What is Capillary Infantile Hemangiomas?
Capillary hemangiomas, often seen in infancy, are the most common harmless growths in the eye area of children. They are a type of benign (non-cancerous) tumor and have been known by many different names in the past, like infantile hemangiomas, juvenile hemangiomas, hemangioblastomas, or strawberry nevi. Currently, everyone refers to them as capillary hemangiomas.
Back in 1982, these growths with a blood vessel origin were initially categorized as angiomas by John Mulliken and Julie Glowacki. It was believed that they were rapidly growing lesions that had their own lifecycle. However, the way we classify these lesions has changed several times since then. As per the updated classification from the International Society for the Study of Vascular Anomalies, capillary hemangiomas are now considered benign vascular neoplasms. This means they are non-cancerous tumors that spring up spontaneously and grow much faster than the rest of the body. These lesions go through a predictable lifecycle and often don’t need treatment unless there are complications.
This is different from what we call vascular malformations, which usually appear at birth, grow slowly and persist into adulthood.
What Causes Capillary Infantile Hemangiomas?
There is no evidence to suggest that genetic factors contribute to the development of these tumors. However, it’s been reported that they are less common in African ethnic groups. It’s also been found that factors like being born prematurely or with low birth weight could increase the risk of developing these tumors after birth.
Risk Factors and Frequency for Capillary Infantile Hemangiomas
Capillary hemangiomas are benign tumors that make up 8-10% of all benign tumors found in children. 80% of these tumors are located in the head and neck region. They are more commonly found in females, with a ratio of 3 to 5 females for every 2 males.
Signs and Symptoms of Capillary Infantile Hemangiomas
The type of symptoms a person experiences from hemangiomas, or blood vessel growths, depends on where they are on the body. There are three types of hemangiomas:
- Superficial type
- Deep type
- Mixed type, which includes both superficial and deep components.
Superficial hemangiomas often appear as bright red, lumpy masses. These are typically seen on the eyelids but might also present as skin discoloration or an eyelid bulge. Sometimes, they can cause actual vision problems by blocking the line of sight or causing an irregular shape of the eye.
Deep orbital hemangiomas are not visible without special medical tools. They usually cause symptoms like bulging eyes, crossed eyes, or decreased vision due to pressure on the optic nerve.
One of the tell-tale signs of hemangiomas is their change in size or darkening in color, often turning to a deep blue, when a child cries or strains. However, this symptom isn’t unique to hemangiomas and can be seen in other vascular irregularities as well.
Sometimes, skin hemangiomas might be linked with similar growths in the internal organs. If a person has four or more superficial hemangiomas, it might be an indicator of such internal growths, often found in the liver.
StatPearls also describes two related syndromes. Kasabach-Merritt Syndrome is when large hemangiomas cause clotting factors to get stuck within them, and lead to a dangerous decrease in blood platelet counts. PHACES Syndrome describes large facial hemangiomas that are associated with additional defects in the brain, blood vessels, eyes, heart, and chest, often seen in female children.
Testing for Capillary Infantile Hemangiomas
If your doctor suspects you have capillary hemangiomas (small, non-cancerous growths formed by tiny blood vessels), they might use certain imaging techniques to get a clearer picture:
One technique is ultrasound. Ultrasounds use sound waves to create pictures of the inside of your body. In this case, capillary hemangiomas will appear as irregular shapes. They will show a high internal reflection and might also show high spikes from the septae, which are tissues inside the growth. Doppler echography, a special type of ultrasound, might show increased flow of blood inside the growth.
Another technique that might be used is a computed tomography (CT) scan. CT scans use X-rays to create detailed images of the body. In a CT scan, capillary hemangiomas might appear as very distinct or possibly irregular shapes in front of or behind the septum (the thin wall separating the nostrils), or inside or outside the cone of the eye. These growths may or may not enhance, or “light up”, when a contrast dye is used. There isn’t usually any evidence of calcification (hardening from depositing calcium) or erosion of the bone.
The last type of imaging that might be used is magnetic resonance imaging (MRI). MRI uses a magnetic field and radio waves to create pictures of the structures and tissues within your body. Under MRI, capillary hemangiomas might appear as very distinct or possibly irregular shapes. The images will likely show the hemangiomas as less intense (darker) on T1 weighted images and more intense (brighter) on T2 weighted images. A distinguishing feature is the presence of flow voids, or areas where blood flow is not seen, within the growth. If a Gadolinium contrast is used, they might diffuse or spread out and this is best seen in images where fat has been suppressed or minimized.
