Hemangioma: Symptoms, Types, Causes and Treatment

Hemangiomas are among the most common benign vascular tumors, particularly in infants and young children, although they can affect individuals of any age. Despite their prevalence, hemangiomas can vary widely in their appearance, location, and potential complications. Understanding the symptoms, types, underlying causes, and available treatment options is essential for patients, caregivers, and healthcare professionals alike. In this article, we explore the key aspects of hemangiomas, drawing on current scientific research and clinical experience.

Symptoms of Hemangioma

Hemangiomas present with a diverse range of symptoms depending on their type, size, location, and stage of development. While many are asymptomatic and discovered incidentally, others can cause significant discomfort or medical complications. Recognizing the signs and symptoms is crucial for timely diagnosis and management.

Symptom	Description	Location/Context	Source(s)
Red/purple lesion	Raised, well-defined, bright red or purplish	Skin (most common)	5 7 8
Pain	Localized discomfort, possible tenderness	Skin, muscle, bone, internal organs	1 4 14
Bleeding	Ulceration, spontaneous bleeding	Surface lesions, GI tract, colon	2 3 5 15
Neurological deficits	Weakness, paralysis, sensory loss	Spine or brain involvement	1
Abdominal pain	May mimic other GI conditions	Gastrointestinal hemangiomas	2 3 14
Anemia	Due to chronic blood loss	GI hemangiomas	3
Swelling/mass	Palpable lump, may be rubbery or soft	Skin, soft tissue, muscle	4 7 8 17

Table 1: Key Symptoms of Hemangioma

Typical Presentations

The most common symptom of a hemangioma is a visible, red to purple lesion on the skin. These often appear in infancy and may be described as "strawberry marks" (capillary hemangiomas), usually with well-defined edges and a slightly raised surface. They blanch incompletely with pressure and feel rubbery to the touch 5 7 8.

Internal and Deep Hemangiomas

Not all hemangiomas are visible on the skin. Deep or visceral hemangiomas—such as those in the liver, colon, muscles, or spine—may present with non-specific symptoms:

• Pain: Deep-seated pain may occur with hemangiomas in muscles, bones, or organs 1 4 14.
• Bleeding: GI hemangiomas often present with rectal bleeding or chronic iron-deficiency anemia 2 3.
• Neurological symptoms: When hemangiomas compress nerves or the spinal cord, symptoms may include weakness, loss of sensation, or even paralysis 1.
• Swelling or Mass Effect: Large or deep hemangiomas may cause visible swelling or a palpable mass 4 17.

Complications

While most hemangiomas are benign and self-limited, possible complications include:

• Ulceration and secondary infection, especially in superficial lesions 15
• Life-threatening bleeding in visceral locations 2 3 14
• Functional impairment if located near vital structures, such as the airway, eye, or spine 1 8
• Cosmetic concerns and psychosocial impact, particularly if the lesion is on the face or visible area 8

Types of Hemangioma

Hemangiomas are a diverse group of tumors, classified by their clinical behavior, location, and histological characteristics. Understanding the different types helps guide diagnosis and treatment.

Type	Description	Common Sites	Source(s)
Capillary (Strawberry)	Small capillaries, bright red, superficial	Skin, especially face/scalp	5 6 7 8
Cavernous	Large, dilated vessels, bluish, deeper	Skin, liver, GI tract	5 6 7 14
Mixed	Both capillary and cavernous features	Skin, muscle, trunk	4 6 7
Intramuscular	Within skeletal muscle, variable size	Limbs, trunk	4 17
Visceral	Located in organs (liver, colon, brain, spine)	Liver, colon, spine	1 2 3 14
Systemic/Multiple	Multiple lesions, may be syndromic	Skin, organs	6

Table 2: Main Types of Hemangioma

Capillary (Strawberry) Hemangiomas

• Appearance: Bright red, raised, well-defined margins, commonly found on the skin of infants 5 7 8.
• Course: Rapid growth in infancy, followed by spontaneous involution over several years 7 8.

Cavernous Hemangiomas

• Appearance: Bluish or purplish, less well-defined, may be superficially visible or deeply seated 5 6 7.
• Sites: Common in deeper tissues, including the liver, brain, and GI tract 14.

Mixed Hemangiomas

• Present with both capillary and cavernous features histologically and clinically 4 6 7.
• Often found on the trunk or limbs, with variable clinical behavior.

Intramuscular and Soft Tissue Hemangiomas

• Occur within skeletal muscle or subcutaneous tissue.
• May be mistaken for malignancy due to rapid growth and variable appearance 4 17.
• Recurrence after excision is possible, but metastasis is exceedingly rare 4 17.

Visceral Hemangiomas

• Liver: Hepatic cavernous hemangioma is the most common benign liver tumor 14.
• GI tract: Presenting with bleeding or anemia 2 3.
• Spine/brain: May cause neurological symptoms if compressing nervous tissue 1 6.

Systemic and Syndromic Hemangiomas

Certain syndromes, such as Sturge-Weber or Von Hippel-Lindau, feature multiple hemangiomas as part of a broader disease spectrum 6.

Causes of Hemangioma

The precise causes of hemangiomas remain an area of active research. While the exact mechanism is not fully understood, several theories and risk factors have been proposed, involving both genetic and environmental influences.

