Hemangiomas

From a pathophysiological perspective, a hemangioma is a benign vascular tumor that arises due to:

• increased proliferation of endothelial cells,
• dysregulation of angiogenesis (the process of new blood vessel formation),
• overexpression of vascular growth factors, including VEGF (vascular endothelial growth factor).

There are two main phases of development for a classic infantile hemangioma:

1. Proliferative phase – rapid growth of the lesion (usually in the first 6–12 months of life).
2. Involution phase – gradual spontaneous regression of the lesion (lasting several years).

In clinical practice, it is important to differentiate between:

• hemangiomas (vascular tumors) – showing active proliferation,
• vascular malformations – which are permanent structural abnormalities of vessels.

In adults, so-called senile hemangiomas (cherry angiomas) are often observed, which are associated with aging processes, genetic predisposition, and hormonal factors.

Hemangiomas in the vast majority do not pose an oncological threat. However, problems may include: 

• rapid growth,
• location (e.g., near the eye, airways),
• bleeding,
• aesthetic concerns.

The clinical presentation of a hemangioma depends on its type, depth, and location. The most common morphological features include:

• red, cherry, or purplish-blue color,
• clear demarcation from the surrounding skin,
• soft, elastic consistency,
• blanching under pressure (diascopy sign).

Depending on the depth of the lesion:

• superficial hemangiomas – have a bright red color and a raised, dome-shaped surface (so-called "strawberry" appearance),
• deep hemangiomas – have a bluish color and may be less visible on the skin surface,
• mixed hemangiomas – combine features of both types.

Typical locations include:

• the face (cheeks, eyelids, forehead),
• the neck,
• the scalp,
• the trunk.

In adults, small senile hemangiomas appear as:

• small (1–5 mm),
• spherical,
• bright red papules.

Lesions within internal organs (e.g., the liver) are usually asymptomatic and detected incidentally during imaging studies (ultrasound, CT, MRI).

Alarm symptoms requiring specialist diagnosis:

• rapid growth of the lesion,
• ulceration,
• bleeding,
• pain,
• organ function disturbances (e.g., vision problems).

The contemporary classification (ISSVA – International Society for the Study of Vascular Anomalies) distinguishes several types of vascular tumors.

1. Infantile Hemangioma

• The most common vascular tumor of childhood.
• Appears in the first weeks of life.
• Exhibits a phase of proliferation and later involution.
• In most cases, it regresses spontaneously.

2. Congenital Hemangioma

• Present from birth.
• Does not show the typical growth phase after birth.
• May regress (RICH) or persist (NICH).

3. Cavernous Hemangioma

• Composed of enlarged vascular spaces.
• Often located deeper within tissues.
• May occur in internal organs.

4. Cherry Angioma

• Occurs in adults.
• Associated with age and genetic predisposition.
• Has solely cosmetic significance.

5. Hepatic Hemangioma

• The most common benign liver tumor.
• Usually asymptomatic.
• Treatment is required only for large symptomatic lesions.

Vascular tumors should be differentiated from:

• arteriovenous malformations,
• venous malformations,
• telangiectasias,
• capillary malformations (so-called "port-wine stains").

Proper diagnosis often requires dermatoscopic examination, Doppler ultrasound, or magnetic resonance imaging.

The choice of specialist depends on the patient's age, the location, and the nature of the lesion.

Most commonly involved in diagnosis and treatment are:

• dermatologist – for skin lesions,
• general surgeon or pediatric surgeon – for large or complicated lesions,
• vascular surgeon / phlebologist – for deep lesions and malformations,
• pediatrician – in the case of infantile hemangiomas,
• hepatologist / gastroenterologist – for liver hemangiomas.

Modern treatment methods include:

• pharmacotherapy (e.g., propranolol in the treatment of infantile hemangiomas),
• laser therapy (dye laser, Nd:YAG laser),
• electrocoagulation,
• sclerotherapy,
• surgical treatment.

In the case of skin lesions with aesthetic significance, the following are used, among others:

• laser vascular closure,
• procedures using high-energy technologies,
• surgical removal of the lesion with histopathological examination.

Any vascular lesion with an atypical appearance, rapid growth, or symptoms of complications should be evaluated by a doctor to rule out other pathologies and select the optimal method of management.