Strawberry Hemangioma

Strawberry Hemangioma

Strawberry Hemangioma (strawberry nevus, hemangioma), also known as capillary hemangioma or simple hemangioma, is the most common benign tumor in newborns, primarily composed of capillaries and small veins.

Etiology and Pathogenesis The etiology and cellular origin of strawberry hemangiomas are unclear. The cells may originate from placental tissue, endothelial progenitor cells, and mesenchymal stem cells. The cause might be that during embryonic development, tissues that would develop into blood vessels did not connect with the normal vascular system and remained in the superficial skin, developing into hemangiomas. Since hemangiomas are common in premature or low birth weight infants, it is speculated that hemangiomas are related to immature embryonic development.

Clinical Manifestations Hemangiomas typically appear one month after birth, with a higher incidence in females (three times that of males). The condition is more common among Caucasians. 80% of strawberry hemangiomas are solitary tumors, 60% affect the head and neck, 20% the trunk (especially around the anus and vulva), and 55% the limbs. They can involve skin, mucous membranes, and other soft tissues like the liver, gastrointestinal tract, larynx, central nervous system, pancreas, gallbladder, thymus, spleen, lymph nodes, lungs, bladder, and adrenal glands. Hemangiomas vary in shape, appearing as dome-shaped, rounded, plaque-like, tumorous, or combinations thereof. Initially red spots, they rapidly enlarge, stop growing at 1-2 years, and slowly regress. Growth characteristics depend on the tumor's size, depth, shape, and texture. Named for their resemblance to strawberries, hemangiomas can affect skin, subcutaneous tissue, and muscle, but usually do not invade bone. Hemangiomas in skin or muscle can damage blood vessels, leading to secondary infections or ulcers.

During the proliferative phase, hemangiomas may ulcerate (5-11%) and become infected, especially in friction-prone areas like the buttocks or perianal region. Ulcerated hemangiomas bleed easily. Large hemangiomas can involve underlying bone, causing deformation. Nasal tip hemangiomas often deform nasal cartilage, and eyelid hemangiomas can affect vision. Large hemangiomas can obstruct airways and impair breathing.

Deep hemangiomas may have normal-looking overlying skin. Color depends on depth: superficial ones appear bright red or crimson, while deeper ones are purple, blue, or flesh-colored, often with radiating capillary dilation and superficial veins.

Hemangiomas are composed of proliferating, clustered endothelial cells, typically undergoing growth and spontaneous regression phases. At birth, they grow rapidly, especially within the first 3-6 months. Natural regression starts at 6-12 months, with 50% of children’s hemangiomas regressing by age 5 and most by age 9.

Pathological Features

During the growth phase, proliferating capillaries and markedly proliferative endothelial cells are visible. These cells are large, irregularly rounded or oval, with pale eosinophilic cytoplasm and irregularly oval nuclei. Endothelial cells form solid cords or clusters, with small and unclear lumens. In the maturation phase, some capillaries become significantly dilated, and in the degeneration phase, capillaries undergo degeneration and later fibrosis.

Diagnosis and Differential Diagnosis

Diagnosis is based on the appearance of rapidly growing, dark red or bright red, strawberry-like soft masses that appear a few weeks after birth, grow rapidly within a few months, and begin to regress at 1-2 years. If the diagnosis is unclear, tissue samples can be taken for routine and special staining (e.g., basic fibroblast growth factor, vascular endothelial growth factor). Differential diagnosis should include:

1. Port Wine Stain (PWS): Compressible bright red patches that do not protrude from the skin, usually apparent at birth and do not regress. Pathologically, capillary dilation without endothelial cell proliferation is seen.
2. Cavernous Hemangioma: Raised bright red or purple tumors that compress and rebound, usually present at birth and do not regress. Pathological changes include numerous blood-filled spaces of varying sizes in the dermis or subcutaneous tissue, lined with a single layer of endothelial cells, without marked endothelial cell proliferation.