Cause/Theory	Key Features	Evidence/Observation	Source(s)
Angiogenesis	Excessive new blood vessel growth	↑ VEGF & FGF in proliferative phase	9 10
Cytokine pathway dysregulation	Abnormal growth factor signaling	Disrupted regulation of endothelial growth	9 11
Cellular origin theories	Angioblast or trophoblast origin	Studies of cell markers and development	10 11
Mast cell involvement	Promote growth & regression	Mast cell numbers vary by phase	12
Genetic/Field defects	Familial cases, developmental patterns	Some clustering and field-related distribution	11
Female sex, prematurity	Increased risk in these groups	Higher incidence in girls and preterm infants	10 11
Unknown/Multifactorial	Many cases lack clear cause	No single unifying theory	10 11

Table 3: Proposed Causes and Pathogenesis of Hemangioma

Dysregulated Angiogenesis

Hemangiomas are characterized by a phase of rapid endothelial proliferation (angiogenesis), with overexpression of angiogenic growth factors such as vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF). These promote the formation of abnormal vascular channels that define the tumor 9 10.

Theories on Cellular Origin

• Angioblast Theory: Suggests hemangiomas arise from precursor vascular cells (angioblasts) that persist abnormally 11.
• Trophoblast Theory: Proposes cells of placental origin may contribute to hemangioma formation in infants 11.
• Cytokine Dysregulation: Abnormal signaling in growth factor pathways leads to unchecked endothelial proliferation 9 11.

Role of Mast Cells

Mast cells are found in varying numbers throughout the life cycle of hemangiomas. They may be involved in both the growth and regression of the tumor by releasing different mediators at each stage 12.

Genetic and Environmental Factors

• Sex and Prematurity: Hemangiomas are more common in females and premature infants 10 11.
• Field Defects: Some hemangiomas follow patterns suggesting developmental "field" abnormalities, possibly linked to genetic or localized environmental factors 11.
• No Single Cause: Most cases lack a clear genetic mutation or environmental trigger, and hemangiomas are likely the result of multiple converging factors 10 11.

Treatment of Hemangioma

The management of hemangiomas is tailored to their type, location, size, complications, and potential for spontaneous regression. While many require no intervention, others can benefit greatly from timely therapy, especially in cases of functional impairment, ulceration, or life-threatening complications.

Treatment	Indication / Use Case	Efficacy / Outcome	Source(s)
Observation	Uncomplicated, small, involuting lesions	Most regress spontaneously	7 8 13
Pharmacological (Propranolol)	Complicated infantile hemangiomas	High efficacy, few side effects	15
Steroid therapy	Rapidly growing, life-threatening lesions	Effective, but side effects	13 16
Laser therapy	Residual telangiectasia, superficial lesions	Good cosmetic results	15 16
Surgical excision	Symptomatic, deep, recurrent, or visceral	Curative if complete removal	1 2 4 14 17
Embolization	Pre-op for vascular lesions, reduce bleeding	Decreases surgical risk	1 14
Radiotherapy	Rarely, for unresectable or recurrent cases	Limited use	1 14 16

Table 4: Treatment Options for Hemangioma

Observation ("Watchful Waiting")

• Most uncomplicated, cutaneous infantile hemangiomas undergo spontaneous regression and do not require treatment 7 8 13.
• Monitoring is appropriate unless complications develop or there's risk of disfigurement or functional impairment.

Beta-blocker Therapy (Propranolol)

• First-line treatment for complicated or rapidly growing infantile hemangiomas 15.
• High response rates, especially when started early; well tolerated with minimal side effects (e.g., sleep disturbance, diarrhea, rare bronchospasm) 15.
• Topical timolol and pulsed dye laser can be used for residual lesions 15.

Corticosteroids

• Previously the mainstay for rapidly growing or life-threatening hemangiomas 13 16.
• Still used in selected cases, but associated with more side effects than propranolol 13 16.

Laser Therapy

• Useful for superficial residual lesions, ulcerated hemangiomas, or cosmetic improvement 15 16.
• Pulsed dye laser is particularly effective for telangiectatic remnants.

Surgical Intervention

• Indicated for deep, symptomatic, or refractory hemangiomas, especially in soft tissue, muscle, or viscera 1 2 4 14 17.
• Complete excision usually curative; recurrence possible in some subtypes 4 17.
• For vertebral or spinal hemangiomas causing neurological deficits, urgent decompression may be lifesaving 1.

Embolization and Radiotherapy

• Embolization: Used to minimize intraoperative bleeding, especially for highly vascular or visceral hemangiomas 1 14.
• Radiotherapy: Rarely used, reserved for unresectable or recurrent cases 1 14 16.

Special Considerations

• Liver hemangiomas: Surgery indicated only if complications such as rupture, bleeding, or compression occur 14.
• Head and neck hemangiomas: Require individualized management due to potential airway obstruction or facial disfigurement 16.
• Multidisciplinary Care: Complex cases may involve pediatricians, dermatologists, surgeons, radiologists, and other specialists.

Conclusion

Hemangiomas are common benign vascular tumors with a broad spectrum of presentations, types, and potential complications. Their management has evolved significantly with advances in pharmacologic therapy and minimally invasive techniques. Key takeaways include:

• Symptoms range from harmless skin lesions to deep masses causing pain, bleeding, or neurological effects.
• Types include capillary, cavernous, mixed, intramuscular, visceral, and syndromic forms.
• Causes involve abnormal angiogenesis, possibly influenced by genetic, cellular, and environmental factors, but a single unifying cause remains elusive.
• Treatment is tailored to the individual, with observation appropriate for most, and interventions such as beta-blockers, steroids, laser therapy, surgery, or embolization reserved for complicated cases.

Summary:

• Hemangiomas are common, especially in infants, and usually benign.
• Visible red or purple skin lesions are the most typical symptom, but deep or visceral hemangiomas can cause pain, bleeding, or functional impairment.
• They are classified by histology, location, and clinical behavior.
• Pathogenesis involves angiogenesis and possibly genetic or developmental factors.
• Most require no treatment, but complicated cases respond well to propranolol, steroids, laser, or surgery.

By understanding the varied nature of hemangiomas and the latest evidence-based management strategies, clinicians and families can ensure the best outcomes for affected individuals.