Strawberry Hemangiomas: Symptoms, Types, Causes and Treatment

Strawberry hemangiomas, often called "strawberry marks" or capillary hemangiomas, are among the most common vascular birthmarks found in infants and young children. While their bright appearance can be alarming for parents, understanding their symptoms, types, causes, and modern treatment options can help families make informed decisions and provide reassurance during early childhood. This article explores the latest evidence and expert perspectives on strawberry hemangiomas, synthesizing current knowledge for families and caregivers.

Symptoms of Strawberry Hemangiomas

Strawberry hemangiomas have distinctive characteristics that set them apart from other skin lesions in infancy. Recognizing their typical symptoms helps guide diagnosis and management.

Appearance	Onset	Progression	Source
Bright red, raised	Not present at birth; appears in first weeks	Rapid growth, then gradual regression	1, 2, 4, 8
Lobulated, well-defined borders	Firm, rubbery mass	May ulcerate or obstruct vital functions	1, 2, 8
Incomplete blanching with pressure	Usually solitary or few in number	May cause anxiety due to rapid size increase	1, 2, 8

Table 1: Key Symptoms

Typical Physical Features

Strawberry hemangiomas are classically described as raised, bright red to purplish-red skin lesions with a lobulated, well-defined border. The surface often appears bumpy or pebbled, and tiny capillaries may protrude above the skin. Most lesions are firm and rubbery to the touch, compressing only minimally if at all 1, 2. Unlike other birthmarks, strawberry hemangiomas are generally not present at birth but develop within the first few weeks of life 1, 4.

Progression Over Time

These hemangiomas have a well-recognized natural course:

• Proliferative phase: Rapid growth during the first six months of life, sometimes causing a dramatic increase in size 1, 4, 8.
• Plateau phase: The lesion remains relatively stable for months.
• Involution phase: Gradual regression, often over the next one to five years, with many lesions resolving or fading significantly on their own 1, 4, 8.

Functional and Emotional Impact

Most strawberry hemangiomas are harmless and cause no symptoms beyond their appearance. However, if located near vital structures—such as the eyes, mouth, or airway—they may interfere with vision, breathing, or feeding 1, 4, 8. Rarely, ulceration, bleeding, or infection can occur, especially with larger or rapidly growing lesions 8. The striking appearance may also cause significant anxiety for parents, even though the vast majority of lesions resolve over time 8.

Types of Strawberry Hemangiomas

Strawberry hemangiomas belong to a broader family of vascular anomalies, and understanding their subtypes helps distinguish them from other similar lesions.

Type	Defining Features	Course & Outcome	Source
Capillary (Strawberry)	Bright red, raised, superficial; made of small capillaries	Rapid growth, spontaneous regression	2, 7, 8
Cavernous	Deeper, with larger, mature vessels; poorly defined borders	Present at birth, slow growth, less likely to involute	2, 4, 7
Mixed	Features of both capillary and cavernous types	Variable course	2, 5, 7

Table 2: Hemangioma Types

Capillary (Strawberry) Hemangioma

This is the classic "strawberry mark," composed of a dense proliferation of small capillaries in the upper layers of the skin. The bright red color is due to blood within these superficial vessels 2, 7, 8. These lesions grow rapidly, then typically regress over a few years.

Cavernous Hemangioma

Cavernous hemangiomas are deeper, often present at birth, and consist of larger, more mature blood vessels 2, 4, 7. They are usually less well-defined, may not be as brightly colored, and tend to grow slowly along with the child. Unlike strawberry hemangiomas, they are less likely to regress spontaneously 4, 7.

Mixed Hemangiomas

Some lesions show features of both capillary and cavernous hemangiomas, referred to as "mixed" types 2, 5, 7. Their clinical course depends on the proportion of each type, making their behavior more variable.

Distinguishing from Other Vascular Lesions

Other birthmarks such as port wine stains (nevus flammeus) and spider angiomas do not share the same tendency for rapid proliferation and spontaneous involution as strawberry hemangiomas 2, 5, 7. Port wine stains, for example, are flat, persistent, and do not fade over time.

Causes of Strawberry Hemangiomas

While the exact cause of strawberry hemangiomas is not fully understood, research has shed light on potential contributing factors and underlying mechanisms.

Cause/Factor	Description	Evidence/Notes	Source
Endothelial cell proliferation	Overgrowth of capillary endothelial cells in skin	Fundamental to lesion formation	7
Hormonal influence	Elevated estradiol-17 beta & receptor activity	May drive growth, explain response to steroids	6
Mast cell activity	Increased numbers in growing lesions	May regulate growth and involution	3, 7
Genetic factors	Rare familial cases, not typically inherited	<10% familial incidence	7

Table 3: Proposed Causes

Endothelial Cell Proliferation

Strawberry hemangiomas are benign tumors arising from the abnormal proliferation of capillary endothelial cells—the cells that line blood vessels 7. The reason for this overgrowth is not entirely clear, but it is central to the development of these lesions.

