow expand infantile haemangioma most quickly while vision, airway and feeding structures are developing.
2
Spontaneous involution
Endothelial apoptosis and replacement by fibrofatty tissue gradually flatten the tumour but can leave stretched or scarred skin.
3
Flow-related organ burden
Large hepatic or high-flow vascular lesions shunt circulation, increasing cardiac output demand and potentially causing heart failure.
4
Beta-blocker tumour response
Propranolol produces vasoconstriction and alters pro-angiogenic signalling, softening colour quickly and reducing subsequent proliferation over months.
Clinical features and red flags
Superficial infantile haemangioma
A bright red raised lesion appears in early weeks and enlarges rapidly during the first months.
Deep haemangioma
A soft blue or skin-coloured subcutaneous mass grows after birth and may obscure its true extent.
Segmental high-risk pattern
A broad plaque follows a developmental territory on face, scalp, lumbosacral or perineal skin rather than a focal nodule.
Ulcerated haemangioma
Pain, crust, open surface or bleeding develops commonly at lips, neck folds or nappy area and needs expedited treatment.
Capillary malformation
A flat pink, red or purple patch is fully present at birth and darkens or thickens with age.
Stridor or breathing difficulty with beard-distribution or oral haemangioma suggests possible airway involvement.
Periocular growth, eyelid closure, proptosis or gaze asymmetry threatens amblyopia and requires urgent eye assessment.
Five or more cutaneous haemangiomas, hepatomegaly, tachypnoea or poor feeding raises hepatic and cardiac risk.
Investigations
01First-line clinical classification and photographyFirst stepFirst line
Why
Determine tumour versus malformation from timing, growth, morphology, distribution and function and create a reproducible baseline.
Interpretation and limitations
A typical focal infantile haemangioma needs no biopsy; atypical timing or mass features prompt imaging or specialist diagnosis.
02Vision and ophthalmology assessment
Why
Measure visual axis, refraction, ocular alignment and pressure when periocular or upper-face lesions create risk.
Interpretation and limitations
Astigmatism or occlusion requires rapid treatment even when the lesion appears cosmetically small.
03Liver ultrasound
Why
Look for hepatic haemangiomas when five or more skin lesions or clinical heart-failure signs are present.
Interpretation and limitations
Number, distribution and flow guide cardiac and thyroid evaluation; a negative scan avoids unnecessary systemic surveillance.
04PHACE-directed MRI and cardiac assessment
Why
Assess brain, cervicocephalic arteries, aortic arch, heart and eyes in a large segmental facial or scalp pattern.
Interpretation and limitations
Arterial anomalies influence propranolol initiation and blood-pressure targets and require multidisciplinary interpretation.
Differential diagnosis
01
Capillary malformation
A flat lesion present fully at birth persists and enlarges proportionally rather than appearing later and undergoing tumour growth.
02
Congenital haemangioma
A vascular tumour is fully developed at birth and may rapidly involute or remain, following a different natural history.
03
Venous or lymphatic malformation
Soft compressible blue swelling or grouped translucent vesicles expand with dependency, infection or trauma and do not involute.
04
Dermal melanocytosis or bruising
Blue-grey pigment remains stable and non-tender, whereas bruises evolve in colour and require mechanism and safeguarding context.
05
Malignant or infiltrative tumour
A firm rapidly enlarging mass, ulceration without typical haemangioma pattern or systemic signs warrants urgent imaging and oncology-aware assessment.
Management
01Low-risk birthmarkClassify and explain natural historyFirst stepA stable lesion has no ulceration, functional threat, segmental syndrome pattern or diagnostic uncertainty.+
1Document presence at birth, growth, morphology, distribution and measurements with consented scaled photography.
2Explain expected persistence, fading or involution for the exact diagnosis and provide change and bleeding return advice.
3Review at a time matched to growth phase and refer if function, ulceration or atypical change emerges.
02High-risk haemangiomaRefer during the growth windowLocation, number, segmental pattern, ulceration or rapid growth threatens organ function or permanent distortion.+
1Arrange urgent dermatology or vascular-anomalies care and same-day acute assessment for airway, cardiac or visual compromise.
2Perform site-specific eye, ENT, liver, cardiac, brain or spinal investigations rather than broad routine scanning.
Complications
01
Amblyopia and visual loss
Periocular tumour can obscure the visual axis or distort corneal shape during a time-critical period of visual development.
02
Airway or feeding obstruction
Subglottic, oral, lip or deep neck haemangioma can cause stridor, respiratory compromise, poor latch and inadequate intake.
03
Ulceration, pain and scarring
Surface breakdown exposes nerves and vessels, causing severe pain, bleeding, secondary infection and permanent tissue distortion.
04
High-output cardiac failure
Extensive hepatic vascular shunting increases venous return and cardiac workload, producing tachypnoea, hepatomegaly and poor feeding.
05
Propranolol adverse events
Fasting-related hypoglycaemia, bradycardia, hypotension and bronchospasm can occur without correct patient selection, feeding and illness precautions.
Monitoring and follow-up
Measure and photograph lesion size, depth, colour, ulceration and effect on vision, breathing, feeding and anatomy at interval matched to growth rate.
During propranolol titration record heart rate and blood pressure as the initiating protocol requires and ask about coldness, lethargy or wheeze.
