IHs are usually absent at birth or a small area of pallor, telangiectasias, or duskiness may be seen. A fully formed mass at birth usually indicates a diagnosis other than IH. Superficial hemangiomas in the upper dermis have a bright-red strawberry color, whereas those in the deep dermis and subcutis, deep hemangiomas, may appear blue and be firm or rubbery on palpation. Mixed hemangiomas can have both features. A minimally proliferative IH is an uncommon type that presents with fine macular telangiectasias with an occasional bright-red, papular, proliferative component. Minimally proliferative IHs are more common in the lower body.A precise history of the growth characteristics of the IH can be very helpful in making the diagnosis. In the first 4 to 8 weeks of life, IHs grow rapidly with primarily volumetric rather than radial growth. This is usually followed by a period of slower growth that can last 6–9 months, with 80% of the growth completed by 3 months. Finally, IHs involute over a period of years. The exceptions to these growth characteristics include minimally proliferative His, which do not substantially proliferate and large, deep IHs in which noticeable growth starts later and lasts longer. If the diagnosis is not clear based on physical examination and growth history (most often in deep hemangiomas with little cutaneous involvement), then either imaging or histopathology can help confirm the diagnosis. On Doppler ultrasound, an IH in the proliferative phase appears as a high-flow, soft-tissue mass usually without direct arteriovenous shunting.
It is generally applied two to three times daily. Surgery
Surgical excision of hemangiomas is rarely indicated, and limited to lesions which fail medical therapy (or when it is contraindicated), which are anatomically distributed in a location which is amenable to resection, and in which resection would likely be necessary and the scar will be similar regardless of timing of the surgery. Surgery may also be useful for removal of residual fibrofatty tissue (following hemangioma involution) and reconstruction of damaged structures. Laser
Laser therapy, most often the pulsed dye laser (PDL), plays a limited role in hemangioma management. PDL is most often used for treatment of ulcerated hemangiomas, often in conjunction with topical therapies and wound care, and may speed healing and diminish pain. Laser therapy may also be useful for early superficial IHs (although rapidly proliferating lesions may be more prone to ulceration following PDL treatment), and for the treatment of cutaneous telangiectasias which persist following involution. Prognosis
In the involution phase, an IH finally begins to diminish in size. While IHs were previously thought to improve by about 10% each year, newer evidence suggests that maximal improvement and involution is typically reached by 3.5 years of age. Most IHs resolve by age 10, but in some patients, the hemangioma does not completely resolve. Residual redness may be noted and can be improved with laser therapy, most commonly PDL. Ablative fractional resurfacing may be considered for textural skin changes.