Treatment

1. General Treatment: Most strawberry hemangiomas regress spontaneously and do not require treatment. Traditional treatments target complicated lesions like ulcers, infections, repeated bleeding, facial disfigurement, or functional impairment (e.g., breathing, eating, excretion). Parents may also seek treatment for cosmetic reasons.
2. Medication:
   1. Oral Medications:
      • Glucocorticoids: Effective for 30-60% of hemangiomas, with rapid and significant effects. Prednisone is typically given at 2-3mg/(kg·d) and reduced as the tumor shrinks, over a 4-6 week course. Side effects are minimal and reversible upon discontinuation. If ineffective, increasing the dose to 5-6mg/(kg·d) may stimulate tumor growth. Since hemangiomas can grow for 6-12 months, premature discontinuation can lead to recurrence. Another regimen is an initial dose of 3-5mg/(kg·d) for 2-4 weeks, followed by alternate-day therapy, with the daily dose doubled, then gradually reduced over two weeks. If lesions do not grow, prednisone is reduced by 5mg every two weeks, for a total course of 6-12 months, monitoring systemic side effects.
      • Interferon: A second-line treatment that inhibits vascular smooth muscle and capillary endothelial cells, thereby suppressing angiogenesis. Liver function and blood counts should be monitored during treatment. Long-term use may cause thyroid and neurological complications.
   2. Local Treatment: Sclerosing agents injected into the hemangioma base weekly or biweekly, at 0.1-0.5mL per session, show efficacy after several treatments. Common sclerosing agents include 5% sodium morrhuate solution or 1-10% sulfate solution.
3. Surgical Treatment: Surgical removal is considered when rapid growth poses significant risks, such as bleeding or damage to normal head and neck structures. Surgery is reserved for life-threatening lesions or those severely impacting physiological functions or causing significant psychological distress. It can remove atrophic or proliferative scars, lax skin, and residual fibrofatty tissue in the regression phase, reducing bleeding risk.
4. Laser Treatment:
   1. Main Laser Devices: Effective in both growth and regression phases, the laser must penetrate to the deep blood vessels (0.6-1.2mm for 585nm lasers) with sufficient energy (over 6J/cm²) and long pulse duration (0.5-10ms).
      • Flashlamp-Pumped Pulsed Dye Laser (PDL, 585nm and 595nm): Commonly used for superficial hemangiomas, it can slow or stop proliferation and accelerate regression with high safety and specificity. For deeper lesions, repeat spot treatments may be necessary. Glass compression can be used to empty superficial vessels, allowing deeper penetration before removing the glass and treating superficial lesions. PDL is effective for ulcerated hemangiomas, healing 70% of ulcers within two weeks after one treatment. Ineffective for old, simple nodular hemangiomas, typical energy density is 6.0-6.5J/cm², with 10-15% spot overlap. Treatment endpoints are uniform darkening of the lesion, with intervals of 2-4 weeks. Early treatment is preferred. Side effects include edema and purpura (lasting 7-14 days), temporary pigmentation changes, and superficial scarring.
      • NdLaser: Penetrates 2-8mm, suitable for deep and indirect hemangiomas, but non-specific absorption can cause side effects like edema and scarring. Proper epidermal cooling and protection are crucial.
      • Dual-Wavelength Laser: Sequential emission of PDL and long-pulsed Ndlasers improves efficacy and reduces purpura and scarring risk.
      • CO₂ Laser: Ultra-pulsed CO₂ lasers can be used to ablate large tumors but are not recommended for skin hemangiomas due to scarring risk.
      • Intense Pulsed Light (IPL): Non-coherent, broad-spectrum IPL is effective for hemangiomas, with commonly used filters at 550nm/560nm/570nm/590nm. Dual or triple pulses with 3-6ms pulse duration and 30-50ms pulse delay, adjusted energy density, and treatment intervals of 2-4 weeks.
   2. Post-Laser Skin Care: Follow the same methods as for port wine stains.

Source: Strawberry Hemangioma