Recalculate dose against current weight while avoiding unsupervised family increases or catch-up doses after omission.
At every propranolol review repeat feeding and illness rules and confirm nursery and other caregivers know when to withhold it.
Monitor ulcer pain, wound healing, infection and feeding or sleep impact rather than documenting surface size alone.
For hepatic lesions, follow cardiac function, growth and thyroid tests under the vascular-anomalies plan.
After involution assess residual fibrofatty tissue, telangiectasia, scar and psychosocial impact for later reconstructive options.
Special situations
Timing separates lesions
Fully present at birth favours a malformation or congenital tumour; postnatal rapid growth favours infantile haemangioma.
Treatment has an early window
Months of routine waiting can allow irreversible amblyopia, cartilage distortion or ulceration during fastest proliferation.
Five spots trigger a liver question
Multiple skin lesions correlate with hepatic burden, but symptoms or a large lesion can justify imaging below that number.
Feed timing is pharmacological safety
A propranolol dose without reliable carbohydrate intake increases hypoglycaemia risk and should be omitted during illness.
Blue-grey is worth documenting
Recording dermal melanocytosis at birth prevents later misunderstanding as an unexplained bruise during safeguarding assessment.
Common pitfalls
01
Calling every red birthmark a haemangioma without asking when it appeared.
02
Waiting for spontaneous involution of a periocular or airway-risk lesion.
03
Using lesion diameter alone and missing a high-risk segmental distribution.
04
Failing to count all cutaneous haemangiomas and assess hepatic symptoms.
05
Giving propranolol during fasting, poor feeding or repeated vomiting.
06
Treating painful ulceration as simple infection without controlling tumour growth.
07
Using topical timolol casually on a large, deep or ulcerated lesion.
08
Failing to record congenital dermal melanocytosis clearly in the newborn record.
Give propranolol during or immediately after a feed and omit it when the infant is fasting, feeding poorly or repeatedly vomiting; hypoglycaemia can occur without a normal adrenergic warning.
Baseline history and examination assess heart rate, blood pressure, cardiac or respiratory disease and PHACE risk; ECG or cardiology tests are targeted rather than automatic in every otherwise well infant.
Most salmon patches and dermal melanocytosis need reassurance, but document congenital dermal melanocytosis accurately to prevent later confusion with bruising and refer changing melanocytic lesions or neurological patterns appropriately.
A large segmental facial lesion requires PHACE assessment before treatment and vascular imaging decisions.
A broad lumbosacral or perineal lesion can signal spinal, urinary, genital or anorectal anomalies.
Ulceration at lip or nappy area causes severe pain and can compromise feeding or become infected.
Lethargy, seizure, wheeze, bradycardia or poor perfusion during propranolol treatment needs urgent medicine and glucose assessment.
05
Spinal and pelvic imaging
Why
Investigate broad segmental lumbosacral or perineal lesions for spinal dysraphism and urogenital or anorectal anomalies.
Interpretation and limitations
Imaging modality and timing depend on age and lesion pattern; normal surface examination does not exclude deeper association.
06Propranolol baseline assessment
Why
Review feeding, glucose risk, respiratory history, heart rate, blood pressure and cardiovascular examination before systemic therapy.
Interpretation and limitations
ECG, glucose or cardiology testing is targeted to abnormal history or examination rather than universal in every healthy infant.
3Begin propranolol or other specialist treatment early enough to alter proliferation and provide wound and pain care for ulceration.
03Propranolol initiationTitrate with feeding and physiological safetyA problematic infantile haemangioma meets specialist systemic-treatment criteria.+
1Check age eligibility, weight, feeding, respiratory and cardiac history, pulse and blood pressure and PHACE considerations.
2Titrate licensed oral solution from 1 to 2 to 3 mg/kg/day across three weeks in two fed doses at least 9 hours apart.
3Recalculate for weight, withhold during poor intake or vomiting and teach hypoglycaemia, wheeze and overdose emergency signs.
04Ulcer pathwayControl pain and accelerate healingThe haemangioma surface breaks down, crusts, bleeds or becomes painful.+
1Use non-adherent wound care, barrier protection, analgesia and bacterial assessment without repeatedly traumatising the surface.
2Expedite propranolol or specialist lesion treatment and address feeding, nappy contamination and sleep disruption.
3Review healing and infection frequently and plan later scar or distortion management after proliferation and involution.
Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
Reduces colour and proliferation and promotes regression of haemangiomas that threaten function, ulcerate or risk permanent disfigurement.
Propranolol oral solution for infantile haemangioma
Use the licensed specialist regimen: week 1 at 1 mg/kg/day, week 2 at 2 mg/kg/day and from week 3 at 3 mg/kg/day, divided into two doses at least 9 hours apart during or immediately after feeds.
Recalculate with weight, omit during fasting, poor intake or vomiting, and seek advice for wheeze; monitor bradycardia, hypotension and masked hypoglycaemia.
Provides local beta-blockade for carefully selected low-volume superficial lesions when systemic treatment is unnecessary.
Topical timolol
A specialist may prescribe a small product-specific amount to a selected thin superficial haemangioma once or twice daily as an off-label regimen, avoiding ulcerated surfaces and mucosa.
Systemic absorption can still cause bradycardia, bronchospasm or hypoglycaemia; it is not appropriate for deep, large, periocular-risk or airway lesions without specialist oversight.