ConditionSkin, hair & nails
Hemangioma (Strawberry Birthmark)
A hemangioma is a benign growth of blood vessels. The most common type is the infantile hemangioma, or strawberry birthmark, which affects about 4 to 5 percent of babies. It appears in the first weeks of life, grows quickly for a few months, then slowly shrinks over years. Most need no treatment. Hemangiomas near the eye, nose, lips, airway or diaper area, large facial ones, or those that ulcerate need early specialist care, usually with propranolol. Adults can have hemangiomas in the liver or skin.
Also called: Infantile hemangioma, strawberry birthmark, strawberry nevus, vascular birthmark, cherry angioma (adult skin type), liver hemangioma
At a glance
- What it is
- A benign tumor of blood vessel cells.
- Infantile type
- Appears in the first weeks of life, grows over 3 to 5 months, then shrinks over years.
- Who
- More common in girls, premature and low-birth-weight babies, and twins.
- Needs early care
- Near the eye, nose, lip, ear or airway; large facial or segmental; ulcerated; five or more on the skin.
- Treatment
- Watchful waiting for most; oral propranolol or topical timolol for higher-risk lesions.
When to get help
Call 911 or go to the ER
- A baby with a hemangioma on the lower face, chin or neck ("beard area") who develops noisy breathing, hoarse cry or difficulty breathing (possible airway hemangioma)
- Heavy bleeding from a hemangioma that does not stop after 10 minutes of firm pressure
See a doctor within a day or two
- A hemangioma near the eye that is growing, especially if it pushes on or closes the eyelid
- A painful, ulcerated or infected hemangioma, especially in the diaper area or on the lip
- A large hemangioma on the face or a segmental hemangioma covering a broad area
- Five or more skin hemangiomas (liver hemangiomas should be checked)
Book a routine appointment
- Any new hemangioma in a baby under 3 months: ask your pediatrician to review it early, since the fastest growth happens before 5 months
- A hemangioma that has shrunk but left loose skin or scarring
Usually safe to manage at home
- A small hemangioma on the trunk or limbs in a healthy baby, already reviewed by a doctor
Types of hemangioma
| Type | Appearance | Behavior |
|---|---|---|
| Superficial infantile hemangioma | Bright red, raised, strawberry-like | Grows, then fades |
| Deep infantile hemangioma | Bluish, soft swelling under the skin | Grows a little later and longer |
| Mixed | Red surface with a deeper blue component | Combination |
| Congenital hemangioma | Fully formed at birth | Either shrinks quickly (RICH) or does not shrink (NICH) |
| Cherry angioma (adults) | Small bright red dots on the trunk | Harmless, increase with age |
| Liver hemangioma (adults) | Found on imaging | Usually harmless |
Hemangiomas are different from vascular malformations such as port-wine stains, venous malformations and arteriovenous malformations, which are present at birth, grow with the child and do not shrink.
Infantile hemangioma growth stages
- Early (first weeks): a pale patch, red mark or cluster of fine blood vessels.
- Rapid growth (proliferation): most growth happens by 3 months of age, and about 80 percent of final size is reached by 3 to 5 months.
- Plateau: growth slows between about 6 and 12 months.
- Involution: the color fades from bright red to dull purple-gray, and the lump softens and flattens over years. Most have finished shrinking by about age 4.
After involution, about half of untreated larger hemangiomas leave loose skin, fatty tissue, scarring or visible vessels.
Causes and risk factors
The cause is not fully understood. Hemangiomas are thought to arise from immature blood vessel cells, possibly triggered by low oxygen levels in the placenta. Risk factors:
- female sex
- prematurity and low birth weight
- multiple births
- older maternal age, placental problems and chorionic villus sampling
They are not caused by anything the parents did during pregnancy.
High-risk hemangiomas
Early referral (ideally by 1 month of age) is recommended for:
- periocular: can block vision and cause permanent amblyopia
- nasal tip, lip and ear: risk of permanent deformity
- beard area: linked to airway hemangiomas
- large segmental facial: may be part of PHACE syndrome, involving the brain, arteries, heart and eyes
- lumbosacral: may be linked to spinal abnormalities
- ulcerated: painful, prone to infection and scarring; common in the diaper area and lips
- multiple (five or more): screen for liver hemangiomas with ultrasound
Diagnosis
Infantile hemangiomas are usually diagnosed by appearance and history. Ultrasound or MRI may be used for deep lesions, unusual cases, PHACE screening or liver involvement. A biopsy is rarely needed.
Treatment
Watchful waiting
Most small hemangiomas in low-risk locations need only monitoring and photos to track changes.
Propranolol
Oral propranolol, a beta-blocker, is the first-line treatment for problematic infantile hemangiomas. It is most effective started early, during the growth phase, and is usually continued until about 12 months of age. Babies are monitored for low blood sugar, slow heart rate and wheezing, and should be fed regularly while on it.
Other treatments
- topical timolol gel for small, thin superficial hemangiomas
- wound care and pain relief for ulceration, with barrier creams and dressings
- pulsed dye laser for residual redness or ulcers
- surgery to remove residual tissue or correct deformity, usually after age 3 to 4
Liver hemangiomas in adults
Liver hemangiomas are the most common benign liver tumor, often found by chance on scans. Most are small, cause no symptoms and need no treatment or follow-up. Large ones rarely cause pain or fullness, and surgery is seldom needed.
Frequently asked questions
What is a strawberry hemangioma?
A strawberry hemangioma is the common name for a superficial infantile hemangioma, a bright red, raised birthmark made of extra blood vessels. It appears in the first weeks of life, grows for a few months, then gradually shrinks over several years.
Do hemangiomas go away on their own?
Most infantile hemangiomas shrink on their own, with most involution complete by about age 4. Larger ones may leave loose skin, scarring or visible vessels. Hemangiomas in risky locations or that ulcerate should be treated early rather than waiting.
When does a hemangioma need treatment?
Treatment is needed when a hemangioma threatens vision, breathing or feeding, is on the nose, lip or ear, is large on the face, ulcerates, or is part of a syndrome. Early review, ideally by 1 month of age, gives the best results.
Is propranolol safe for babies with hemangioma?
Propranolol is the standard, well-studied treatment for problematic hemangiomas and is generally safe under a doctor's supervision. Babies need regular feeds to avoid low blood sugar, and doses are paused during illness with poor feeding or wheezing.
Is a liver hemangioma dangerous?
Usually not. Liver hemangiomas in adults are common benign growths found incidentally on scans. Most cause no symptoms and need no treatment. Very large hemangiomas may rarely cause discomfort and occasionally need surgery.
Sources
This guide was written from current patient and clinical guidance, including:
- American Academy of Pediatrics: Clinical Practice Guideline for the Management of Infantile Hemangiomas
- American Academy of Dermatology: Hemangiomas - Diagnosis and Treatment
- International Society for the Study of Vascular Anomalies (ISSVA): Classification of Vascular Anomalies
- MedlinePlus: Hemangioma
- American College of Gastroenterology: Focal Liver Lesions Guideline