HISTORY
Chief Complaint: Growth on the Forehead
* A 4-month-old girl has had an enlarging red-to-purple nodule on her forehead for 12 weeks. There was a pink patch present at birth that started growing at about 4 weeks old. It seems to be asymptomatic.
* Prior treatment: none.
* Prior biopsy: none.
* Skin history: no history of other growths or rash.
* No other significant laboratory/study findings.
Image Quality Assessment
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT1
One image was provided that showed an erythematous nodule with overlying telangiectasia on the right forehead (Figure 1).
Interpretation of Images
Lesion A
The presented lesion and history are most characteristic of an infantile hemangioma (IH).
RECOMMENDATIONS
Skin Care and Treatment Recommendations
Given the relatively small size, slow growth, and location, no treatment is indicated for this IH. The parents should be reassured and instructed to watch for continued growth or ulceration.
Recommended Follow-Up
Type of Visit
Return to primary care provider for continued monitoring.
CLINICAL PEARL
IHs are the most common type of tumor in children. They are benign vascular tumors that have a distinct growth pattern. IHs may present as a pink patch at birth or may not be present at all initially. Within the first 2-6 weeks, the tumor proliferates and may become raised and red or, if it is entirely deep, will present as a blue-hued, soft, subcutaneous nodule. Some IHs are mixed and will have both a deep blue component with an overlying telangiectatic, red, velvety surface. Because of their increased vascularity, they may feel warm when palpated. Around the age of 8-10 months, IHs stabilize and slowly decrease in size. Rates of around 10% per year are often quoted, although some IHs resolve much more quickly than this (Holland & Drolet, 2013). As IHs resolve, there is typically fibrofatty tissue left behind, sometimes with overlying telangiectasia.
IHs are typically asymptomatic for infants unless they are ulcerated, in which case they are painful and require more aggressive treatment. Hemangiomas on any body location may potentially ulcerate, although this is most likely to happen when they are located on the lips, in skin folds (neck, inguinal folds, wrists, etc.), and in the anogenital region. There are certain locations that should be noted where IH can be problematic, even if they are small and localized. On the nasal tip and ears, IHs allowed to grow can splay and destroy underlying cartilage and cause permanent disfigurement. Near the eyes, enlarging IHs may encroach over the pupil and disrupt normally developing visual pathways. Hemangiomas on the lips may interfere with feeding if allowed to substantially grow and also cause increased risk of ulceration, even furthering a risk of oral aversion. IHs on the breasts of infant girls may affect breast bud development and lead to asymmetry after puberty.
In most instances, IHs are not related to other systemic findings and occur in otherwise healthy infants, but there are exceptions to this rule. In these cases, cutaneous IHs can be a sign of underlying pathology and require further investigation. Segmental hemangiomas of the jaw, chin, or neck can be associated with oral cavity, pharynx, or airway involvement. Infants with these patterened hemangiomas along with segmental hemangiomas of the upper face should also be evaluated for PHACE(S) syndrome (Metry et al., 2009). PHACE(S) syndrome consists of posterior fossa abnormalities; IHs, usually segmental and on the face and/or neck; arterial anomalies of the cerebral or neck vessels; aorta coarctation; eye anomalies; and sternal clefting or supraumbilical raphae. Similarly, segmental IH of the lower abdomen, pelvic girdle, or upper thighs can be a part of LUMBAR syndrome (also termed SACRAL and PELVIS syndromes) and may be associated with occult spinal dysraphism, spinal cord defects (especially tethered cord), and bony, arterial, anorectal, or urogenital malformations (Iacobas et al., 2010). Finally, when IHs are multifocal in nature and a child has >=5, there is an increased risk of visceral involvement (Holland & Drolet, 2013). This risk is largest for hepatic involvement but can include other organs as well. Abdominal ultrasounds are indicated in this setting because of an increased risk of arteriovenous shunting within the hepatic system. Large hepatic or cutaneous hemangiomas may also lead to hypothyroidism by increased production of thyroid deiodinase.
Treatments exist for IHs in both topical (timolol drops or gel) and oral (propranolol or, less often, corticosteroids) forms, although some are used off-label. There are certain situations when hemangiomas may require treatment such as those outlined above (Blei & Guarini, 2014). In other cases, early treatment to prevent growth and eventual residual tissue changes may be cosmetically superior to observation alone. Finally, in many patients, observation and education of parents on prognosis, growth pattern, and expected outcomes are all that is needed. For these patients, developing a strong relationship with parents to ease the anxieties often associated with these types of birthmarks is very important. It is also essential to continue to monitor these lesions during the first several months of life during their growth phase as decisions on whether or not to treat may change in these instances.
REFERENCES