Hormonal Influences

Recent studies have found abnormally elevated levels of estradiol-17 beta (a form of estrogen) in infants with strawberry hemangiomas, along with increased expression of estradiol receptors within the lesion tissue 6. These findings suggest that hormonal factors may play a role in triggering or sustaining the growth phase. The response of some hemangiomas to corticosteroid therapy may also be linked to these hormonal pathways 6.

Mast Cell Involvement

Mast cells, which are immune cells involved in inflammation and tissue remodeling, are found in higher numbers during the active growth phase of hemangiomas 3, 7. Their activity and granule content change as the lesion transitions from growth to involution, indicating a possible role in the natural regression process 3.

Genetic and Environmental Factors

While most hemangiomas are sporadic, rare familial cases have been reported, with some studies noting a genetic link in up to 10% of patients 7. However, there is no clear evidence of a simple genetic inheritance pattern. Environmental triggers remain speculative and unproven.

Treatment of Strawberry Hemangiomas

Although most strawberry hemangiomas resolve without intervention, certain situations may warrant treatment. Understanding the options and when to use them is crucial for optimal outcomes.

Treatment	Indications	Effectiveness / Side Effects	Source
Observation	Most uncomplicated cases	High spontaneous resolution, safest	2, 4, 8
Corticosteroids	Rapidly growing, function-threatening lesions	Can induce regression; hormonal side effects	6, 8, 10
Laser therapy (e.g. pulsed dye, argon)	Persistent, cosmetically concerning, or obstructive lesions	Effective, minimal scarring; some risk of pigment changes or scarring with certain lasers	8, 9, 10, 11
Surgery / Cryotherapy	Rare, severe cases with complications	Reserved for non-responders or vital function risk	2, 4, 8, 10

Table 4: Treatment Options

Observation and Reassurance

For the vast majority of strawberry hemangiomas, no treatment is necessary. These lesions typically undergo spontaneous involution, and the best results are often achieved by simple observation and reassurance for parents 2, 4, 8. Intervention is generally reserved for special cases.

Medical Therapy

Corticosteroids—either systemic or injected directly into the lesion—can hasten regression in rapidly growing or problematic hemangiomas, particularly those that threaten vision, breathing, or feeding 6, 8, 10. This approach targets the hormonal and inflammatory pathways involved in lesion growth. Side effects of corticosteroids can include mood changes, increased appetite, and, rarely, more serious complications, so their use is carefully considered.

Laser Treatments

Laser therapy has become an important option, particularly for superficial or cosmetically significant lesions. The flash lamp-pumped pulsed dye laser is favored for its ability to target superficial blood vessels with minimal risk of scarring or pigment changes 8, 10. Argon and Nd:YAG lasers have also been used, but may carry higher risks of complications such as scarring or delayed healing 9, 10, 11. Laser therapy is especially helpful for lesions that ulcerate, fail to regress, or are slow to improve in older children 8, 9, 10.

Surgical and Other Interventions

Surgery, cryotherapy, or radiation are rarely indicated and generally reserved for life-threatening complications (e.g., airway obstruction) or lesions unresponsive to other therapies 2, 4, 8, 10. Surgery carries risks of bleeding and scarring, so it is used judiciously.

Individualized Approach

Treatment decisions should be individualized based on lesion size, location, growth behavior, and impact on function or appearance. Parental anxiety and psychosocial concerns are also important factors to consider 8, 10. Collaboration between pediatricians, dermatologists, and other specialists ensures the best outcomes.

Conclusion

Strawberry hemangiomas are common, benign vascular tumors of infancy with a characteristic appearance and natural history. Most resolve spontaneously, but some require intervention. Understanding their symptoms, types, causes, and treatment options empowers families and clinicians to make the best choices for affected children.

Key Takeaways:

• Strawberry hemangiomas appear as bright red, raised skin lesions in infants, usually developing after birth and growing rapidly before regressing over several years 1, 2, 4, 8.
• The main type is capillary (strawberry) hemangioma; other vascular tumors include cavernous and mixed types 2, 7, 8.
• Causes involve endothelial cell proliferation, hormonal influences (notably estradiol), increased mast cell activity, and occasionally genetic factors 3, 6, 7.
• Most cases require only observation and reassurance. Treatments like corticosteroids and laser therapy are reserved for problematic lesions, with surgery or other interventions used rarely 2, 4, 6, 8, 9, 10, 11.
• Early recognition and a tailored, evidence-based approach ensure the best physical and emotional outcomes for children and families.

By staying informed, families and clinicians can navigate the journey of strawberry hemangiomas with confidence and compassion.