Treatment Options for Capillary Infantile Hemangiomas
Capillary hemangiomas, or abnormal build-up of blood vessels in the skin, usually do not cause any trouble and don’t need treatment. However, about 10% can lead to problems like distorted vision due to uneven eye shape, droopy eyelids that block vision, lazy eye, painful sores or bleeding, or severe bulging of the eye. This could put pressure on the key nerve in the eye or cause damage due to dryness. These conditions need to be managed.
Beta-blockers are widely used to treat capillary hemangiomas. Interestingly, doctors only discovered their positive effects coincidentally in 2008, when they observed the blood vessel growths in kids shrink. These kids were given beta-blockers to manage heart and kidney problems. Since then, the beta-blocker propranolol has taken the place of oral steroids as the preferred treatment method.
Beta-blockers work by suppressing chemicals that promote blood vessel growth. They also hinder key signaling processes in cells and trigger self-destruction in growing cells. Two types of beta-blockers are typically used: oral propranolol and topical timolol, which is a gel for surface-level issues. They often start to diminish the hemangioma and alter its color as early as one week into treatment. However, to fully work, it needs to be used continuously for up to a year with periodic decreasing doses to prevent the hemangioma from coming back.
Please bear in mind that beta-blockers can have side effects such as low blood pressure, slow heartbeat, low blood sugar, difficulty breathing, disrupted sleep, diarrhea, and high potassium levels. To manage these, it’s essential that patients are properly monitored when starting the treatment and that caregivers are well-informed about these potential effects.
Before beta-blockers became popular, steroids were the go-to treatment for capillary hemangiomas. Steroids can be effective early on, but they have several side effects including weight gain, round face, suppressed adrenal function, high blood pressure, local skin color change, fat loss, and blockage of the key eye nerve. Due to these issues, steroids are generally less favored now, and are primarily used during surgeries to help with the removal of these growths.
In conditions where steroids are ineffective, immune-modifying agents have been used. Nonetheless, these can lead to complications such as weakened bone marrow and liver damage.
For surface-level hemangiomas, pulsed-dye lasers can be used to reduce the size and lighten the color.
Surgery is usually the last option taken, used only for large hemangioma that threaten vision. As these blood vessel growths are irregular and not contained within a specific area, it could be challenging to remove them entirely. Even so, meticulous surgical techniques can successfully treat many large growths in the orbital and eyelid areas. Steroids might also be injected into any remaining hemangioma tissue during surgery.
What else can Capillary Infantile Hemangiomas be?
Based on the location and size, certain benign conditions like lymphangioma, arterio-venous malformations, mucocele, or meningocele can be confused with other types of lesions.
It is also worth noting that if the lesions are accompanied by quick onset of eye bulging (proptosis), they can resemble a type of cancer called rhabdomyosarcoma.
What to expect with Capillary Infantile Hemangiomas
In simple terms, the outlook for a baby with capillary hemangioma, which is a common type of birthmark or red skin bump, is generally very good. Most of the time, these birthmarks disappear on their own. Large birthmarks respond exceptionally well to a medication called propranolol, which is given orally. This treatment leads to a complete, or nearly complete, fading of the birthmark.
Possible Complications When Diagnosed with Capillary Infantile Hemangiomas
Capillary hemangiomas, or small blood vessel growths, usually shrink on their own over time. However, in certain cases, they may quickly grow in size and lead to vision issues, eyeball protrusion leading to exposure keratitis (a type of eye inflammation), or pressure on the optic nerve (the nerve that sends visual information from the eye to the brain). Skin breakdown and bleeding are also possible but rare occurrences.
Regarding the intake of oral steroids to treat these growths, complications can include low blood pressure, slow heart rate, low blood sugar, muscle contraction in the airways, sleep issues, diarrhea, and high levels of potassium in the blood. These potential side effects can be managed by closely monitoring the patient during the initial phases of treatment and making sure the patient’s caregivers are properly informed about what to expect.
Surgical removal of these growths can lead to damage to surrounding tissues such as the levator aponeurosis and levator muscle which help in lifting the eyelids. Moreover, the irregular nature and lack of encapsulation of these growths often result in some part of the tumor being left behind in the eye socket after surgery.
Side Effects and Complications:
- Vision issues
- Eyeball protrusion
- Pressure on the optic nerve
- Skin breakdown
- Bleeding
- Low blood pressure
- Slow heart rate
- Low blood sugar
- Muscle contractions in the airways
- Sleep issues
- Diarrhea
- High blood potassium
- Damage to tissues near the eyes
- Partial tumor left after surgery
Preventing Capillary Infantile Hemangiomas
Parents should be aware of how capillary hemangiomas (a type of birthmark that appears as a red or blue tumor) normally develop and change over time. Thanks to modern medicine, a medication called oral propranolol is often successful in treating these birthmarks. However, it’s important to note that the treatment can take a long time and may need to continue for an extended period. Most hemangiomas that require treatment will respond positively to this medication.