Synopsis
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.
- 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.
- 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.
Key red flags
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.
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.
Visual-axis obstruction, stridor, feeding failure, heart-failure signs or rapid destructive growth requires urgent specialist care.
Investigation priorities
Determine tumour versus malformation from timing, growth, morphology, distribution and function and create a reproducible baseline.
Management branches
A stable lesion has no ulceration, functional threat, segmental syndrome pattern or diagnostic uncertainty.
- Document presence at birth, growth, morphology, distribution and measurements with consented scaled photography.
- Explain expected persistence, fading or involution for the exact diagnosis and provide change and bleeding return advice.
- Review at a time matched to growth phase and refer if function, ulceration or atypical change emerges.